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Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Posted by Jan R. on 5/27/04 at 10:23 (151378)

I would be interested in your opinion regarding this publication:

Buchbinder R.
Clinical practice. Plantar fasciitis.
N Engl J Med. 2004 May 20;350(21):2159-66.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Dr. Z on 5/27/04 at 18:15 (151407)

Hi

I just downloaded the article. I don't know where to begin to comment but I will say that I though the original article with regard to ESWT in the AMA journal was her most ridiculous I mean best article so far but she has out done herself with this one. Is this doctor from Mars or is it Venus. I am laughing as I write this but I will be serious for one sentence.
With regard to ESWT where are Dr. Rompe( spelled correctly) articles. Where are the FDA studies for either the ossatron and or the dornier?

This article is guily of picking and chosing references to support her own personal beliefs or what may be conclusions that needed support before the data was gathered. It give Dr. Z hope that someday one of his article will be published meaning anyway or anything can get into the New England Journal of Medicine. I use to have respect for these journals until they started to publish topics that I know something about

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

David L on 5/27/04 at 19:42 (151415)

Dr Z....
You should write a letter to the editor of NEJM? I believe that Dr. Buchbinder is an epidemiologist and not a clinician. This is evidenced by the JAMA article she wrote that you mention where ESWT was focused on the thickest part of the plantar fascia as opposed to the area of pathology.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Dr. Z on 5/27/04 at 20:28 (151420)

Do you think that the New England Journal of Medicine would print my post on heel spur.com. I did receive you e-mail with the Dr. Day letter. I will take your suggestion seriously.

Re: ScottR -- I hope this is okay with you, placing the article here...

Ed Davis, DPM on 5/27/04 at 21:16 (151429)

Previous Volume 350:2159-2166 May 20, 2004 Number 21
Next


Plantar Fasciitis

Rachelle Buchbinder, M.B., B.S., F.R.A.C.P.





This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 55-year-old overweight woman presents with a three-month history of pain in her right inferior heel. The pain is worse on taking her first steps in the morning. The physical examination is normal except for nonspecific tenderness in the region of the medial calcaneal tubercle. How should the patient be evaluated and treated?

The Clinical Problem

Epidemiologic Features

Plantar fasciitis, reportedly the most common cause of pain in the inferior heel, is estimated to account for 11 to 15 percent of all foot symptoms requiring professional care among adults.1,2 Reliable population-based incidence data are lacking, although plantar fasciitis has been reported to account for about 10 percent of injuries that occur in connection with running3,4,5 and is common among military personnel.6 The incidence reportedly peaks in people between the ages of 40 and 60 years in the general population and in younger people among runners.7,8,9 The predominance of the condition according to sex varies from one study to another.5,8,10 The condition is bilateral in up to a third of cases.6,7,8,10

Pathological Features

The site of abnormality is typically near the site of origin of the plantar fascia at the medial tuberosity of the calcaneus (Figure 1). Histologic examination of biopsy specimens from patients undergoing plantar fascia–release surgery for chronic symptoms has shown degenerative changes in the plantar fascia, with or without fibroblastic proliferation, and chronic inflammatory changes.11,12,13

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Figure 1. Plantar and Medial Views of the Foot Demonstrating the Origin and Insertion of the Plantar Fascia and the Location of Nerves in Proximity to the Heel.
The windlass mechanism, or bowstring effect, of the plantar fascia refers to its function in raising the arch of the foot during the push-off phase of walking.




Risk Factors

The cause of plantar fasciitis is poorly understood and is probably multifactorial. Limited data from case–control studies have identified such risk factors as obesity, occupations that require prolonged standing, pes planus (excessive pronation of the foot), reduced ankle dorsiflexion, and inferior calcaneal exostoses (or heel spurs).6,9,14,15,16,17,18

Because of its high incidence among runners, plantar fasciitis is commonly assumed to be caused by repetitive microtrauma.3 Proposed risk factors include running excessively (or suddenly increasing the distance run), wearing faulty running shoes, running on unyielding surfaces, and having a cavus (high-arched) foot or a shortened Achilles tendon, but evidence for most of these factors is limited or absent.19

Clinical Course

On the basis of long-term follow-up data in large case series that predominantly involved patients seen in orthopedic practices, the clinical course for most patients with plantar fasciitis is favorable, with resolution of symptoms in more than 80 percent of patients within 12 months.8,20,21,22 Up to 5 percent of patients in reported case series are treated surgically,3,7,8,22 although reliable data on surgical rates in unselected patients are lacking.

Strategies and Evidence

Clinical Diagnosis

The diagnosis of plantar fasciitis can be made with reasonable certainty on the basis of clinical assessment alone. Patients typically report a gradual onset of pain in the inferior heel that is usually worse with their first steps in the morning or after a period of inactivity. Patients may describe limping with the heel off the ground. The pain tends to lessen with gradually increased activity but worsens toward the end of the day with increased duration of weight-bearing activity. Associated paresthesias are uncommon. Patients may report that before the onset of their symptoms, they increased the amount or intensity of their regular walking or running regimen, changed footwear, or exercised on a different surface. There is often a localized area of maximal tenderness over the anteromedial aspect of the inferior heel. Limitation of ankle dorsiflexion due to tightness of the Achilles tendon may be present. Other causes of pain in the inferior heel are usually distinguishable on the basis of history and physical examination (Table 1).23,24

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Table 1. Differential Diagnosis of Pain in the Inferior Heel.



Imaging

Imaging plays a limited role in routine clinical practice, although it may be useful in selected cases to rule out other causes of heel pain or to establish the diagnosis of plantar fasciitis when it is in doubt. Occasionally, it may be difficult to differentiate plantar fasciitis from calcaneal stress fracture on clinical grounds. Plain radiographs may rule out calcaneal stress fracture and other rare bony lesions. Although the detection of heel spurs is of no value in either confirming the diagnosis of plantar fasciitis or ruling it out, a 'fluffy periostitis' with ill-defined borders may suggest an underlying spondyloarthropathy.

When plain radiographs are normal, bone scans are useful for distinguishing plantar fasciitis from calcaneal stress fracture. Positive findings on bone scanning for plantar fasciitis have been reported in 60 to 98 percent of cases,25 although the false positive rate is unknown. Typical findings in the early images include increased blood flow and blood pooling; in the delayed images, findings often include a focal increase in activity at the plantar fascial insertion site in the calcaneus. By contrast, a linear fracture line or more diffuse calcaneal uptake on delayed images is consistent with calcaneal stress fractures.

Ultrasonography may be diagnostically useful, although, like other imaging techniques, it is not routinely used. The plantar fascia can be easily distinguished from the hyperechoic superficial heel pad of fat and the underlying calcaneus and is normally 2 to 4 mm thick.26 Many studies have found a marked increase in the thickness of the plantar fascia in plantar fasciitis (to a total of approximately 5 to 7 mm) and have variably demonstrated local or diffuse hypoechogenicity at the calcaneal insertion of the plantar fascia, loss of definition at the interface between the plantar fascia and the surrounding tissue, and peri-insertion edema.25,26

Magnetic resonance imaging can also be used to visualize the plantar fascia, with sagittal and coronal images.27 Normally, the plantar fascia is characterized by homogeneous low signal intensity on all pulse sequences. In plantar fasciitis, a marked increase in plantar fascial thickness can be detected, together with variable features of moderately increased signal density in the substance of the fascia on T2-weighted and short tau inversion-recovery pulse sequences (consistent with edema and intrasubstance microtears) and abnormally increased signal intensity in adjacent subcutaneous tissue and in the calcaneus at the plantar fascial insertion site. Markedly increased signal intensity in the calcaneus may be suggestive of plantar fasciitis associated with an underlying spondyloarthropathy.28

Treatment

A variety of therapies are used for plantar fasciitis; however, there are few data from high-quality, randomized, controlled trials that support the efficacy of these therapies.29 Initiation of conservative treatment within six weeks after the onset of symptoms is commonly believed to hasten recovery from plantar fasciitis,23,24 but this is also unproved. The role of various management strategies should be considered in the light of the self-limiting nature of the condition.

Physical Therapy

Many types of physical therapy have been proposed as treatments for plantar fasciitis.24 Support for the use of ice, heat, and massage and for strengthening of the intrinsic muscles of the foot comes predominantly from anecdotal data. Stretching of the calf muscles and plantar fascia and taping or strapping of the foot are commonly recommended, but these therapies have generally been assessed in combination with other interventions, making it difficult to interpret the results of any individual intervention. A recent trial involving 101 participants showed that heel pain was either eliminated or much improved at eight weeks in 24 of 46 patients (52 percent) who were treated with an exercise program to stretch the plantar fascia, as compared with 8 of 36 patients (22 percent) who reported such results after participating in a program to stretch the Achilles tendon.30 However, the study was not blinded, there was a large difference in the dropout rate between the groups (28 percent in the group in which patients stretched the Achilles tendon and 10 percent in the group in which patients stretched the plantar fascia), and only those who completed the trial were included in the analysis. Two randomized, placebo-controlled trials31,32 did not demonstrate a benefit of using magnetic insoles, and small randomized, placebo-controlled trials29 found no significant benefit of ultrasonography, laser treatment, iontophoresis, or exposure to an electron-generating device.

Orthotic Devices

A wide variety of prefabricated and custom-made orthoses, including heel pads and cups that are variously designed to elevate and cushion the heel, provide medial arch support, or both, are used to treat plantar fasciitis. There are no data on the efficacy of these devices as compared with placebo or no treatment, and the available data on their efficacy in comparison with that of other interventions are conflicting or limited. One study, involving 103 patients, compared mechanical treatment ( taping and orthoses) with the use of a heel cup or antiinflammatory treatment (three corticosteroid injections administered at weekly intervals, plus nonsteroidal therapy). Among the 77 patients who completed the trial, mechanical treatment was more effective in achieving an outcome rated as 'excellent' or 'fair' at three months (reported for 19 of 27 patients, or 70 percent) than was use of the heel cup (7 of 23 patients, or 30 percent) or antiinflammatory treatment (9 of 27 patients, or 33 percent).33 In a trial involving 236 participants, prefabricated shoe inserts (a silicone cone, felt pad, or rubber heel cup) were found to be superior both to using custom-made orthotic devices and to stretching alone. (The percentages of patients whose condition had improved at eight weeks were 95 percent for a silicone-cone insert, 88 percent for a felt pad, 81 percent for a rubber heel cup, 68 percent for custom-made orthotic devices, and 72 percent for stretching alone.2 )

Splinting and Walking Casts

The use of night splints, designed to keep the ankle in a neutral position with or without dorsiflexion of the metatarsophalangeal joints during sleep, has been evaluated in two randomized, controlled trials, with conflicting results.34,35 One trial involving 116 participants showed no benefit of a night splint worn for three months as compared with no treatment.35 In contrast, a crossover trial involving 37 participants suggested a benefit of a night splint worn for one month as compared with no treatment.34 However, a crossover design may not be a valid method for studying interventions for treatment of a self-limiting condition. A third trial involving 255 participants showed no benefit of a posterior tension splint used at night as compared with either custom-made orthoses or over-the-counter arch supports.36 There are no published data from controlled trials of immobilization with casts or other devices. A retrospective review reported a recurrence of pain, usually within a month after cessation of the use of a plaster cast, in 11 of 24 patients (46 percent) for whom follow-up data were available.37

Antiinflammatory Agents

Nonsteroidal antiinflammatory drugs are often used in practice, but randomized trials have not been conducted to assess their benefit. The injection of corticosteroids, usually mixed with local anesthetic and injected with the use of a medial approach, is another common treatment for heel pain.29 Limited data suggest that this treatment provides only short-term pain relief. One trial, involving 91 participants, showed that 1 ml of prednisolone acetate (25 mg) with 1 ml of local anesthetic, injected with the use of a medial approach, resulted in significantly greater improvement in pain at one month than did injection of local anesthetic alone; the mean (±SD) changes in the pain score, measured on a 10-cm visual-analogue scale, were 2.0±2.9 and 0.06±3.0, respectively.29 At three and six months, there were no differences between the groups in pain measures, but a high rate of loss to follow-up precluded the drawing of conclusions. A tibial-nerve block given before injection did not appear to reduce the discomfort of the injection. One concern is that corticosteroid injections may be associated with an increased risk of rupture of the plantar fascia,38,39 although data to support this association are limited and inconclusive.13,38

Extracorporeal Shock-Wave Therapy

Extracorporeal shock-wave therapy has been proposed as an alternative approach on the grounds that it may stimulate healing of soft tissue and inhibit pain receptors.40 However, the available data do not provide substantive support for its use. Of six randomized, double-blind, placebo-controlled trials assessing the efficacy of extracorporeal shock-wave therapy,40,41,42,43,44,45 three studies (involving 166, 272, and 88 participants) showed no benefit,40,43,44 and two studies (involving 150 and 302 participants) reported small benefits that were of questionable clinical importance.41,42 A sixth trial, involving 45 runners, showed that extracorporeal shock-wave therapy, as compared with placebo, resulted in a significant reduction in the score for pain on first walking in the morning (a mean reduction of 2.6 on a 10-cm visual-analogue scale) at six months.45

Surgery

Surgery may be considered for a small subgroup of carefully selected patients who have persistent, severe symptoms despite nonsurgical intervention for at least 6 to 12 months. The surgical procedures used for plantar fasciitis include variations of open or closed partial or complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression.46,47 In case series, favorable outcomes were reported in more than 75 percent of patients who underwent surgery, although the recovery times varied and were sometimes months,48 and persistent pain occurred in up to a quarter of patients who were followed for an average of two or more years.48,49 Potential complications include transient swelling of the heel pad, calcaneal fracture, injury of the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain. As compared with open release surgery, closed procedures may allow for more rapid recovery and resumption of usual activities,47,50 although the risk of nerve injury may be higher with endoscopic release and other closed procedures than with other approaches.51 Controlled trials are required to verify these findings.

Prevention

The efficacy of preventive strategies such as stretching exercises and control of the intensity of running (e.g., limiting distance, frequency, and duration) is not known.52 A randomized trial that involved 390 male infantry recruits showed that improved shock absorption, obtained with the use of basketball shoes rather than standard infantry boots, during 14 weeks of training resulted in a significantly lower incidence of foot-overuse injuries (including heel pain, arch pain, and metatarsalgia but not metatarsal stress fracture). Overuse injuries occurred in 15.5 percent of the men who wore basketball shoes, as compared with 29.1 percent of those who wore standard infantry boots (relative risk, 0.53; 95 percent confidence interval, 0.36 to 0.80).53

Areas of Uncertainty

The cause or causes of plantar fasciitis remain uncertain. The potential role, if any, of imaging studies in guiding treatment, monitoring the course of the disorder, or both has yet to be clarified; currently, imaging techniques have little role in routine clinical practice. One study showed that ultrasound-guided corticosteroid injections had the same outcome as injections administered without such guidance.54 Randomized clinical trials are needed to assess whether the commonly used treatments are beneficial in modifying the natural history of plantar fasciitis.

Guidelines

The American College of Foot and Ankle Surgeons issued a practice guideline in 2001 that is based on expert opinion.55 The recommendations generally reflect current clinical practice, but most of them are of unproven benefit. Initial treatment options include administering nonsteroidal antiinflammatory drugs, padding and strapping the foot, injecting corticosteroids, regularly stretching the calf muscles, avoiding the use of flat shoes and walking barefoot, applying ice to the affected area, using over-the-counter arch supports and heel cushions, and limiting activities. Second-line options for those patients who have not had any improvement after six weeks include the use of custom orthotic devices, night splints, and immobilization of the foot with casts and other devices during activity for four to six weeks. Plantar fasciotomy is reserved for patients in whom conservative measures have failed; removal of the plantar spur is not believed to add to the success of surgery.

A position statement regarding endoscopic and open heel surgery that was issued by the American Orthopaedic Foot and Ankle Society recommends that endoscopic plantar fascia release not be performed if there is nerve compression.51 This recommendation is based on suggestions that the risk of nerve injury may be higher with endoscopic procedures than with open procedures.

Conclusions and Recommendations

Patients, such as the woman in the introductory vignette, who have symptoms and signs consistent with plantar fasciitis including heel pain that worsens on first walking in the morning and tenderness over the anteromedial aspect of the inferior heel should be informed that the condition is self-limiting and that in more than 80 percent of patients, the symptoms will resolve within a year, regardless of therapy. Since there is limited evidence about the value of treatments for plantar fasciitis, a reasonable approach to intervention is to start with patient-directed, low-risk, minimal-cost interventions, such as regularly stretching the calf muscles and the plantar fascia, avoiding flat shoes and walking barefoot, using over-the-counter arch supports and heel cushions, and limiting extended physical activities. A trial of nonsteroidal antiinflammatory drugs may be reasonable. Corticosteroid injections may provide a short-term benefit.

More costly treatments such as the use of custom-made orthotic devices, night splints, and immobilization with casts or other devices may be options for patients in whom the condition does not improve, although the value of these treatments is currently uncertain. Surgery should be reserved for those patients whom conservative therapy has not helped after 6 to 12 months. In the absence of data to guide the surgical approach, referral to a surgeon with expertise in treating patients with plantar fasciitis is recommended.

I am indebted to Daniel Riddle, Stephen Hall, and Peter Lowthian for their insightful comments.

Source Information

From the Department of Clinical Epidemiology, Cabrini Hospital; and the Department of Epidemiology and Preventive Medicine, Monash University both in Melbourne, Vic., Australia.

Address reprint requests to Dr. Buchbinder at Cabrini Medical Centre, Suite 41, 183 Wattletree Rd., Malvern, VIC 3144, Australia, or at (email removed).

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Re: comments.

Ed Davis, DPM on 5/27/04 at 21:31 (151431)

I realize that I am using up a lot of space with the article -- hopefully Scott can accomodate it.

Drs. Rompe, Z and all:

Buchbinder's main point in the article is that there are a lot of commonly used treatments for plantar fasciitis that lack the depth of studies that she would like to see have performed.

That criticsim is understandable yet is a criticism that can be made about many common maladies and treatments. It would be my preference and wish to see more studies on this nevertheless, for now, we have massive experiential information on plantar fasciitis, an amount of experience which is so vast and involving so numerous a population that it cannot be ignored. Much is understood about the biomechanics of the foot and how that affects plantar fascial tension so much can be inferred from that basic understanding of physics, some of that understanding is so basic that further studies would be largely for confirmatory purposes.

Her bias against ESWT is obvious and she, obviously, is supporting her own flawed work while ignoring a significant amount of supportive evidence.

Her comments on imaging are interesting and, I beleive, cogent since use of radiographs has its limits in determining pathology of the plantar fascia. The is some implied support for increased usage of diagnostic ultrasound which, despite somewhat limited usage, can supply more valuable data, particularly in recalcitrant cases. She mentions the issue of hypoechogenicity but fails to mention the importance of thickness measurements. She does totally ignore the fact that podiatrists take weight bearing radiographs in order to look at certain biomechanical factors which may contribute to plantar fasciitis.

Regards,
Ed Davis, DPM

Re: ScottR -- I hope this is okay with you, placing the article here..ps.

Ed Davis, DPM on 5/27/04 at 21:41 (151433)

ps If I or others use a lot of online space, we could reimburse you as you feel necessary.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Ed Davis,DPM on 5/28/04 at 00:53 (151445)

David L:
I am a bit surprised by the access she has gotten to top journals. Considering the quality of her publications and her lack of qualifications I cannot help but question the role of politics in her access.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Jan R. on 5/28/04 at 02:15 (151448)

You all should take the opportunity and send Letters to the Editor at

http://authors.nejm.org/Misc/LetterInstrx.asp .

You got no more than 175 words and no more than 5 references, so be concise when bringing forward your concerns.

Here is my Letter:

LETTER TO THE EDITOR ABOUT A RECENT JOURNAL ARTICLE

Date Submitted: 5/27/2004 11:50:39 AM

Corresponding Author: Jan D. Rompe, MD
Dept. of Orthopaedic Surgery, Johannes Gutenberg University School of Medicine, Langenbeckstr. 1, Mainz, D-55131 Germany
Phone: +49-6131-177302
Fax: +49-6131-176612
Email: (email removed)

Issue Date: 5/20/2004
Articles Referenced:
· Clinical Practice - Plantar Fasciitis

To the Editor: (Words 148)

Sir,

in 'conclusions and recommendation' Buchbinder (1) favored surgery in chronic cases of plantar fasciitis though relying on results reported in uncontrolled trials only. It is difficult to understand that the authors 'forgot to recommend extracorporeal shock wave therapy (ESWT) in this connection, ignoring deliberately that in a well comparable cohort of chronic patients several placebo-controlled trials have shown a benefit of ESWT against sham treatment.

Keeping to the standards of evidence based medicine, ESWT - having virtually no side effects, having shown again a >80% success rate most recently (2) – should clearly be recommended prior surgical intervention in my view.

I agree with Speed (3) that currently there is evidence of benefit from some regimes of ESWT for chronic plantar fasciitis. There is a need for further research into the effects of ESWT; and investigation relating to the treatment and optimal regimes of dosage in specific conditions.

Jan D. Rompe, MD
Dept. of Orthopaedic Surgery, Johannes Gutenberg University School of Medicine
Mainz D-55131 Germany
rompe@mail.uni-mainz.de

References:

1. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med 2004; 350:2159-66.

2. Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int 2004; 25:290-7.

3. Speed CA. Extracorporeal shock wave therapy (ESWT) in the management of chronic soft-tissue conditions. J Bone Joint Surg. 2004 ; 86-B :165-171.

Re: Buchbinders article on plantar fasciitis in the New England Journal of Medicine

scott r on 5/28/04 at 07:08 (151454)

No one should be surprised at what gets published in JAMA or NEJM concerning the feet because podiatrists are their competitors. But i agree with her, at least in general, that much of the quality of what gets published in journals concerning heel pain is pretty low.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Pauline on 5/28/04 at 09:26 (151463)

Perhaps we don't know alllllll of her qualifications.

Wonder if she was a he if that would make a difference. I noticed that even Dr. Rompe was somewhat guarded in his letter to the editor using an 80% success rate for ESWT not the higher number that is usually quoted on this site.

Her reporting is interesting, that's for sure.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Pauline on 5/28/04 at 09:38 (151465)

One of the best resolutions might be to have her undergo EPF surgery, then we might get the benefit of seeing her posting on heelspurs surgery board:*

Re: Buchbinders article on plantar fasciitis in the New England Journal of Medicine

Ed Davis, DPM on 5/28/04 at 12:40 (151485)

scottr:
Your observation is right on. Science should be science. The fact that Buchbinder largely ignores the podiatric perspective reveals an unfortunate bias.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Ed Davis, DPM on 5/28/04 at 12:43 (151488)

Pauline:
As an epidemiologist one really has to wonder exactly what her agenda is. I can speculate. I do feel that science should be science and the less politics interfering with patient care the better.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Pauline on 5/28/04 at 15:18 (151499)

We don't know for certain that politics plays a role in her research or not because to my knowledge there is no concrete evidence to prove it.

Epidemiologist appear to me to be 'horn blowers' Look at Alice Steward who challenged govermental radiation levels and their link to cancer.

I think at this time it's just as easy to consider Burchbinder a 'horn blower' as it is to assume that she is somehow a political activist.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Ed Davis, dPM on 5/29/04 at 12:44 (151548)

Pauline:
This is not political activism. Someone paid for her first study and is supporting her work. She is not challenging the 'status quo' but supporting it. I cannot presuppose motives but one must ask why a seemingly disinterested specialist is placing this much effort into discrediting treatment that is needed by millions.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Robert S. on 5/29/04 at 17:47 (151571)

Did you ever think of writing to the woman and asking her directly? Sometimes that approach supplies the best answers to those that are seeking them.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

elliott on 6/01/04 at 08:57 (151680)

Dr. Z:

Hi, it's been a while. You say, 'With regard to ESWT where are Dr. Rompe( spelled correctly) articles. Where are the FDA studies for either the ossatron and or the dornier? This article is guily of picking and chosing references to support her own personal beliefs or what may be conclusions that needed support before the data was gathered.'

Actually, if you would have read more carefully that one little paragraph in her article that has you so agitated, she does indeed cite Rompe (reference 45). She does indeed cite both FDA studies (references 41 and 42). Is it too much to ask for you to be a little more careful? This is regardless of whether you agree with her conclusions.

Dr. Ed:

Hi there too; been a while. Rather than copy a whole article, a link when available is a nice solution, and the article is more readable that way too. I've provided a link below, but in case it doesn't work when I post it, the NEJM site is the first hit that comes up in a google search on 'New England Journal Medicine', and then Buchbinder's article is the first hit using the search feature there on 'plantar fasciitis'.

Yes, maybe Buchbinder is being given too much prominence, but the main issue should have been how well she summarized the plantar fasciitis treatment protocol in her article; funny, no one here dealt with that. I'll also add that those here screaming the loudest make a substantial chunk of their income off ESWT--not exactly the best independent perspective on things.

http://content.nejm.org/cgi/content/full/350/21/2159?fyear=1994&tmonth=May&where=fulltext&tyear=2004&hits=20&fmonth=May&excludeflag=TWEEK_element&sortspec=Score+desc+PUBDATE_SORTDATE+desc&search_tab=articles&andorexacttitleabs=and&searchtitle=Articles&sendit=GO&searchterm=plantar+fasciitis&andorexactfulltext=and&searchid=1086096294268_3891&FIRSTINDEX=0&journalcode=nejm

[]

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

elliott on 6/01/04 at 09:02 (151681)

Link didn't work. Try this one; the link to her article is lower down on the page:

http://content.nejm.org/content/vol350/issue21/index.shtml

[]

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Dr. Z on 6/01/04 at 09:04 (151682)

Elliott,

I knew I could get you to come out again.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

elliott on 6/01/04 at 09:13 (151683)

Dr. Z, when I'm finished with you, you'll regret flushing me out. :>

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Dr. Z on 6/01/04 at 09:29 (151689)

Hi,

I wasn't angry about the New England Journal article. What I meant by not referring to the FDA studies or Dr. Rompe's article was that it appeared that there was no weight AT ALL given to them. There were alot of other issues that I could have or should have addressed in this article and would be happy to comment on any area if asked.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

elliott on 6/01/04 at 14:19 (151719)

Sorry, I don't buy it. The entire thrust of your original post was to scorn Buchbinder for selectively choosing references. I'd say more likely is that you did not take a minute or two to actually check the references she cited.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Dr. Z on 6/01/04 at 15:02 (151722)

and choosing the information contained in the references. Didn't know you were a mind reader.

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

Ed Davis, DPM on 6/01/04 at 17:00 (151729)

Elliott:

I think the reason why Buchbinder has been given so much prominence (too much) is the fact that it is the study used to argue against ESWT most often. It was used by the Blue's Tech Committee as the primary evidence against ESWT.

I did not link as access is paid for and was unsure if a link would be allowed or blocked. I felt the article, while not particularly fond of it, had sufficient importance to be incorporated into the discussion. You amy have access via your work but I did actually have to pay for access and did not want other readers here to have to do the same.
Ed

Re: Buchbinder´s article on plantar fasciitis in the New England Journal of Medicine

elliott on 6/02/04 at 10:07 (151782)

Dr. Ed:

Whatever the reason for Buchbinder being given too much prominence, the Blue's evidence against ESWT is not all laughable, despite the impression constantly left here on these boards. And as if adding ESWT coverage will solve everything: it shifts the burden yet further to patients, most of whom already find health insurance unaffordable or close to it.

There are still many questions about ESWT, a treatment needed by 'millions', before it or a particular ESWT device is universally adopted by insurance. ESWT, assuming it works, is a nice alternative to risky surgery. But it is still very expensive. If it would cost $100 per treatment, as it may one day, this would not be an issue.

You used to be far more measured and cautious before you got ESWT machines yourself. No doubt you have witnessed firsthand the high success rates, but it does not change the fact that one making money off ESWT cannot be viewed as an impartial advocate for it.

Re: The perfect ESWT study?

Bill jr on 6/11/04 at 07:18 (152711)

Elliott,

I know that you have read and analysed ESWT journal articles and that you take the view that some of the positive results are not convincing. I have to agree that there is not a grand conspircy to prevent insurance coverage of ESWT. Assuming that the studies are lacking something, is there a simple study that could be completed whose results would be compelling?

For example, a double blind, placebo controlled study that looked at the VAS score for the first few minutes of walking in a group of 200 participants over four months. Inclusion in the study would be 6 months PF, 4 failed conservative treatments, etc... If the results were positive, would that study be compelling? If not, is there a simple study that would work.

Finally, a study like this would have to have the support of an equipment manufacturer. Would the supplying of a technician and the limited use of the machine corrupt the results? If so, how do you see this study getting done? APMA funding?

It would be great if everyone would objectively discuss this question. I think that if we can get a good description of the 'ideal' study we might be able to make it a reality.

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