Sharing Insights On The PSSD

In regard to the article “Restoring Sensation In Diabetic Patients” (see pg. 38, September issue) and the editorial (see “PSSD: Assessing Its Value And Potential,” pg. 12, September issue), we have been using the Pressure Specified Sensory Device (PSSD) at the University of Texas since March of 2001. We have been pleasantly surprised with the results of the testing. It has been beneficial in both diabetic and non-diabetic patients with nerve symptoms. The strength of the device is it allows you to look critically at the severity of nerve damage and allows earlier, more sensitive detection of neuropathy as well as nerve entrapments of other etiologies. It helps you tie your clinical exam with the PSSD and allows you to become more critical in your evaluation of patients. As far as weaknesses of the device go, it is a time-consuming test and has a large learning curve. However, once these obstacles are overcome, it is a great test. In one particular case, a primary care doctor prescribed codeine to a 30-year-old diabetic female for her neuropathic pain and her parents were frustrated with this. They brought her to our clinic and her clinical exam and PSSD test were positive for neurolysis procedures on her legs. Now she’s holding down a great job, is able to get her shoes on and is no longer taking any type of pain medication. Prior to this, she had been released from several jobs and had put off her wedding until she could get rid of the pain. She was a very rewarding case. – Suhad A. Hadi, DPM Assistant Professor Director of Resident Education Department of Orthopaedics/Podiatry University Of Texas Health Science Center Reconsidering The Heel Spur One great reward of no longer being a student is the freedom to think for oneself and draw one’s own conclusions. Drs. Levin and Barrett (see “Debating The Merits Of The EPF Procedure,” Letters, pg. 10, September issue) disagree about the value of endoscopic plantar fasciotomy (EPF) but they are both in agreement that the heel spur itself is not to be implicated in heel pain. Dr. Levin states, “We were taught as far back as the late ‘70s that the spur is not the cause of heel spur pain, but rather the inflammation surrounding it.” Dr. Barrett seems to only disagree in that he thinks it wasn’t until 1990 that the profession reached this conclusion. As a student, I too learned in the ‘70s that “it is not the spur.” However, after some time in practice, I reconsidered this “fact” and came to the conclusion that there are some patients with heel pain for whom the heel spur itself is the primary cause. For years, I have been removing exostosis from digits and occasionally tarsi with great results. It became obvious to me that a heel spur is nothing more than one more exostotic prominence. Not every exostosis causes symptoms and neither does every heel spur, but clearly a percentage of them do cause symptoms. Implicated in this syndrome, I suspect, is the medial calcaneal nerve but the pressure comes from the spur. As in any surgical case, judgmental selection plays a key role. The proof of this theory is anecdotal. One patient after the next has a heel spur removed and relates complete eradication or a significant reduction of symptoms. The surgical method you use for spur resection is critically important. I believe that, in the past, too many damaging heel spur surgeries lead to many poor results. Luckily, I think I have an easy way to remove the spur and the patient only has to recuperate from minor surgical trauma. Maybe EPF has a place in the treatment of heel pain or maybe it doesn’t. However, it has become clear to me that heel spur removal is sometimes the treatment of choice for recalcitrant heel pain. – Frederic Schwartz, DPM New Bedford, MA

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