Conservative Retrospective: Part 3, Hindfoot Welcome back to our no-surgery-allowed discussion.  I can imagine the chiropodist on my right shoulder, shaking his fist at the surgeon on the other shoulder, who’s shaking his fist yelling, "Medial slide osteotomy for that PTTD!" Meanwhile the chiropodist shouts, "Ankle foot orthotic, you knife hog!" The argument rages. In reality, we podiatrists battle with this very issue daily. Maybe I’m a "surgopodist"? How about a "chiropogeon"? The reality is we’re all surgeons and nonsurgeons. I’ve heard good advice that says, "You have to know biomechanics to be a good surgeon." This statement speaks to the need to be well rounded in our training, continuing education, and patient care. Either way, we need to be the best DOCTORS (not surgeons or biomechanists) we can be.

Jarrod Shapiro, DPM PRESENT New Docs Editor Joined Mountain View Medical & Surgical Associates of Madras, Oregon July 2008

Ankle injuries — For the acute sprains, I’ll temporarily immobilize the ankle (pick a method) after x-rays, PRICE (protection, rest, ice, compression, elevation), then start a physical therapy regimen once they’re ambulatory.  If it’s a mild sprain, I’ll prescribe home exercises.  If more severe, they’ll be prescribed formal physical therapy.  I emphasize proprioception, strength, and flexibility.  They may get an orthotic if there’s an apparent biomechanical abnormality (ex. rearfoot varus).  I always order x-rays for ankle sprains, and I don’t follow the Ottowa ankle rules.  I’ve seen people with ankle fractures walk, and patients don’t always hear or feel a popping sound.  For chronic lateral ankle pain, I’ll order an MRI to check for talar dome lesions, tendonosis, etc.

Hindfoot arthritis — I’m not sure quite why, but since moving to Oregon, I’ve seen more monoarticular osteoarthritis than in Michigan.  For instance, I treated a lady with an isolated posterior subtalar joint arthritis with only mild involvement of other joints.  I’m currently treating a man with isolated talonavicular arthritis.  The surgeon on my shoulder is rubbing his hands in anticipation of the TN arthrodesis for this fella if the injection, padding, and orthotics don’t help.  The surgeon very much enjoyed the subtalar fusion he did on the lady after injections and a Ritchie brace didn’t get rid of her pain.

PTTD — I’ll see the occasional early stage acute posterior tibial tendon dysfunction, which I’ll treat with a walking boot, anti-inflammatory, PRICE, etc.  More often, though I see mid to late stage 2 PTTD without tendon rupture.  I’ll prescribe a Ritchie brace and physical therapy before considering surgery.  Long before surgery, I’ve ordered an MRI.

Plantar fasciitis/fasciosis — Heel pain is probably the most common complaint I see.  Most often it’s plantar fasciitis.  I try to keep a regular algorithm to start.  First visit, prescription: weightbearing x-rays, education (weight loss, shoegear changes, etiology, etc.), no barefoot ambulation, massage to the arch and heel, ice bottle, calf stretches, and nonweightbearing exercise (swimming, bicycling, sit-down circuit training).  I have also found a dancer’s pad to be very successful in many cases.  I’ll incorporate this into a low dye strapping and discuss orthotics if successful.  I do not give an injection on the first visit; I want to see what level of relief patients receive with these basics first.  I see them back in about 2 weeks for a re-evaluation.

Let’s assume from here out that nothing has helped.  I’ll then try to tailor my recommendations to the patient.  If they have a lot of pain, I’ll offer an injection (dexamethasone phosphate and marcaine), a night splint, and discuss orthotics again.  I think orthotics are really the mainstay of nonsurgical care.  If these fail, I’ll prescribe formal physical therapy (while continuing all the other methods).  Each time I see the patient, I’ll recheck to be sure I didn’t miss a diagnosis.  For example, a lumbosacral radiculopathy or tarsal tunnel syndrome can be the true cause.  If I suspect this, I’ll order an EMG.

Here are a couple of considerations with plantar fasciitis.  First, always check your patients for equinus, which is hopefully elementary at this point.  Second, always check for a limb length discrepancy.  I can’t tell you how many of my patients had seen other physicians – yes, podiatrists too – who missed a long leg, with great improvement after a lift was placed in the short side shoe.  Third, this is a disorder of obesity and hard surface.  We’re fighting an uphill battle and patients are more successful when they lose weight.  Even so, it takes time to resolve this without surgery.  Fourth, the literature is pointing increasingly to fasciosis (degenerative rather than inflammatory nature) as the true pathology.  It seems the future of treatment will target the degenerative nature of this.

If they’re still painful after all this, I’ll discuss surgery.  Now, I know this is a nonsurgical issue, but I wanted to say a quick word about using coblation therapy for plantar fasciosis.  I had read a small prospective trial from Dr Weil’s group in Foot & Ankle Specialist 1(1), Feb 2008 about using bipolar radiofrequency for this.  Since reading this study, I have done the procedure on two patients.  These patients were very aware of the early nature and lack of major study as of yet, but wanted a less invasive method.  I combined this procedure with an endoscopic gastrocnemius recession with success.  Both patients are doing well about 8 weeks postop.  I like this procedure because it is minimally invasive, apparently effective, has a rapid recovery, and does not alter structure (as compared with a partial plantar fasciotomy).  If this method continues to prove successful, then I will be offering this much earlier than 6 months.  If I had plantar fasciitis, I’d ask for this on the first visit!  I look forward to the bigger studies.

A Letter to the Editor:

***DVT Prophylaxis***

I regularly put my cast patients and/or post op patients on ASA 325mg if no gastric ulcers etc, what are your thoughts on that over lovenox?

—Nicole D. Hancock, D.P.M.
[email protected]

Editor’s Response:

Dr Hancock brings up a good point on the use of ASA for DVT prophylaxis.  I think antithrombotic prophylaxis is still quite controversial.  Most of the studies I’ve read recommend “comprehensive prophylaxis” which is to say adding some type of compression (usually pneumatic) to medicines.  This is usually found to be superior to medication alone.  This makes sense since  this method targets two of the three corners of Virchow’s triad (stasis with compression and hypercoagulability with medication).  These methods only indirectly deal with intimal injury.

I tend towards low molecular weight heparins (LMWH) like Lovenox because I’d rather overtreat.  If one of my patients had a DVT or PE while on aspirin I think I’d have trouble defending this when the standard of care tends towards more advanced treatment.  Here’s a quote from Emedicine.com about aspirin and surgical prophylaxis:

The bottom line?  More research is necessary, and we need to constantly question our methods.  Only then do we improve our patient care.  Kudos to Dr Hancock for keeping us on our toes.

For those of you who have questions or comments, please write in. I like my own opinion, but the real fun and usefulness of this editorial is your thoughts and concerns. Write in and be part of the community!

Best wishes...

Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]

GRAND SPONSOR

MAJOR SPONSORS