surgical release of plantar fascia -- NEVER!Posted by Ed Davis, DPM on 9/04/04 at 15:38 (159315)
I just got off the phone having a conversation with Dr. Cocheba, one of the authors of the following paper:
The effects of cutting even a small portion of the plantar fascia are DRAMATIC from a biomechanical point of view. I question whether insurers should cover the plantar fascial release except in the most extreme cases.
The information gleaned from Dr. Cocheba today is very SIGNIFICANT in that the surgical procedure harms the patient. Insurance companies that state that they are willing to pay for the surgery but not ESWT should be held ACCOUNTABLE for that decision as they are basically encouraging malpractice in my point of view.
Re: surgical release of plantar fascia -- NEVER!Pauline on 9/04/04 at 19:08 (159341)
I believe in your principle that P.F. surgery shouldn't be done, but I think you place the blame on the wrong party. Insurance companies don't do the surgery, doctors do.
If I hit a parked car, my insurance company isn't at fault for insuring me. I'm at fault, because I did the deed.
Your blame on insurance companies doesn't fly with me simply because a treatment isn't covered.
Re: surgical release of plantar fascia -- NEVER!Ed Davis, DPM on 9/04/04 at 19:42 (159344)
What you are saying, in principle, should be the way things ought to be (beleive me -- most doctors wished they were that way) BUT, realistically, patients tend to accept treatments based on their insurance coverage. We have gone through a generation of people expecting their insurance company to cover all that is necessary for their health treatment. Now that the insurers are cutting back, many patients are frustrated and confused. Insurers routinely lie to patients making statements like a treatment 'is not medically necessary' or that the treatment is 'experimental.' Some managed care organizations actually have what we term 'gag clauses' which forbids doctors from informing the patients about non-covered services as that will make patients angry at the insurers. I would estimate that about 15% of the population will make treatment decisions independent of their insurance coverage restrictions.
Re: surgical release of plantar fascia -- NEVER!Ferreri on 9/07/04 at 00:13 (159467)
This is very interesting discovery. My podiatrist perfoms this kind of surgery routinely. He believes that by making a small lateral cutting of the fascia releases the tension. He also removes the spur (by grinding it off or by chiseling maybe). This is what he had suggested before I opted to have a go at ESWT which to me is another questionable therapy but less harmful compared to this crazy act of butchery.
I am now wondering if hard custom-made orthotics that he asked me to wear are really necessary in the treatment of plantar fasciitis.
Thank you Doctor.
Re: surgical release of plantar fascia -- NEVER!Ed Davis, DPM on 9/07/04 at 09:38 (159483)
Orthotics, if made correctly, can releive a lot of tension on the fascia.
One would generally consider ESWT before surgical treamtent.
Re: surgical release of plantar fascia -- NEVER!Ferreri on 9/08/04 at 14:20 (159567)
And how would we know they were made correctly? I know a series of measurements were taken and they observed the way I walk, the height of each foot arch. Measurements were taken before the orthotics were ordered. They were crafted by Northwest Podiatric Laboratory and they are kinda hard but I can tell you that I am used to them now. The good news is that I can run and feel good I mean, no pain, while playing tennis but not with orthotics in. Is that something I should force myself to?
I still ice my foot by rolling a bottle of icy water underneath and on naproxen 500 mg x2 a day. I wonder if I will be in pain if I drop naproxen. What do you think?
Thanks again Dr.Davis
Re: surgical release of plantar fascia -- NEVER!Mark Evans on 9/13/04 at 17:08 (159831)
Dr.Davis- I agree with you on the whole that surgical release of the plantar fascia should (mostly) be avoided.
However, the study you refer to was carried out on the feet of cadavar specimen. In the real life situation, following surgery the fascia will eventually heal in a lengthened position and therefore resume some of the pressure load function.
It has to be accepted there are patients who have run the gamut of treatments unsuccesfully and surgery may be their last and only hope.
Re: surgical release of plantar fascia -- NEVER!Dr. Z on 9/13/04 at 19:18 (159838)
I agree with what you are saying however I have seen patients where the fascia heals with severe loss of load bearing ability with permanent weight transfer to the cuboid and forefoot areas. This is why I feel that ESWT is a better choice then pf release. I will however perform pf releases if ESWT fails to resolve the heel pain.
Re: surgical release of plantar fascia -- NEVER?Mark Evans on 9/13/04 at 19:40 (159841)
I don't doubt it Dr.Z. And I have also seen patients who have had a good long term (5 year plus) result without transfer loading pressures. I can only speculate why this is but it is likely to be multifactorial (patient selection, foot function, weight, surgical variables etc). As always in medicine and surgery, (and life) there are no absolutes. Few treatments offer a black-and-white solution. The patients who are reporting on every facet of treatment, and related anectodes from here is testimony to this inevitable fact. But I am sure I am talking to the converted. I like this website and commend the originator and the patient participation is fabulous. I do have a concern that a website such as this is likely to skew outcomes, and perceptions, by quite a margin since happy people will not be as vocal as the unhappy people. Lets face it when we are happy with a procedure/treatment, not many of us will then 'do' the WWW to let the world know. The 'study' population suffers from a self selecting bias; and such bias in science is a 'bad' word.
That said, I am also always on the lookout for new treatments to help this pervasive irksome condition. And I hope patients also understand their doctors are likely (mostly!) to want the same for them.
Re: surgical release of plantar fascia -- NEVER?Dr. Z on 9/13/04 at 21:06 (159845)
I agree . I also have many many many pf releases that are 20 years plus that are happy. It is the ones that I see pain in other areas of the foot such as neuroma, DJD at the midtarsal areas years down the road. The patient is happy and doesn't realize that these new problems may have come from the pf release five, ten years ago. . It is my opinion that it is very possible that there are long term changes in the foot after pf release and this is why I favor ESWT.
Re: surgical release of plantar fascia -- NEVER?Mark Evans on 9/14/04 at 10:29 (159856)
OK, but how can we be sure the 'new' problems would not have occured anyway and are in fact related to poor foot function. The heel pain patient is likely to have a degree of biomechanical abnormality which may be responsible for a variety of pathology in the foot.
Re: surgical release of plantar fascia -- NEVER?Dr. Z on 9/14/04 at 12:53 (159863)
That is another explanation for the additional problems. I have a gut feeling that the severing of the plantar fascia is one of the reasons
Re: surgical release of plantar fascia -- NEVER?Mark Evans on 9/14/04 at 20:27 (159904)
Dr Z - I am sure you are right especially if the surgical approach is overly aggressive. I have had good results with multiple small stab incisions 5-6 no longer than 2-3 mm and then stretching the fascia to reduce stress on the fascia.
Re: surgical release of plantar fascia -- NEVER!Ed Davis,DPM on 9/17/04 at 00:36 (160025)
You are correct in that surgery is still something to be considered. We want people to know that there are a lot of options out there to try before considering surgery.
Re: surgical release of plantar fascia -- NEVER?Ed Davis,DPM on 9/17/04 at 00:39 (160026)
Interesting -- you are essentially performing a plantar fascial lengthening. Was that procedure one of your origination or are others using it?
Re: surgical release of plantar fascia -- NEVER?Ed Davis,DPM on 9/17/04 at 00:41 (160027)
ps What is the pattern of cuts that you are making?
Re: surgical release of plantar fascia -- NEVER?Mark Evans on 9/17/04 at 11:17 (160062)
Ed - it has always been my dream to 'invent' a new and successful procedure. Sadly I cannot claim this to be my idea. The procedure is used by some of the British Podiatrists. I am fairly confident it has also been described in the American Podiatric literature. I am sorry I cannot offer you a reference at the moment. I am packed ready to return to England.
The incision are made in a staggered arrangement as proximal to the heel as possible. The procedure depends on the surgeon's ability to palpate the fascia. Depth of incision is also gauged by the length of the blade. Experience on cadavers show that if a microblade is used, when almost fully inserted the blade usually transects the fascia without damaging underlying structures. After the foot is adequately anaesthetised the procedure takes only a few minutes to perform.
I have always thought of it as 'conservative' in nature as the fascia is lengthened in a controlled fashion and the tension is reduced along the width of the insertion, so perhaps there is less risk of causing overloading problems.
I cannot claim to have extensive experience of fascia release, as most patients lean away from surgery once the pros & cons have been discussed in a transparent manner. I make it a policy to let patients know all the facts so they can participate in making a decision about the treatment. Some of my colleagues seem to favour this procedure if surgery is finally deemed necessary; or as an alternative a partial medial fasciectomy cutting no more than 1/3 of the width from medial to lateral.
Re: surgical release of plantar fascia -- NEVER?Pauline on 9/17/04 at 15:52 (160087)
Please don't leave without providing us your office address and phone number. You'd be the perfect referral to pass along to our U.K. posters.
Your HPC number would also be helpful for those that have difficulty locating you including the HPC itself.
Wishing you safe travels.
Re: surgical release of plantar fascia -- NEVER?Julie on 9/17/04 at 16:22 (160088)
Good thinking, Pauline. I hope Mark's return home to the UK won't mean his leaving heelspurs, though. It IS possible to participate from across the sea, if you see what I mean... :) I've been doing it for years.
Re: surgical release of plantar fascia -- NEVER?Dr. Z on 9/17/04 at 16:33 (160089)
What is a HPC number?
Re: surgical release of plantar fascia -- NEVER?Mark Evans on 9/17/04 at 18:05 (160092)
If I am guessing correctly Pauline is referring to the Health Profession Council. This is a new regulatory body overseeing registration of health care professionals. Right now the HPC is screwing things up big time for Podiatrists in the UK! There is a lot of politics behind this - please don't get me started.
I plan to continue visiting the website - this is beginning to feel like family already! I am not sure there is any point posting my practice address details as patients need to be referred into the NHS system by the primary health care team within the health care district, due to the flow of funding. My service is secondary care i.e. referral based - surgical / specilaised care works this way here.
It is possible, if ESWT is what I hope it is, that I may purchase the equipment myself and commence private practice, in the event the NHS won't fund the treatment for our patients.
Re: surgical release of plantar fascia -- NEVER?Dr. Z on 9/17/04 at 20:03 (160098)
Here is a list of physician who may be using ESWT in England
Great Britain . If I am correct Dr. Coombs help to write one of the first book on ESWT.
Dr. Richard Coombs
Charing Cross Hospital / Fulham Palace RD, GB London W6 8RF
tel: 0044 2088 461657; fax: 0044 2088 461439; E-mail:
The Owls, 12 Kirkstall Drive, Formby, L37 4HL Merseyside
tel.: +44(0)1704878844; fax.: +44(0)1704878844; e-mail: (email removed)
West Hill, SW 15 3SW London
tel:; fax:; E-mail: email@example.com; firstname.lastname@example.org
Dr. David Kevin Jones
42 Pant Lodge, Llanfairwll, Anglesey, North Wales, United Kingdom, 1161 5YW
tel: 0044 1248 715808, fax: 0044 1248 716135, E-mail: email@example.com.
Dr. David Silver
Royal Devon and Exeter Hospital, Barrack Rd, EX2 5DW Exeter
tel.: 01392 403733; fax.: 03192 402330; e-mail: firstname.lastname@example.org
Re: Not a lot of pain after ESWTGdog on 9/19/04 at 09:29 (160164)
I just got ESWT performed on my foot yesterday. I was put under anesthesia which put me to sleep for the procedure, and there was also anesthesia on my foot. A day after the procedure, I am surprised at the LACK of PAIN. I am surprised that this procedure could generate a result without any post procedure pain. Is it normal that there be little pain after ESWT??
Re: Not a lot of pain after ESWTDr. Z on 9/19/04 at 14:17 (160174)
There are many patients that report this lack of pain from ESWT. This is due to the interaction of the sound waves blocking your pain receptor sites. Most patients will continue with this resolution of pain. Some will have a return to the original pain and then final pain resolution ove a few weeks to few month period
Re: surgical release of plantar fascia -- NEVER!Steve on 9/20/04 at 07:13 (160189)
What is the normal cost of the ESWT procedure, I have had heel pain for 4 months, two sets of shots, orthonics, stretching etc. The process is slow to recover and I do not want surgery. My insurance does not cover ESWT, but might consider the ESWT procedure.
Re: surgical release of plantar fascia -- NEVER?DR Flab on 9/30/04 at 05:30 (160733)
IF U SEE U ON THIS WEBSITE AGAIN I WILL HAUNT U DOWN AND CHOP OF UR DICK AND STICK IT UP UR BIG FAT ASS.