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Surgery or not

Posted by Pauline on 9/05/04 at 10:56 (159363)

Whether a patient chooses to have surgery or not is their own decision whether its cover by insurance or not. It's no different than a person who choses to continue doing drugs or smoke. Neither of these is covered by insurance either.

It's a choice for the patient as well as a choice for the doctor doing the surgery. The patient may or may not hear all the risks, yet the doctor knowing all the risks involved and poor outcomes still continue to offer to perform the surgery.

If a doctor honestly believes it shouldn't be done they should and could say 'NO I don't do that surgery anymore because etc, etc, etc. If
you want that done you'll have to see someone else'.

Just like abortions, some doctors refuse to do them because they don't believe in it. At one time you could not get an abortion performed at a Catholic Hospital even though it was covered by insurance. Ths hospital made that choice. Doctors on staff doing abortions would have to use another hospital to do this procedure.

In my mind I see this as double talk. Tell us how bad the surgery is, yet continue to perform them. The answer is simple if doctors really believe what the article says and know that they are doing permanent injury to a patient. The answer they should be telling their patients is 'NO' even if that patient leaves their practice for another doctor willing to cut their feet.

Doctors who do not perform abortions do this all the time. They don't talk about their belief they show it by their actions.

That isn't happening with P.F. surgery. Most doctors continue to perform a surgery that they say to us produces life long injury to patients. The only person who profits by this is the doctor.

Re: Surgery or not

april l on 9/05/04 at 12:00 (159365)

Pauline, both my current and former doctors do not believe that foot surgery for PF is a bad thing that will cause permanent damage and injury to the patient. They do believe in avoiding surgery if at all possible because if symptoms can be alleviated through other means of course that's the best way. Surgery should never be the first option as there can be complications with any surgery, even minor surgery. Are you talking about the doctors here? I have only heard that it is a bad thing on this message board. I can't believe that any doctor would continue to do a particular surgery if he/she believed it would harm the patient. Wouldn't that result in lawsuits? Especially if the surgery is known to be so damaging.

Re: Surgery or not

Dr. Z on 9/05/04 at 12:57 (159367)

The only reason I am against pf releases is because ESWT does achieve the same result, without the complications associated with pf release. The complications that I saw were RSD, complete foot instablity, long healing, chronic pain.
What these complications rate were I am don't feel they were extremely high but when they did occur they were permanent.
If ESWT didn't exist I would offer Miminial incision plantar fasciotomy with partial remove of bone spur.

Re: Surgery or not

Pauline on 9/05/04 at 13:53 (159369)

I am merely comparing what we are hear and the articles that are presented to us as evidence and saying put the blame where it belongs, not with insurance companies but with the doctors who continue to operate instead of saying NO.

Re: Surgery or not

Dr. Z on 9/05/04 at 18:42 (159373)

The only person that comes to my mind that feels that all pf surgery causes harm to patients a particular poster on this board.
PF surgery has complications so does hip replacement surgery , knee replacment surgery. By the way both of the above have death as one possible complications
The wrong that I see with doctors is that they only offer covered procedures such as pf release in chronic cases.
ESWT isn't offered in all cases due to the lack of insuranced coverage.
Who is the source of debate is not my reason for this post but it never is a one source.
I have personally cured hundreds of patients with pf release and I have seen compications that now are avoided with ESWT.

Re: Surgery or not

april l on 9/05/04 at 19:35 (159375)

I'm glad to hear that Dr. Z. I'm just a patient who had the EPF surgery twice and it was successful both times. I was under the impression from reading posts here that surgery is a bad choice and should be avoided always or not done ever. I hate to see other people who have tried everything else continue to suffer because they are too afraid to have the surgery. Just curious...what percentage would you say had permanent complications?

Re: Surgery or not

Dr. Z on 9/05/04 at 21:31 (159379)


That is a very difficult question to answer. I will try to answer specific complicatoin rate.
Infection: rare
RSD- Very rare
biomechanical temporary instablity- high
Stress fracture- rare
Nerve damage - ??
Long term healing pain - high
Biomechanical instability- moderate to high can take six months plus to
I have a question why didn't you try ESWT. ?
Were you told about ESWT ?
If so why didn't you go thru with ESWT?

Re: Surgery or not

april l on 9/05/04 at 22:05 (159381)

Dr.Z, My doctors (had a different one for each foot) didn't ever mention ESWT to me. If they had I'm still not sure I would have tried it, especially if it wasn't covered by my insurance. My first EPF was 7 yrs. ago, and since it worked I was hoping to get the same results on my other foot, which was done a year ago. Yes, I had a long recovery both times, but now my feet are as normal as they ever were. I don't know what the success rates are for ESWT.

Re: Surgery or not

Dr. Z on 9/05/04 at 22:57 (159385)


I am glad that you are honest about your choice. It proves my point that insurnace does control treatments that doctors offer to their patients. My most difficult patient to convert to ESWT were the ones like you who
because the first foot was a great result think that they won't receive the same result. Di it ever occur to you that the surgery from the first foot might have contributed to the second foot surgery.
I will talk to you straight up front . You have a potential of developing complications years down the road since the pf support system has been compromised. I have seen patiens develop problems 15 years down the road from pf release who were as normal as they ever were. You feet are pain free but they aren't normal they have been altered in the their functions to what degree only time will time.

Re: Surgery or not

april l on 9/05/04 at 23:37 (159387)

I know that the pf in my left foot was not caused by having surgery on my right foot. I had PF in both feet at the same time, altho not as bad in my left foot, from years of working on my feet. Time will tell if I have problems down the road because of the surgeries. Prior to the surgeries, I had knee and hip and ankle pain that all corrected itself after I began walking normally for the first time in years. I did not take lightly having the second surgery because the first one took way over a year to become pain free and that's why I waited 6 yrs before going ahead with it again. You probably could've convinced me to have ESWT if I could afford it AND there was a convincing success rate.

Re: PS. Dr.Z

april l on 9/05/04 at 23:44 (159388)

No disrespect to you, but I have learned not to believe everything that doctors tell me. My first podiatrist actually told me that surgery would be 100% guarantee success, that I would be working 7 days after surgery (waitress), and that the plantar fascia is not needed in the foot at all for support! I believed him, like a fool, I did no research at all. When I went for my post op visit telling him my foot still hurt he said that that was impossible! Called me a baby for complaining. I never went back.

Re: Surgery or not

Ed Davis,DPM on 9/05/04 at 23:50 (159390)

There are quite a few lawsuits concerning this type of surgery out there.

Re: Surgery or not

Ed Davis,DPM on 9/05/04 at 23:56 (159391)

You are presenting a viewpoint that reflects a logical choice and an 'ideal' situation. In reality, the vast majority of patients tell doctors to 'do what my insurance covers.' A concientious doc will spend the time explaining why the insurer does not always represent the best interest of the patient. The 'fact of life' is, fortunately or unfortunatley, that most of medicine as practiced in the US today is determined if not directed by insurance companies. If and when we obtain a 'Patients Bill of Rights' things may change.

Re: PS. Dr.Z

Ed Davis,DPM on 9/06/04 at 00:00 (159392)

Another thing to look at is one's occupation. An individual who is, say, a construction worker may lose up to 6 months of work after surgery -- a fairly high cost to pay. An office worker may have minimal time loss after surgery. ESWT involves no time loss other than, perhaps, the day it is performed.

Re: Surgery or not - to Dr Z and April

Julie on 9/06/04 at 06:35 (159402)

April, Dr Z has just told you exactly what I did when I mentioned the need for support for the plantar fascia after surgery. The pf support system has been weakened, and this can result in problems down the line. Doesn't that encourage you to investigate orthoses now, or soon? Why wait to see?
I am not trying to weaken your confidence in your doctor, or in your decision to have surgery, which has been successful. You have been fortunate. I hope you won't develop problems later, but you should be aware of the possibility that they might arise, and perhaps take avoiding action before they do.

Where people new to the board, who don't know the whole picture, are concerned, I feel increasingly that they should be encouraged to learn everything they possibly can before considering surgery (particularly in view of the fact that there is such a clear bias towards it, given the present attitude of many insurance companies).

Also, I wonder if you saw the link to the research abstract that Dr Ed posted earlier, and also on the Social board. I've copied the abstract, which says:

'Plantar fasciotomies have become commonplace in podiatric and orthopedic medicine for the treatment of plantar fasciitis. However, several complications have been associated with plantar fascial release. It has been speculated that the cause of these complications is excessive release of the plantar fascia. The aim of this project was to determine whether the amount of fascia released, from medial to lateral, causes a significant increase in force in the remaining fascia. A dynamic loading system was developed that allowed a cadaveric specimen to replicate the stance phase of gait. The system was capable of applying appropriate muscle forces to the extrinsic tendons on the foot and replicating the in vivo timing of the muscle activity while applying force to the tibia and fibula from heel strike to toe-off. As the plantar fascia was sequentially released from medial to lateral, from intact to 33% released to 66% released, the real-time force and the duration of force in the remaining fascia increased significantly, and the force was shifted later in propulsion. In addition, the subtalar joint was unable to resupinate as the amount of fascia release increased, indicating a direct relationship between the medial band of the plantar fascia and resupination of the subtalar joint during late midstance and propulsion. (J Am Podiatr Med Assoc 93(6): 429-442, 2003)'

(Dr Z, doesn't this suggest the unwisdom of performing surgery on the plantar fascia? Pauline is not the only person who thinks this: I think Dr Ed more or less thinks it, because he headed his post about the abstract 'Surgical release of plantar fascia - NEVER'.)

Re: Surgery or not

Janice N on 9/06/04 at 06:59 (159405)

I remember going to the podiatrist office for xrays.
He told me what he found on them. I told him how long I had pain and what I did for it. Ice, heat, meds, rest, stretching etc. He had given me one steriod injection prior to this. Then he tells me how he can make this one incision and do this and that. I would walk on crutches a couple of wks. That was all the info I was given. My impression was it was a no big deal surgery. But, I had found this site and knew better. I was the one who brought up the subject of ESWT. He said yes he had 15 patients so far who had it done. 13 had had good results. That I would need 1-3 treatments. Now I thought if he had good results why offer surgery right off the bat? Then he says
that with ESWT if will delay surgery a few yrs maybe.
I am just glad for me I didn't take the surgical route and knew it wouldn't just be a snap.

Re: Surgery or not - to Dr Z and April

april l on 9/06/04 at 09:59 (159411)

Thanks Julie, I do appreciate your comments. For work I have Spenco inserts in my shoes and they are very comfortable. I will ask my doctor about this. The thing is I disagree with those who say that since I had 1/2 of my plantar fascia released that I no longer have support or that the remaining fascia is overstressed. My fascia is intact, I can feel it there just as before surgery. The only thing that the surgery did was lengthen it. I believe the support was compromised only until the healing process was finished. Scar tissue forms as the fascia reconnects to the heel bone in a longer position. This is what my doctor explained to me.

Re: Surgery or not

april l on 9/06/04 at 10:06 (159412)

I'm sure there are lawsuits with any type of surgery. What I'm saying is I doubt doctors who had 50-60% failure rate would continue doing the surgery. Those who do the surgery must be having success with it for the most part.

Re: PS. Dr.Z

Dr. Z on 9/06/04 at 10:18 (159413)

Doctors are people and that is just a fact of life.

Re: Surgery or not

Dr. Z on 9/06/04 at 11:16 (159414)


If a doctor can avoid one specific type of complication and this complication was permanent then he should move on to another form of treatment ie ESWT that avoids this type of complication. ESWT avoids cutting of the pf and therefore avoids chronic instablity whether temp and or permanent.
There are many procedures out there that look great in the short term but turn out with complications in the long term.
It is malpractice for any doctor to not offer and or explain ESWT if it is available in his area.
I also don't think that pf releases have such a high rate of failure 50-60%
If there wasn't any plantar fascia instablity with releases I would still be doing these procedures today.

Re: Surgery or not

Dr. Z on 9/06/04 at 11:18 (159415)

I have patient post five years that are pain free after ESWT treatment for chronic PF. The literature, European experience confirm my results

Re: Surgery or not

april l on 9/06/04 at 13:32 (159419)

Dr. Z, it sounds like we agree then. I am not opposed to ESWT at all, I just didn't know about it when I had my surgeries. Like i said before, I trusted my doctor and didn't research. If it works and surgery can be avoided then it should be covered by insurance.

Re: Surgery or not

Rose on 9/06/04 at 18:21 (159426)

My podiatrist told me about ESWT when I first started seeing him. He explained it and said it was not covered by my insurance. He also said that the success rates were about the same as other methods. I knew nothing about it until I got on this board. Possibly surgery seems so negative because there are a number of us who are here for support and help because we are still in pain and looking for answers. Possibly those who have been healed either by other methods or surgery are not longer visiting this message board regualrly. Just a thought.

Re: Surgery or not

Dr. Z on 9/06/04 at 18:41 (159427)

So you choice was foot surgery ??

Re: Surgery or not

Pat on 9/06/04 at 19:24 (159437)

I was told that ESWT requires multiple treatments and, unfortunately, my insurance doesn't cover it. If someone told me to pay $3,000 and I'd need one treatment and this PF would be gone forever I would sell everything I own to do it. But I know someone who did just that and the ESWT didn't help at all. I think the last time I had it done (10 years ago) it was a complete cut of the PF and full removable of the bone spur. It was also a year of more problems than I can even mention here - my foot should be in a textbook. You said if ESWT didn't exist you would offer Minimal Incision with partial removal of the bone spur - what about your patients that need surgery and can't afford ESWT. What procedure do you recommend for them (I think I'm in this category).

Re: April

Pat on 9/06/04 at 19:27 (159439)

I read your post about having PF twice and I'd be interested in hearing your experience - I had it 10 years ago and now have chronic PF in my other foot that is really affecting my quality of life. Of course I'm getting opinions from everyone and don't know if this new procedure (I had the old one with them cutting the bone spur and all that is different). I'd appreciate it if you could post your story here or send it to me at (email removed) - Thanks

Re: PS. Dr.Z

Pat on 9/06/04 at 19:30 (159440)

How much does ESWT cost? I'm getting all kinds of different answers and I'm not really sure what it does? Is it breaking up the heel spur? How many patients need more than one treatment? It's funny but I was up in Canada back in June for two weeks and I should have had it up there since it's suppose to be cheaper but I could be wrong.

Re: Surgery or not - to Dr Z and April

Ed Davis,DPM on 9/06/04 at 19:37 (159442)

Julie and April:
Sometimes the fascia heels back lengthened and sometimes not. It is a long term effect with no predictability though.

Re: Surgery or not

Ed Davis,DPM on 9/06/04 at 19:42 (159444)


The doctors who avoid lawsuits are more likely to be those who are truthful and don't try to sell or rush the surgery. I don't think that there are surgeons out there who can beat the odds coming out with better percentages because the effects of releasing the fascia, biomechanically, are consistent but the manifestations of those effects are variable and the long term results unpredictable.

Reframing the situation; assume your surgery did not work and you were not presented the alternative of ESWT, how would you feel?

Re: Surgery or not

april l on 9/06/04 at 20:06 (159449)

I guess I would be pretty upset if my surgeries were not successful and my doctor had not informed me about ESWT. I had surgery believeing that I had only two choices... surgery or continued crippling pain. I have nothing against ESWT. Don't get me wrong, I agree with most people here that all conservative treatments should be tried first and surgery should be a last resort.

Re: PS. Dr.Z

april l on 9/06/04 at 20:29 (159453)

That's true, but my first doctor knew I was a waitress and told me to go back to work one week later. He said 'use it or lose it'.

Re: April

april l on 9/06/04 at 20:36 (159454)

Sure, don't have time tonight though.

Re: Surgery or not

Dr. Z on 9/06/04 at 20:39 (159455)

We have payment plans for patients that can't afford to pay the full amount at once. I always offer a fair method of payment and ESWT first. Do some patients go elsewhere. Sometimes. I have had patients come back to me with the complications that pf cause praying I can reverse the problems they now have.
Beware of the doctor that only talks about the cost of ESWT and not the benefits of ESWT.

Re: Surgery or not

Debra on 9/06/04 at 21:24 (159459)

I can only afford to have ESWT done once do you think it will help me?

Re: Surgery or not

Dr. Z on 9/06/04 at 21:29 (159460)


Yes. Our group includes a second ESWT treatment if needed. If you would like our ESWT informational packet just e-mail Dr. Z at (email removed)

Re: To Debra - ESWT costs

Julie on 9/07/04 at 01:34 (159471)


I have learned from this board that the cost of ESWT varies wildly, from state to state, machine to machine, doctor to doctor. You've been quoted $3000 for one treatment. Other doctors offer three treatments for a flat fee of under $1000. Look around, do some research, and consider going somewhere out of your area for treatment. The cost of a flight and a night or two's accommodation would be minimal compared to top-of-the-range ESWT treatment. That's what I would do, I think.

Re: To Debra - ESWT costs - ps

Julie on 9/07/04 at 01:36 (159472)

I meant to add: ESWT seems to be much cheaper in Canada. Do a search on Bayshore.

Re: Surgery or not

Pat on 9/07/04 at 18:11 (159519)

Actually whenever the doctor starts talking about ESWT I tell them my insurance won't cover it (they find that hard to believe since I have Blue Cross but it's for Federal Employees and I guess we're in a different class) and then they change the topic. The problem is I've had other things done this year and my out of pocket medical (and I have good insurance) is already at the $4,000 mark so to pay outright for ESWT is something I couldn't afford to do. Then I was told you might need multiple treatments so maybe I'm not getting all the right information. Where are you located?

Re: Surgery or not

Rose on 9/09/04 at 10:04 (159595)

Yes, after tryiing everything else for several years. Including acupuncture, chiropractor and all the recommended methods. I had a very painful neuroma on the other foot that reaquired surgery so I ahd both feet done at once.

Re: Surgery or not

Betsy F on 9/10/04 at 10:51 (159633)

Hi - I am supposed to get surgery next week and am very very concerned after reading this website. The recovery period is my biggest issue

How long was your recovery? I only am having one foot done at a time

Re: Surgery or not

Les on 9/10/04 at 14:16 (159654)

I was 1 week in a cast, 1 week in a removable boot and about 1 week half with and without the boot. I had my surgery June 23rd - I had partial release with the spur removed. I did what I was told by my dr. - lots of rest and ice.

I'm pretty functional now but my foot tells me when I've over done it. I've been lucky and been able to work at home for the summer. I don't know how I would have gone back to work earlier than 4 weeks...I guess it would depend on how much you'd have to be on your feet and your trip back and forth to work.

Re: Surgery or not/ Thanks Dr. Z

BudP on 9/17/04 at 10:59 (160058)

Dr, Z
Thank you for setting the surgery option straight. A new person visiting this site would get the belief that surgery does not work. That would make a great deal of people think some most Podiatrist are performing surgeries that are not successful. When I first came to this board this was the impression I got. I had to bite my lip when I was getting a second opion for EPF. Then after continued visits to this site,I found that a large percntage of people have done very well with EPF surgery. I had my Pod. do the surgery 9 months ago and so far so good. I do agree with you that if the same results can be accomplshed without surgery. Those are the options people should try first.