Cath Lab Digest

      Anyone questioning whether Dr. Barrett is trying to sell Instratek instrumentation for endoscopic plantar fasciotomy (EPF) procedures need look no further than his recent article, “Should You Change Your Approach To Plantar Fasciosis?” (see page 48, November issue), which is basically a long-winded advertisement for the EPF procedure.

      There are several points not mentioned in this less than scholarly work that should be brought to the forefront.

      The first point is that conservative care works and works very often. Throughout the article, Dr. Barrett addresses the supposed futility of conservative care and the insinuation that it always leads to surgery. Quite the opposite is true. The second point is the usefulness of diagnostic ultrasound at the first visit to properly diagnose the patient. His argument on this is so specious that it is not really worth addressing but in his attempted refutation of it being used just for reimbursement is the underlying message that the reimbursement is good.

      The last point is Dr. Barrett’s dismissal of anything more than a passing occurrence of complications with the endoscopic plantar fasciotomy (EPF) procedure. That has not been my experience with people I treat from other offices after they have undergone the EPF procedure. The most common problem is cuboid syndrome, which I see as a fairly common complication (about 30 percent) among patients who have undergone an EPF procedure. I have never seen this complication after an open fasciotomy.

      Although Dr. Lemont’s work on the establishment of pathologic tissue submitted to his lab after open fasciotomy performed on people with presumed longstanding plantar fasciitis not showing inflammatory cells is important, I am not sure if it is germane to the argument. Certainly, “fasciosis” is a valid term for the chronic patient but how does this apply in the acute setting? Were these fascial specimens submitted from patients with one week of heel pain followed by open fasciotomy? If not, how is this representative of the acute pain patient and the presence of inflammatory cells?

      I see many people with several days of acute heel pain just as I see many patients with months of pain before presentation. How does this jibe with the “fasciosis” theory? Could there actually be degeneration of fascial tissue within days of onset? Eighty percent of my patients completely
resolve their pain with nonsteroidal, antiinflammatory (NSAID) therapy. Is it incidental to my treatment and not efficacious?
      How does that jibe with the “fasciosis” theory? Certainly, Dr. Barrett’s theory precludes the possible efficacy of NSAID therapy but how is it that NSAIDs work and work consistently for plantar fasciitis? Placebo action?

      From what I can tell, Dr. Barrett would like to change the medicolegal realm to accommodate his beliefs: initial visit ultrasound examination as the norm with immediate EPF and – when that fails – there would be no argument from the attorney that “not enough conservative care was explored” as it is ineffectual anyway.

      Dr. Barrett’s theory is completely unrepresentative of the vast clinical experience of your average practitioner.

      — David Secord, DPM, FACFAS

Defending The Use Of Cryosurgery For Heel Pain

      As a practicing podiatric physician who has been performing cryosurgery for almost three years, I am shocked and surprised about the unsubstantiated statements about cryosurgery made in Dr. Barrett’s article.

      He states: “It is well documented that freezing peripheral nerves can result in neuromas in continuity.” This well documented reference is one article that was written in 1985, over 21 years ago. The procedures that Dr. Barrett references were performed on horses’ hoof nerves. The specimens were open in order to visualize the nerve, which in itself can cause neuroma formation.