A Closer Look At Practice Management Aspects Of Treating Heel Pain

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By Lowell Weil Jr., DPM, MBA
However, in the cases of failure, we have often found that the plantar fascia itself has changed and become scarred and thickened. This entity is more appropriately termed plantar fasciosis. What About Extracorporeal Shockwave Therapy? It is very difficult to treat plantar fasciosis conservatively. My preferred initial treatment for plantar faciosis is extracorporeal shockwave therapy (ESWT). Over the last seven-plus years, we have treated hundreds of chronic plantar fasciosis patients successfully with ESWT. Dozens of prospective placebo-controlled, double-blind studies have proven ESWT effective. This modality offers a completely non-invasive alternative with no risks or complications. Over the past year, we have utilized multiple treatment, low-energy ESWT with tremendous success. The EMS Swiss DolorClast was FDA approved in the spring of 2007 and has been our mainstay of treatment ever since. This technology offers patients the benefits of treatment without the use of any anesthetic whatsoever. Research has shown that the use of ESWT without anesthetic is superior to the use of anesthetic as biofeedback is controlling the treatment. We have found that this technique offers us results at least as favorable as higher energy treatments with anesthetic. There are also the added benefits of reduced costs to the patients and the elimination of the need for sedation or local anesthetic. I believe one should consider ESWT as synonymous with LASIK procedures for the eyes. LASIK is a proven technology that physicians perform hundreds of times on a daily basis yet insurance companies do not cover the procedure. Patients are accustomed to and comfortable with paying cash for this simple and low risk procedure with great benefits. Extracorporeal shockwave therapy is no different in this respect. We should feel comfortable telling patients that this is a beneficial procedure but that it is an out of pocket expense. With the DolorClast, the costs can be much more affordable. Typically, three treatments are necessary for optimal results and one would usually perform these treatments on a weekly basis. Charges for this procedure are commonly quoted at $300 to $500 per treatment or $900 to $1,500 for the series. If the patient receives only 80 percent success, it is easy to throw in a fourth treatment, gratis, with no extra cost to the podiatric physician. The Swiss DolorClast is the only ESWT device that is available under $100,000 and we have two devices that we use daily. This easily allows us to recoup or investment while providing our patients with the most up-to-date treatment available. Percutaneous Microfasciotomy: A Viable Option For Plantar Fasciosis? When ESWT fails or circumstances do not allow for ESWT as an option, we have utilized percutaneous Topaz microfasciotomy (Arthrocare) for cases of plantar fasciosis. Over the last two years, we have utilized the Topaz radiofrequency technique and created a percutaneous approach to it. We introduce the Topaz wand into the plantar fascia through tiny “pin prick holes” on the plantar aspect of the affected heel. One can perform multiple Topaz microfasciotomies in the plantar fascia. This stimulates angiogenesis and normalization of the tissue. Patients wear a short CAM walker (usually DJO with air code) for four days and may subsequently resume wearing their normal footwear. Total healing can take 12 weeks but virtually everyone is continuing activities of daily living within one to two days. In an evidenced-based research study that we are conducting, we have found that patients heal much faster with this technique than any other open or endoscopic release of the plantar fascia without the complications associated with releasing the fascia. In Conclusion As insurance companies continue to reduce payments, it is necessary for podiatric physicians to continue to properly care for their patients but get reimbursed appropriately for their services. Heel pain is the most common condition podiatric physicians see in practice and having a regimented treatment protocol that has proven successful with the reimbursement knowledge in place can help create and maintain a thriving practice. Dr. Weil is the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.

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