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Docto's and anyone's advice

Posted by Mike M on 5/29/04 at 13:39 (151555)

have chronic pf. Surgery is an option, tried everyting inc ESWT. Can walk for sometimes up to an hour without pain becoming to bad. Can only stand for a short time. No 1st step pain. Am I taking a risk with surgery when I can currently get around ? What do you think, put up with the pain as it is. Conscious that i could get worse after surgery and i should be grateful i can still now get around.

thanks

Re: Docto's and anyone's advice

Ed Davis, dPM on 5/29/04 at 14:26 (151556)

Mike:
Hopefully you have tried more than one round of ESWT. Considering your degree of limitation and provided that you have had at least 2 rounds of ESWT as well as adequate biomechanical intervention (see Scott's Heel Pain Book) then I think that the risk of surgery is reasonable.
Ed

Re: Mike

Steve G on 5/29/04 at 14:27 (151557)

Mike - that's a tough one. All of us, ask it at one point or another, especially after ESWT has not eliminated the pain. There are people that post that they are glad they got the surgery. I would, if I were you, continue with the conservative treatment and see if you cannot continue to improve. I say this because

1. If does not sound like you are in a lot of pain
2. If you can walk up to a mile, you are in pretty good shape
3. Most importantly, if you don't have first-step pain, you are not a good candidate for surgery. Dr. Z has stated this on the board several times.
4. The surgery can lead to big problems, and should be approached with trepidation, if at all.
5. If it does not go well, you are in a hell of a fix. See, for example the following post -

bbt.cgi?n=103165

See if continued care does not lead to more improvement

Re: Where there you go

Steve G on 5/29/04 at 14:31 (151559)

Two different answers. Since Dr. Davis is the expert, you might want to give it a try. I would, however, definitey try another round of ESWT. I noticed improvement with both ESWT treatments

Re: Mike

Ed Davis, dPM on 5/29/04 at 14:47 (151561)

Steve:
Being able to be on his feet for only 'up to' one hour is not very good function. I am assuming that he does not have a job that involves standing -- he could not perform such a job at his current level.

I, as you know, am far from pro-surgery, when it comes to PF release although to place things in proper perspective; about 60% of patients will be cured, 20% the same and 20% worse. There are a lot of people who would argue the numbers but lets just use these for now. The real downside if he is in the last 20%. I am more concerned with the 60% cure figure because I just see very few who really are in that last 20%. There is almost always a 'story' attached to such individuals; eg. inadequate follow up care, inadequate orthotics, lack of adequate use of casting after the surgery, failure to control potential scar tissue. Additionally, I prefer surgeons who use the traditional open approach or the minimal incision approach used by Dr. Z and myself. EPF unto itself is not a flawed technique but has a lot of negatives attached to it. First, EPF has been used as a means to 'sell' the surgery as 'new' or better technology sometimes often with the implication that one is back in shoes too quickly (ie. no casts) and the post-op care is downplayed.
Also, associates have noted a number of patients in which, by nature of the EPF itself, some of the most problematic medial fibers are missed.

The other reason for plantar fascial release failure is failure to understand the 'shift' in biomechanics that occurs. Sometimes that means making a new orthotic that is more supportive of the lateral column. It just needs to be watched closely. Also the role of a tight gastrosoleus cannot be ignored -- I lengthen the achilles (tendo achilles lengthening or gastroc recession) in about 40 to 50% of those who are getting a plantar fascial release. The bottom line is that while the release is fairly simple, the effects on the foot are not and need to be watched for several months, fairly closely. My numbers of such surgeries are way down though due to the success of ESWT.
Ed

Re: Mike

Dr. Z on 5/29/04 at 15:51 (151567)

Mike

You have received advice from both Dr. Ed and Steve that have many positive points. A 2nd round of ESWT can in fact improve and or cure your current pain regardless of what effect the first ESWT round did or didn't help. I used Miminial incision pf with and without bone spur removal with many happy patients that still to this day refer to Dr. Z. There are complications with pf release that can and do happen but if I had pain and ESWT didn't resolve the pain I have and would do a pf release

Re: Mike

Ed Davis, DPM on 5/30/04 at 13:57 (151599)

Dr. Z:
I did mention the second round as a pre-requisite. I realize that it is not 'official' but have had some patients see benefit from more than two rounds. Nobody, in the US, is going to spend the money to go to the FDA and do a study that would only potentially benefit the small percentage of patients that are not helped by our two round high energy approach.
I realize that I am getting on my bandwagon again, but we really need to reform the FDA approval process.
Ed