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Interesting Case #3

Discussion in 'Foot Surgery' started by drsarbes, Dec 17, 2008.

  1. drsarbes

    drsarbes Well-Known Member


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    37 y/o F with Hx of heel pain consistent with heel spur/fasciitis. She had been treated with cortisone/orthotics by previous Podiatrist and was doing quite well.

    Approx. 3 months after receiving the Orthotics she relates having a “miss-step” and “could hardly walk the next day.”

    She returned to her Podiatrist who gave her anti-inflammatories, strapped her foot and instructed her to ice the area. She did somewhat better but after three weeks continued having pain in her heel with any activity.

    When we first saw her she had an acute heel, more painful than normally associated with Fasciitis. An X-ray was taken although she stated she had had one prior to receiving orthotics which showed a spur.

    Dx: Fractured heel spur.

    She was unresponsive to PT so an excision was performed. We saw her two weeks post-operative doing quite well. She has been in regular shoes since one week post op, improving almost daily. 42 y/o F with Hx of heel pain consistent with heel spur/fasciitis. She had been treated with cortisone/orthotics by previous Podiatrist and was doing quite well.
     

    Attached Files:

  2. I did'nt even know they could do that! Although it makes perfect sense when you think about it.

    Thanks again Steve!
     
  3. Dr. DSW

    Dr. DSW Active Member

    Dr. Arbes,

    I've seen this injury several times over my years of practice. I'm curious as to why when you saw the patient for the acute injury/fracture of the heel spur, you decided to send the patient for physical therapy. When I have seen this injury, I simply immobilize the patient in a non-weightbearing cast, and have rarely needed to excise the fracture fragment.

    My rationale is that I do not send patients to physical therapy following any other acute fractures, therefore I would not send a patient to physical therapy for an acute fracture of the infra-calcaneal spur.

    However, I do regularly cast patients for acute fractures, therefore I also cast patients for an acute fracture of the infra-calcaneal spur, which as previously stated usually results in eliminating the need for surgical intervention.

    I welcome your comments.
     
  4. drsarbes

    drsarbes Well-Known Member

    " I'm curious as to why when you saw the patient for the acute injury/fracture of the heel spur, you decided to send the patient for physical therapy. "

    Only because of our surgical schedule, we couldn't get her in for 3 or 4 weeks so while she was waiting she did PT.

    Casting; partial or weight bearing, in my opinion, would not have helped. I have had little success trying to "heal" a fractured spur, whether an osteophyte or enthesopathy. She had a work issue and needed to get better sooner rather than later.
    After one week she was back into a regular shoe with less pain than preoperatively.

    Steve
     
  5. Dr. DSW

    Dr. DSW Active Member

    In my original post I stated that I would immobilize the patient and have the patient remain NON weightbearing, not partial weightbearing.

    I now understand that your patient preferred to be "back in action" as soon as possible, but you have to admit that after a surgical procedure, there is no way to predict that the patient would be back in a shoe and ready to walk in one week. There is always the possibility of post operative discomfort for several weeks.

    I guess our experiences have differed. I have had significant success immobilizing these patients and keeping them NON weightbearing, while at the same time keeping the patient out of the operating room and eliminating the potential complications that can result from ANY surgery.
     
  6. drsarbes

    drsarbes Well-Known Member

    Hi DSW:
    Well.....this case is not suppose to be about me, but since you asked I guess the only way I can answer your question is to tell you a little about my practice.

    I perform, on average, 100 heel spur resections a year, more than 2 per week (I do vacation) - some years I perform more (I'm not as young as I use to be)
    The procedure I now perform on heel spur/fasciitis I've been doing since 1994. Prior to that I performed a MIS/closed procedure. Prior to that I did an open procedure.

    Out of a 100 heel spurs a year, I would estimate that at least 95 are back into their own shoe in 1 week. Rare is the patient who is not. I have them decrease their activity for an additional 2 weeks. After 3 weeks the vast majority are ready to ease into their regular routine.

    As far a work: If a patient sits at work they can return in one week. If they are on a 12 hour shift, factory, steel toed shoe and lifting, they are off 4 weeks. Most patients fit in between these two extremes.

    Due to my experience and the routine nature of these procedures, I did not hesitate to suggest the procedure to her. That is not to say that perhaps a non weight bearing course may not have helped her, but, again, I did not have that luxury of waiting to see if it might.

    Hope that clarifies things.

    Steve
     
  7. Adrian Misseri

    Adrian Misseri Active Member

    G'Day all,

    Interesting to hear about surgical repair of a fractured calcaneal spur. Makes you wonder about how many of those really persistant plantar fasciitis/heel spur cases, the ones who do not respond to orthotic therapy, immobilisation (i.e. camm walker), cortisone etc. are actually fractured, be it occult, stress or hairline?
    :confused:
     
  8. Dr. DSW

    Dr. DSW Active Member

    Dr. Arbes,

    Please don't take this wrong, as I'm not attempting to get into a debate or question your practice philosophy. I am sincerely asking this question out of curiosity and not to be disrespectful.

    I practice in a pretty "progressive" area, Philadelphia, a city which is filled with DPM's, 3 and 4 year podiatric residency programs, a podiatric medical school, and more than our share of foot & ankle orthopedic surgeons. Therefore, I believe I'm pretty up-to-date on what most of my colleagues are doing to treat plantar fasciitis/heel pain syndrome.

    I'm staggered to learn that you are performing 2 heel spur resections weekly/100 annually. I will "assume" your practice is larger than mine, but I do see at least 20 heel pain patients weekly, and I know of practices in my area that have 7 doctors in the office, and I know from the residents what is booked in the O.R. And I can tell you that heel spur resections are rarely performed in this neck of the woods, and partial fascia releases are even performed pretty sporadically.

    Given the statistics nationally by the APMA, ACFAS, ABPS and even the orthopedic foot & ankle society of the tremendous success rate of conservative care, and the general consensus that the actual "spur" is rarely the cause of the pain, I find it interesting that you are performing this many "spur" resections.

    I understand that one argument may be that your experience has shown that instead of the long, drawn out process of conservative care, you can have these patients functioning much more quickly with surgical intervention, but do you attempt conservative care with these patients prior to surgical intervention or is your philosophy to take them to the O.R. to eliminate the problem ASAP?
     
  9. Dr. DSW

    Dr. DSW Active Member

    Adrian,

    You raised an interesting point regarding occult/stress fractures and conservative vs. surgical care. I co-authored a paper several years ago with 2 orthopedic surgeons and several musculoskeletal radiologists from Jefferson University Hospital (part of the medical school) in Philadelphia, regarding MRI and plantar fasciitis and outcomes of various treatments.

    Basically, there was no significant difference in outcomes in patients regarding treatment results in most patients when there were findings of edema, marrow abnormalities, partial tears or even stress/occult fractures. Many of these patients responded to the same conservative care and many of these patients responded to cast immobilization, even if there were negative or positive findings. It was the symptoms that mattered most.

    As stated in a prior post, I have treated several cases of a fractured infra-calcaneal spur, and the majority of the cases I treated with cast immobilization NON weightbearing healed uneventfully.
     
  10. drsarbes

    drsarbes Well-Known Member

    "I'm staggered to learn that you are performing 2 heel spur resections weekly/100 annually"

    Please don't fall, I use to do more. We do keep busy!

    The majority of Heel pain patients I see have been referred and generally have already had attempts at conservative treatment so most are referred for surgical removal. I sometimes think that there can't possibly be any more heel spurs here that I haven't removed...but they keep coming.
    Criteria for surgery: at least 6 months of daily pain and two categories of failed conservative treatment (biomechanical, medical, PT)

    As far as fractures. They are not common. I've used fluoroscopy on each and every spur since '94 and can only recall 3, and these were diagnosed preoperatively.

    One more note: I think we all need to concern ourselves with recurrence of symptoms following conservative treatment. If a patient responds to, say, cast immobilization but their symptoms return in 10 months, is this still a successful treatment?
    If they have done well following cortisone injections but a year down the road have a return of symptoms when they increase activity levels is this considered a NEW pathology?
    IF a patient has done well with orthotics for 3 years but have a recurrence and now their pain is not responding to another dose of conservative treatment, was this original treatment successful?
    How long does a patient need to be pain free in order to be labeled "cured?" Are most studies less than five year follow up? three? one?

    One nice thing about resection/fasciotomy, they normally do not recur. It's incredibly common for patients to come in that I've done a heel spur on years ago and now their other foot has a spur/fasciitis. They commonly state that they don't want to "go though all that" again, meaning cortisone, orthotics, PT, etc...... they just want it out.

    Steve
     
  11. drsarbes

    drsarbes Well-Known Member

    Correction:
    I just counted the HS from '08- we did 82, that includes heel spurs removed when I performed tarsal tunnel releases as well.

    Also: Dr DSW: Philly? I did my undergrad at Rider University in Trenton. Not far from you. I almost went to Jefferson Medical school. I was accepted there but opted for ICPM in Chicago to the chagrin of my parents who wanted me to be a REAL doctor!

    Steve
     
    Last edited: Dec 22, 2008
  12. Dr. DSW

    Dr. DSW Active Member

    Dr. Arbes,

    Yes, I know Rider well. I live in South Jersey and I'm very involved with soccer. I've spent a lot of time at Rider because there's a big soccer tournament ever year at Rider for "club" soccer teams called the Rider Cup that my son competed in for several years prior to going to college.

    Although I'm ABPS certified, and actually served as an examiner for the oral portion of the ABPS exam for 10 years, it's obvious that our philosophies regarding the treatment of plantar fasciitis differ drastically. I think it's also pretty safe to say that the majority of doctors in the country are actually leaning away from resecting the spur and are really avoiding releasing the plantar fascia except in extreme cases.

    You do bring up some excellent points regarding the possible recurrence of plantar fasciitis with conservative care, but with proper biomechanical control, soft tissue stretching/night splints, Dyna-Splints, and proper foot wear, I sincerely believe that this can be significantly reduced.

    However, as I'm sure Dr. Kirby will agree upon, the plantar fascia plays an extremely important function in stability and the biomechanics of the foot. I don't believe that it is prudent to perform fasciotomies when conservative measures have proven to be effective approximately 90% of the time according to most literature. Surgical release of the fascia has significant potential complications/sequelae.

    Additionally, I believe it's also pretty well established that the majority of the literature published in the past 10 years or so will support the idea that the actual "spur" or more accurately "shelf" of bone has little if anything to to with the pain that the patient experiences.

    So even if you believe that a plantar fascia release IS indicated for a "quicker" recovery and to reportedly prevent recurrence, why do you feel it is necessary to actually resect the plantar shelf of bone? Do you really believe that this plantar shelf of bone is contributing to the pain?

    Thanks for your thoughts. Once again, I'm not attempting to be adversarial, it's simply that the trend and new teachings are to preserve the integrity of the plantar fascia and to not resect the "spur", and I'm curious as to your rationale, especially regarding the bone resection.
     
  13. Adrian Misseri

    Adrian Misseri Active Member

    Dr. DWS,

    Any chance of the reference for that paper? Or could I get a copy emailed?

    Thanks!
     
  14. Dr. DSW

    Dr. DSW Active Member

    Adrian,

    It's Dr. DSW (not DWS!), but you can call me David. Attached is the link to a website that I believe will have the abstract. If you can not access the paper, or would like the entire paper, please let me know and I'll be happy to forward the paper to you.

    The paper isn't rocket science and simply discussed some unique findings at the time (I believe 1999) and correlated outcomes. The majority if not all the patients utilized in the study were from my office. Unfortunately, due to "editorial" freedom, the editor chopped up some of the conservative care rendered and/or the conservative treatment options mentioned in the paper.

    For a little background.....Jefferson University Hospital in Philadelphia is a major teaching hospital in Philadelphia and has an associated medical school. The radiology residency program at Jefferson was ranked the #1 radiology residency in the USA last year. Jefferson is well known for the strength of it's radiology department. Over the years I've developed an excellent relationship with the radiologists at Jefferson, because I send all my MRI's to Jeff.

    Mark Schweitzer, MD was one of the musculoskeletal radiologists at Jefferson who has since moved on, but if you perform a google search you will see that he has published hundreds of papers on foot/ankle MRI. The other authors were radiologists, Fellows in radiology and two foot/ankle orthopedic surgeons in Philly. AJR/American Journal of Roentgenology is the officical journal of the American College of Radiologists.

    Here's a link to the abstract. Please let me know if you need assistance with the entire paper.

    David

    http://www.ncbi.nlm.nih.gov/pubmed/10470906
     
  15. Adrian Misseri

    Adrian Misseri Active Member

    Thanks David,

    My humblest apologies for the misspelling! Quite often get my letters mixed up....

    Thaks again!
     
  16. drsarbes

    drsarbes Well-Known Member

    Hi Dave:
    Yes, this is not a virginal discussion by any means.

    Fasciotomy and post biomechanical problems....of course. In my humble opinion it depends on the foot type and how much you release.

    Not resecting spurs....again....why not remove it? It takes minutes and does not add to the healing time that I have been able to see. My failure rate when I was just performing fasciotomies was almost 20%. Showing these patients the results of a study suggesting not removing the spur does not make them feel better. The actual spur is normally quite medially located, and with fluoroscopic aid you can rasp the medial plantar tubercle to the point where it looks anatomic.

    Conservative treatments...... we all use them. Again, my patient population with a CC heel pain is most likely very different than yours. I would say our criteria for surgery is not that different, if at all, I just see many more that fit the criteria.

    Why do we argue against success?

    Happy Holiday

    Steve
     
  17. Dr. DSW

    Dr. DSW Active Member

    Steve,

    It's funny, because in your post regarding heel "spurs", because they are relatively simple to remove/rasp, you state "why not remove it" and my philosophy is since I don't believe it's causing any pain is "WHY remove it"!!!

    I guess I just feel that any surgery, even if it's quick, simple or a no-brainer shouldn't be performed if I don't feel it's absolutely necessary. I also personally believe that if I can leave the bone alone by not resecting the spur, rasping the spur, etc., than there is less of a chance of an inflammatory bone reaction, periosteal reaction, osteomyelitis, stress fracture, etc. Even though the chances are remote, I still personally am not convinced that the "spur"/bone needs to be disturbed, unless there is some unusual circumstance.

    However, that's why there is chocolate and vanilla, and we will obviously agree to disagree!

    So, as long as you believe you are providing the best care for your patients, and I'm doing the same, everyone wins.

    Have a great holiday, and a healthy, happy New Year.

    David
     
    Last edited: Dec 23, 2008
  18. drsarbes

    drsarbes Well-Known Member

    Hi Dave:

    "my philosophy is since I don't believe it's causing any pain is "WHY remove it"!!!"
    ........well obviously I do believe it contributes, otherwise I would leave it. As I said, experience tells me outcomes are much better taking the spur.

    In any event, these heel spur dialogs, probably because they are SO common, come up often. This isn't the first time we've had varying opinions regarding heel spurs; probably won't be the last.

    Yes, obviously, if either of us thought there was a better way then we would do it.
    I'm sure you, as I, and most everyone here, like nothing better than helping our patients.

    On a side note, I'd like to add that one thing I have found over and over again on Podiatry Arena, is that no matter what the dialog, most of the time all participants are quite professional and polite.
    I do enjoy and appreciate that.

    Thanks again Dave.

    Steve

    ps
    I like chocolate
     
  19. David:

    I am also surprised by the number of heel spur excision surgeries that Steve Arbes says he performs per year. I don't know of anyone here in Northern California that is doing even close to that many but maybe practices and practice habits are different in other parts of the country?

    However, Steve's point about making certain that patients have had a good six month period of conservative care before the surgery is a good one and is what I consider the standard of care. I don't remove plantar heel spurs anymore, unless they are exceptionally large, since the heel pain seems to get better quicker in my hands with a simple partial plantar fasciotomy procedure. In fact, the plantar fascia doesn't even attach to the plantar calcaneal spur so I would doubt that the plantar spur would actually be the cause of pain in most of the patients with plantar heel pain.

    However, Steve obviously has lots more surgical experience than I do so I will be happy to listen and learn from his considerable surgical experience in this regard.


    Steve:

    I am curious as to your thoughts as to why so many patients with radiographically evident plantar calcaneal spurs have no heel pain if the calcaneal spur is the cause of the pain. In addition, there are many patients without any evidence of plantar calcaneal spurs that do have quite significant heel pain. Is this something you have also noticed? What are your ideas regarding these contrary observations?
     
  20. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    Steve:

    "I am curious as to your thoughts as to why so many patients with radiographically evident plantar calcaneal spurs have no heel pain if the calcaneal spur is the cause of the pain. In addition, there are many patients without any evidence of plantar calcaneal spurs that do have quite significant heel pain. Is this something you have also noticed? What are your ideas regarding these contrary observations?"

    Very good question, perhaps the same reason a patient with severe HAV may not have any complaints of pain while some do, or why retrocalcaneal exostoses are sometimes symptomatic and sometimes not, or flat feet, or arthritis or a thousand of other clinical entities.

    I've always considered chronic fasciitis more a fasciosis or fibrosis which, due to the antiinflammatory nature of most conservative treatments, does not respond. If in fact inflammation is not causing a majority of the symptoms than it stands to reason antiinflammatories are not going to help. Perhaps other are in fact inflammed but we are sometimes unsuccessful in keeping the inflammation from recurring.

    I also find it infrequent to find a patient with symptoms consistent with chronic fasciitis (over six months) who does not demonstrate a spur. Some of these so called chronic fasciitis patients with no spur in fact have tarsal tunnel or medial plantar nerve pathology.

    I don't mind taking a little jab for removing the spur. Experience only has taught me that my failure rate was significantly higher when I was merely releasing the fascia. Nothing is more important when performing surgery than good surgical outcomes. In addition, a few of the 82 heel spurs I have removed so far this year (not including the one I did this afternoon) were post fasciotomies from other clinics.

    I'm surprised you think a couple of heels spurs a week is a lot! I've never really thought I was performing that many considering how many we all see. I know orthopods that do over 400 total knees per year.
    I know Podiatric surgeons that perform over 250 bunions a year. I think THAT'S a lot. Considering how incredibly common heel spurs are, I think it's a rather low number.

    I guess I shouldn't tell you how many ankle scopes I do.

    Merry Christmas

    Steve
     
  21. Dr. DSW

    Dr. DSW Active Member

    Once you wrote the line "I'd better not tell you how many ankle scopes I do" I realized that other than our intentions to help people....our practice philosophy sounds worlds apart.

    I do all I can do avoid placing a scope in a patient's ankle, but then again, I honestly can not remember the last time I resected a heel spur.

    Have a great holiday.

    David
     
  22. drsarbes

    drsarbes Well-Known Member

    Hey Dave:
    ooooooooooooooo. Well, we need general Podiatry too.

    Didn't mean to upset you. Not sure why you feel surgery is a bad thing. I assume you don't have many friends that are surgeons!

    If you have ever repaired a talar dome OCD open and then with a scope you might appreciate arthroscopic surgery. These are some of the most rewarding and appreciative patients I have.

    Not sure how this got to be about practice types. You must have practices in the great East Coast that are limited to surgery.

    In any event, this seems to me to be getting carried away a bit. Egos always seem to rise to the top here then drag the postings into the gutter. This thread was intended to show a case with a fractured heel spur which I do not see often and wanted to share with the Podiatry Arena. Period.

    Dave, it's OK, nothing is as bad as the economy!

    Have a great holiday, headed to Chicago.

    Steve
     
  23. Dr. DSW

    Dr. DSW Active Member

    Steve,

    I don't need "friends" that are surgeons, I'm pretty well versed in surgery myself. And I never stated that surgery is a "bad thing". As stated in an earlier post, I did serve as an examiner for the oral portion of the ABPS certification exam for 10 years and served as a residency director for a surgical residency. I was involved with the training of surgical residents for a significant portion of my career.

    My practice is pretty well rounded, and the only surgical procedures I don't perform are surgical procedures I have chosen NOT to perform voluntarily. I enjoy a full scope of practice, from the routine to complicated. It's my "routine" patients that are often the referral source of my surgical patients. My surgical "ego" is far behind me after 23 years of practice. I've done my triples, I've done my subtalar arthrodesis procedures, I've applied my external frames, I've scoped my ankles, I'm up to date on all the new procedures, hardware, subtalar arthroereisis implants, etc., and I've debrided my share of nails and trimmed piles of calluses.

    Philadelphia is over-run with managed care, and presently has the highest malpractice premiums in the nation. Many insurance plans are "capitated", and performing surgery is part of the capitation, therefore a lot of DPM's in Philadelphia aren't so quick to bring a patient to the O.R. since it actually costs the doctor money to perform surgery. However, I will perform surgery on any patient regardless of insurance when I believe surgical intervention is indicated.

    I treat patients, not insurance carriers. However, I honestly believe that a significant number of ailments that I treat can be successfully managed conservatively without taking the patient to the O.R., even though I possess the training and surgical capability to manage the patient surgically IF and WHEN that patient ends up in the O.R.

    Although there are too many DPM's in Philadelphia, I can honestly only think of 2-3 practices that are predominately surgical (>60%). Those are academic/university based practices associated with 3 & 4 year residency programs.

    Yes, the use of anke arthroscopy can be very rewarding when indicated, but unfortunately I have treated too many patients in my office that have had significant damage to their ankles from "exploration" of their ankles from an inexperienced arthroscopic surgeon that took a weekend course and was scoping ankles to recoup the cost of the course. As a result, ankles with minimal to no pathology pre-op were coming out with significant pathology post-op. Therefore, I guess I'm a little sensitive since I've personally seen arthroscopy of the ankle significantly abused (I'm not inferring you abuse this procedure). Those are ankles that I've subsequently had to re-scope or open up to clean up some iatrogenic mess.

    Conversely, please don't assume that just because I offer my patients conservative care and have a high success rate with conservative care, that I don't have a full scope of surgical procedures in my armamentarium of treatment.

    So, what have we learned here:

    1) I do NOT think surgery is a "bad thing".

    2) I have many friends that are surgeons, and many that have palliative practices, and most that have mixed practices.

    3) I am fully capable of performing the plethora of surgical procedures on my patients if and when I feel the procedure is indicated.

    4) I have no ego problem, and that's exactly why I am happy to debride the mycotic toenail of one patient and install an external frame on that patient's daughter. I refer no patient out of my office for the simplest treatment or the most complex treatment, since I'm comfortable with the entire spectrum, just to set the record straight regarding your "assumptions" about my surgical philosophies and/or skills.

    David
     
    Last edited: Dec 25, 2008
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