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New Surgical Approach, Part II

Posted by Robert J on 4/30/04 at 13:25 (149839)

Some of you may recall the exchange earlier this month about a new -- or at least different -- surgical approach to PF being taken by an orthopedic surgeon in the Washington DC area. This is the surgery based on the notion that PF is a degenerative injury rather than an inflammatory one, and that the degenerative tissue, which is a tissue causing the pain presumably, can be excised from healthy tissue. The surgeon's name is Dr. Nirschl and he runs a well-known sports injury clinic.

OK, I have now found a reference to a journal article that Nirschl wrote about PF but I have not been able to locate the article itself. I am hoping that some of you are far better at this kind of search and can track down. It's my guess that this article describes Nirschl's surgical approach and discusses his results. Here's the citation:

'Plantar Fasciitis: A New Perspective' by Nirschl P in the AMAA Quarterly, Summer, 1996.

FYI, 'AMAA' stands for the American Medical Athletic Association. If anyone finds the article, please let me know. Thanks.

Re: New Surgical Approach, Part II

Dorothy on 4/30/04 at 18:37 (149849)

This is not the article you seek but it does give a good overview of Dr. Nirschl's ideas in a Q & A format, where he answers a question.:
http://www.golf.com/apps/fitness/askexperts/more.asp?qid=2

If you do a simple Google search using 'Nirschl + Plantar' you will find lots of info. that may lead to the article you seek. I was doing this just briefly, being short on time, and found lots of stuff. Good info. in any case - very good, I would say.
Good luck.

Re: New Surgical Approach, Part II

Pauline on 4/30/04 at 19:35 (149861)

Dorothy,
Good find between you and Robert, but he can't be any good he trained at that inferior institution called the Mayo Clinic:)

Re: New Surgical Approach, Part II

Ed Davis, DPM on 4/30/04 at 19:42 (149862)

No mention of ESWT in the discussion. It is amazing that no one is questioning a 'new' approach, demanding a double blinded peer reviewed study, FDA approval, etc. Insurers have no problem considering payment for this, I would assume, but giving ESWT the 'third degree.' Does this not lead one to beleive that there is a problem inherent with our 'system.'
Ed

Re: New Surgical Approach, Part II

Dr. Z on 4/30/04 at 21:31 (149866)

It all to do with the cost of the procedure and how much money insurance companies will be required to pay

Re: New Surgical Approach, Part II

Ed Davis, DPM on 5/01/04 at 21:04 (149881)

Dr. Z:
Insurers pay based on the code used. It is likely that the surgeron is not using an 'unlisted' code but simply using an existing code. Only if they start asking for op -reports would there be any question but that would be unusual.
Ed

Re: New Surgical Approach, Part II

Dr. Z on 5/02/04 at 19:46 (149918)

ED,

I am confused with your answer. What I was saying is that insurance coverage has alot to do with how much a procedure such as ESWT will cost the health care system. This is a major determination when deciding coverage in the long term. In the short term is it the effectiveness of the procedure

Re: New Surgical Approach, Part II

john h on 5/03/04 at 09:33 (149938)

Dorothy: When I had surgery about 4-5 years ago I had what is known as the Baxter procedure. A small half moon section of fascia was removed in the general are the Doctor mentioned. I doubt my Doctor had the tissue sent to the lab but I sure wish he had. The premises of the Baxter procedure was not to remove inflamed tissue but remove fascia over the Baxter Nerve which Dr. Baxter has concluded causes much of what we perceive as PF pain. I found Dr. Nirsi's article very informative and in line with some of what I have been reading the past year which is PF is not in many cases an inflamatory problem. I particularly paid attention to his statement that rest was no cure. From my personal experience over the years I find that some use of the foot in walking,etc is required for my feet to do well. Of course, one must not overdo this and it is up to each individual to find what works for him/her. I think that many many of our posters have approached the PF problem with rest or complete imobilization which may in fact worsen the condition. He also mentions shoes with good mid sole flexability. This is counter to what I have been doing and if one wears a rigid orthotic I would think there would be zero mid sole flexability. Would this not suggest an orthotic that is either semi rigid or soft be more appropriate if you agree with Dr. Nirsi?.

Re: New Surgical Approach, Part II

Robert J on 5/03/04 at 12:55 (149945)

Dorothy, I did a Google search as you recommended but, alas, the Journal article did not turn up. I will continue looking. It just occurred to me that perhaps Nirschl's office could supply a copy.

For Drs. Ed and Z, I think you guys are sort of missing the point. The interest in Nirschl's work stems from his well-taken point that PF is a degenerative injury and not an inflammatory one. All the evidence in the past 5-10 years suggests that he is correct about this, as far as I can tell. The difference is huge and could explain not only why so many traditional treatments fail but could also how more effective treatments could be developed, of which surgery is only one.

To keep whacking at Nirschl, and to suggest that he is manipulating the insurance codes, simply because he doesn't champion ESWT strikes me as a baffling response. As a matter of fact, we have no idea what Nirschl thinks of ESWT or whether he promotes it in his practice. But either way, what difference does it make in regards to his surgical technique or other
treatments that flow from a degenerative theory rather than an inflammatory theory? Nirschl is either onto something or he's not,

Re: New Surgical Approach, (third attempt)

Robert J on 5/03/04 at 12:58 (149947)

Dorothy, I did a Google search as you recommended but, alas, the Journal article did not turn up. I will continue looking. It just occurred to me that perhaps Nirschl's office could supply a copy.

For Drs. Ed and Z, I think you guys are sort of missing the point. The interest in Nirschl's work stems from his well-taken point that PF is a degenerative injury and not an inflammatory one. All the evidence in the past 5-10 years suggests that he is correct about this, as far as I can tell. The difference is huge and could explain not only why so many traditional treatments fail but could also how more effective treatments could be developed, of which surgery is only one.

To keep whacking at Nirschl, and to suggest that he is manipulating the insurance codes, simply because he doesn't champion ESWT strikes me as a baffling response. As a matter of fact, we have no idea what Nirschl thinks of ESWT or whether he promotes it in his practice. But either way, what difference does it make in regards to his surgical technique or other
treatments that flow from a degenerative theory rather than an inflammatory theory? Nirschl is either onto something or he's not,and ESWT has nothing to do with that.

In any case, if I find that Journal article, I will pass it along.

(Something wacky happened with the posting mechanism here, and I apologize if this appeared multiple times)

Re: New Surgical Approach, Part II

Ed Davis, DPM on 5/03/04 at 14:00 (149948)

Dr. Z: I think that we all realize that ESWT costs a lot less than surgery. The issue with ESWT could be the potential for higher utilzation since it is a relatively harmless modality.
Ed

Re: New Surgical Approach, Part II

Ed Davis, DPM on 5/03/04 at 14:08 (149949)

Robert:
We have long maintained that PF really is a form of plantar 'fasicosis,' that is, a degenerative process of the plantar fascia. This is not a new concept here. In fact, that is what ESWT is all about -- a modality that has the ability to improve that tissue quality. The important thing to understand is that the process occurs on a microscopic level, that is, one cannot simply go in, find the tissue that is bad vs. the tissue that is good and excise the bad tissue only. Yes, if one simply bills for a 'plantar fascial release' irrespective of HOW that is done or how much of the fascia is 'released' , one will get paid by most insurance companies. If you want to be baffled, ask yourself how one can take tissue that is pathologic, cut out part of it and expect the rest to become healthy.
Ed

Re: New Surgical Approach, (third attempt)

Dorothy on 5/03/04 at 17:58 (149962)

Even if it does appear multiple times, it is worth repeating! Great response. When I had a little more time than earlier, I looked a little more for the article, but to no avail. Your idea about contacting Nirschl may prove fruitful - but a good librarian will also be able to help you, especially since you have the exact citation.
Best wishes-

Re: New Surgical Approach, Part II

Dr. Z on 5/03/04 at 22:28 (149977)

Ed,
Are you sure that ESWT costs less then pf foot surgery ? The last time I looked ESWT cost more.

Re: New Surgical Approach, Part II

Ed Davis, DPM on 5/04/04 at 22:42 (150055)

Dr. Z:
Only if you are looking at Healthronics...
Ed