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new surgical concept

Posted by Robert J on 3/29/04 at 11:58 (148065)

I just came across this article and was startled by the description of the 'advanced surgical concept' for PF described in the next-to-last-paragraph. Has anyone else heard of this technique, or Dr. Robert Nirschl?

http://golf.com/apps/fitness/askexperts/more.asp?qid=2

(sorry about the address. apparently it didn't go to hypertext, so you have to key it in)

Re: new surgical concept

john h on 3/29/04 at 14:01 (148070)

I find this article to be perhaps the most profound (If accurate) insight into longterm PF since I have been on this board. It would certainly explain why some of us continue with this disease and may be doing some things all wrong. It might also explain why ESWT may work for some people and not for others in that if the ESWT beam is not placed on the exact diseased portion of the fascia there is no result. Everyone should digest the Doctor's explanation carefully because if this is true it should change many of our views on PF. Other than by open exploratory surgery I would like to ask him how the diseased portion of the fascia could be removed? What he is saying is not uncommon in hip replacements as with Bo Jackson. Inadequate blood supply. I wonder exactly what sort of therapy he would suggest to increase blood supply. ESWT might do it but if you have a large section then a single treatment of ESWT would not do it. How does he diagnosis this condition? This takes me back to the article I read on taking your blood pressure on your arm and then on your ankle and see if the ratio falls within what is considered normal. This might give some indication of blood flow to the area. Perhaps our resident Doctors might want to start keeping some records on their patients with PF comparing normal blood pressure measured at the arm with blood pressure measured at the ankle. I will have to go back to my original post on this to see whether it was systolic or diastolic and what the reference ratio should be. It seems the Doctor publishing this to be a quality Doctor. I am going to try and do a search on Dr. Nirschi. He has a sportsmedicine clinc in Washington, D.C. If I lived in that area I would definitely make an appointment with him to further check this out. If you do not have the proper blood supply to the fascia even a novice like me can imagine the results.

Re: new surgical concept

john h on 3/29/04 at 14:07 (148071)

The text took me straight there. thanks. good job!

Re: new surgical concept

Dr. Z on 3/29/04 at 14:53 (148073)

John,

Isn't this similiar to the baxter's operation that you had done.?

Re: new surgical concept

john h on 3/29/04 at 15:48 (148076)

Dr Z: I thought about the Baxter Procedure but in that procedure only a small half moon section over the Baxter nerve is removed. Diseased or not! How would one know what section (if any) is diseased without exploration? His thesis makes a lot of sense and would explain a lot but seems like it would take an autopsy to locate the diseased tissue? What do you think? Could an MRI or Catscan or some other device locate diseased tissue?

Re: new surgical concept

Dr. Z on 3/29/04 at 16:23 (148082)

John,
We know in most cases where the diseased tissue should be from experience. They have some newer ultrasound machine that may or may not help us out. I do believe that there is a fasciosis in the area and that healing of this diseased tissue in the chronic cases should be the goal

Re: new surgical concept

Robert J on 3/29/04 at 16:26 (148084)

John --

I'm not a doctor, of course, but I believe I can answer your question about the method used to identify the injured tissue versus healthy tissue during surgery. I have come across a separate paper on PF that says injured tissue takes on a distinctly different look from healthy tissue. In other words, you can see it with the naked eye. If I can find the Internet address for that paper, I will post it. I agree with you that this procedure makes sense but I also have questions. Namely, if it has been successful, why doesn't everyone know about it? And what is this doctor's track record with the procedure? I believe the doctor, Nirschl (?), has a web site and I think there's a hyperlink to the site on the article. Perhaps we should both try to communicate with him and see what he says.

Re: new surgical concept

Robert J on 3/29/04 at 16:29 (148085)

Dr. Z. --

I would love to know what you think of this approach. Dr. Ed also, if he's reading. Have you heard of the doctor, and why wouldn't a successful surgery procedure the well-known? Or have we fallen off the curve on this message board and missed a significant development?

Re: new surgical concept

Robert J on 3/29/04 at 16:41 (148086)

Jon --

Here is the address of the other paper I mentioned, which appeared in the Clinical Sports Medicine journal. I believe there are several references to the visual appearance of injured tissue but in section 2.1 of the paper the authors say, 'mucoid degeneration causes the affected region to soften, lose its normal glistening white appearance and become gray or brown...'

http://www.clinicalsportsmedicine.com/articles/common_tendinopathies.htm

Re: new surgical concept

BrianJ on 3/29/04 at 17:19 (148088)

John --

For more info regarding the change in tissue character, take a look at tendinosis.org.

Re: new surgical concept

Dr. Z on 3/29/04 at 18:00 (148090)

Robert
I agree you can look at tissue and determine if it is healthy or not. The problem is the exposure to see this with the heel. You would have to
use a plantar incision and or a big medial incision to SEE the entire area. IT could be done, but you could have a situation where the operation was a success but the patient died, if you know what I mean. Maybe a very traumatic exposure??

Re: new surgical concept

Dr. Z on 3/29/04 at 18:12 (148092)

I think we or Dr. Z should contact this doctor for additional information about this procedure.

Re: new surgical concept

Pauline on 3/29/04 at 18:43 (148096)

Good article. One worth saving.
Thanks

Re: new surgical concept

Dr. Z on 3/29/04 at 19:08 (148098)

Robert
I still think at first glance this is a pf release at the medial 1/3,where the plantar fascia is attached to the medial tubercle of the heel bone.
All of the specimens that I use to send to the lab came back with tissue consisted with fasciosis. All of my Miminial incision pf releases were done at the insertion and all were sent to Dr. Harvey Lamont. This is the doctor whose abstract has been quoted on this site.
I am very open and would appreciate anyone explaining to me what is the difference between this surgical procedure and my mis release at the insertion. I fully agreed that we are talking about a degenerative fasciosis condition and not a fasciitis for those cases that don't response to either systemic and or local nsaid.

Would someone point out the difference to me. I been working since 7am ?

Re: new surgical concept

Robert J on 3/29/04 at 20:18 (148102)

Dr. Z:

As one who has never had foot surgery and certainly has never performed it, let me take a stab at the differences as I see it. I believe Dr. Nirschl is saying that he does not ' release' the fascia at all. Rather, he shaves off the layers of degenerated tissue and leaves the healthy tissue intact. This maintains the basic structure of the fascia in place so it can continue to perform the support functions. It did occur to me, as it did to you, that such a procedure would require a significant incision for the surgeon to see which tissue needed to be removed. I am still puzzled as to why, if this surgery has proved successful, so few people seem to be aware of it. I would love to get more information from Dr. Nirschl, who seems to be a prominent sports medicine orthopedic surgeon in Washington DC.

Re: new surgical concept

Dr. Z on 3/29/04 at 20:41 (148106)

Ok. I see what you are talking about. This would be very similiar to what we call a debridment. This is the term that is used when you remove just the diseased tissue on a tendon. This is how we treat diabetic ulcerations. Interesting approach. Hear is another question ? What if you have to remove alot of tissue and the fascia is so thin and or weak it would be prone to a rupture. In tendon surgery they place a graph in the area when you have to debride alot of tendon.

Re: new surgical concept

JudyS on 3/30/04 at 00:33 (148112)

Robert, John - did you see this (Dr. Robert Hirschl's) website?
http://www.nirschl.com/ankle_heelspurs.htm

Re: new surgical concept

john h on 3/30/04 at 10:44 (148127)

Good show Judy. I had been looking in Washington, D.C. which is why I could not find him.

Re: new surgical concept

john h on 3/30/04 at 10:57 (148129)

I wonder if there has ever been a study of the fascia as it relates to foot problems using human bodies. clearly such a study could correlate diseased tissue with a persons foot problems. Dr. Z or Ed did you all ever use cadavers in your training? Since this disease does not get much press then probably not as it would require following a person with foot problems until death and then viewing the plantar tendon. We are unfortunately among those with an 'orphaned' disease with only a very few looking at it with limited resources.

Re: new surgical concept

Ed Davis, DPM on 3/31/04 at 23:49 (148238)

Never hear of Dr. Nirschl.
He is way behind the times if he has not even mentioned ESWT.
Ed

Re: new surgical concept

Ed Davis, DPM on 3/31/04 at 23:52 (148239)

John:
When we used cadavers, we dissected the entire body but did so to learn anatomy during our first year. We were not specifically looking for pathology at that time.
Ed

Re: new surgical concept

Ed Davis, DPM on 3/31/04 at 23:58 (148240)

John:
This implies that it is possible to isolate the diseased tissue and remove it (debride it) away from the good tissue. Afte looking at many hundreds of plantar fascias on diagnostic ultrasound, I think that that is RARELY possible. It is disturbing to see him not even mention ESWT. We don't need another guy who wants to cut on something that should rarely be treated surgically.

Holy smokes, we want the FDA to review a zillion studies before approving a relatively harmless modality such as FDA but allow people with knives and impressive sounding credentials to 'experiment' with his own procedure on live human beings. What is wrong with this picture?
Ed

Re: new surgical concept

Dr. Z on 4/01/04 at 10:30 (148258)

Well stated Ed !!

Re: new surgical concept

john h on 4/01/04 at 13:05 (148265)

One thing we apparently know is that ESWT does create new blood supplies for the tissue injured by the ESWT. If the lack of blood flow in the tendon is caught early enough then hopefully ESWT may initiate enough new blood flow to regenerate the diseased tissue or prevent it from further decay. Do we know how much tissue is damaged by an ESWT procedure? Is it just the width of the beam? Does the tissue get damaged beyond the beam? is it a theory or fact that ESWT damages the tissue and new blood vesseles are formed in the healing process.

I do not recall Dr. Nirschi actually talking about removing the dead tissue as a procedure. Does he actually do this? If so I would sure be interested to know how he does it.

Re: new surgical concept

Robert J on 4/01/04 at 13:46 (148268)

I went to Dr. Nirschl's web site and he mentions the procedure in passing. Nothing detailed, but he does say that the procedure removes the injured tissue and leaves the healthy tissue. His criticism of the traditional release surgery is that it leaves the injured tissue in place. This brings up an interesting point: if this injury is a degenerative injury -- and there seems to be a growing consensus that's the case -- rather than an inflammatory injury, what causes the pain? If you go to the tendinosis.org web site you'll find a Journal article that addresses this question and suggests, without claiming it's the Gospel, that the pain of the injury arises from the biochemistry of the injured tissue. In other words, the injured tissue emits neuro-toxins that cause the pain, or at least that's the theory.

So I believe Dr. Nirschl sees his procedure as addressing the crux of the problem. In stubborn, chronic cases where conservative approaches have failed, a removal of the injured tissue will remove the cause of the pain. Presumably it will also leave the healthy fascia tissue intact to continue performing its function. I am not planning to sign up with Dr. Nirschl and his surgery, but this approach intrigues me. From what I've read of the most recent medical studies of soft tissue injuries such as teninosis, it makes sense. But I am still puzzled that there's so little discussion of this approach in the literature I've read. The Nirschl web site offers no feature where you can e-mail the Dr., so communicating directly with him is an obstacle.

Re: new surgical concept

JudyS on 4/01/04 at 17:15 (148272)

Robert, you can get Dr. Nirschl's email by first clicking on his name in the column on the left of the home page, then on '.....sportsmedicine clinic.....' way at the bottom of his personal page.
I sent him an inquiry email a few days ago but have not heard from him....unless my email filter's worked too well.

Re: new surgical concept

Robert J on 4/01/04 at 18:43 (148273)

Judy--

Many thanks. You're better than me at this stuff. I will also send an email inquiry. Let me know if you hear from him.

Re: new surgical concept

Will B on 4/05/04 at 19:58 (148452)

I would think that Dr. Dr. Nirschl does know about ESWT. With all due respect just because it is not inmplicitly mentioned on the site does not mean he does not advocate or used it or trained on it. Lets be open minded here. Even 'if' he is behind a tad concerning ESWT, any new technique - or 'debridling' as Dr Z. calls it it worth a look. You just never know when something truely great for a specific injury might be the ticket for 'some' people's suffering.I remember when ESWT was in it's infacy, and was totally without any insurance coverage. I remember it being mentioned on this site as something great. Lets take into account.. that just as it has helped 'some' people - there are others who had absolutely no benefit from two treatments of it. This may sound a tad crazy, but I envision in the future that a combination of precision guided lazer surgery and a far more refined version of ESWT will nearly cure most types of foot pain (5-10 years from now). Infa_red guided imaging with neon color die (injected) to show any damaged tissue right down to the smallest and most exacting amounts. And pratically no chance for a doctor to cut wrong, because .. after all guesswork will be taken 'out' of the picture for the most part by lazers that are guided to the inth of tolerance and are calibrated perfectly (because it's a computer program and a lazer and not a human hand). Kind of like 'Auto pilot'. I say this because I see some people 'with' typical PF that get no relief from ESWT, so lets not blatantly discount any theory by an educated doctor who has an open mind_ anyway - That's how I feel about it. I would imagine that this doctor knows full well about ESWT, but is simply 'looking' at other ways to get relief, or to operate on the foot for better results for a specific type of injury.

Re: new surgical concept

Sheila C on 4/21/04 at 18:02 (149306)

I am a patient of Dr. Nirschl. He is a good surgeon and very well respected in his field.