Key Points Not Addressed In Article On Plantar Fasciosis

      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.       I have performed well over 700 procedures and have not caused any peripheral nerve damage with disastrous consequences as Dr. Barrett implies. I would be more than glad to document cases of patients who have undergone failed EPF procedures, failed ESWT treatments and failed nerve decompression procedures, whom I have treated successfully with cryosurgery.       Lawrence Fallat, DPM, has previously published an article on cryosurgery for heel pain in Podiatry Today (see “Chronic Plantar Fasciitis: Is Cryosurgery The Answer?,” May 2005) so there has already been groundwork that cryosurgery can be an effective treatment for plantar fasciitis. Could approximately 90 Cryostar certified podiatrists with over 3,000 procedures performed collectively be wrong?       I would be happy to have Dr. Barrett come to my office and see the procedure being performed, and the results I am obtaining.       — Steven H. Goldstein, DPM       Certified Cryostar Surgeon

Another Defense Of Cryosurgery

      On behalf of Cryotech LLC, I write in regard to Dr. Barrett’s article, “Should You Change Your Approach To Plantar Fasciosis?,” which appeared in the November issue of Podiatry Today.       Having given due consideration to the article and specific comments that relate to “emerging treatments,” it is Dr. Barrett’s citation of cryotherapy that causes us the greatest concern as the article cites cryotherapy as being “incredibly ridiculous, medically unsound and simply dangerous.”       As a company responsible for selling these FDA-approved devices in the United States for the last two years, we would question the sources of data used by Dr. Barrett to qualify such a statement. Clearly, it is not from the 90 doctors operating in 27 states around the country who regularly report clinical efficacy of 85 percent or higher from a single cryotherapy treatment.       Dr. Barrett’s article specifically references “neuromas in continuity” attributed to cryotherapy from a 1985 paper published in the American Journal of Veterinary Research. Accordingly, I feel compelled to point out that there is a mass of evidence supporting the theory that cryotherapy (cryoneuroblation) is not associated with neuroma formation and while surgical resection, alcohol injections and the use of phenol can be, cryoneuroblation is often seen as a specific treatment that can be used to counter such effects as neuroma formation.       Finally, it would appear that Dr. Barrett’s article has been written with a commercial bias. His article makes specific reference to the success of the EPF procedure but fails to point out that Dr. Barrett was responsible for the development of this technique and has two patents filed for EPF and endoscopic decompression of intermetatarsal neuroma. As these endoscopic techniques can be used to treat peripheral nerve entrapments using minimally invasive surgical procedures, it is not difficult to see how such procedures can be seen to be competing with newly established treatments such as cryotherapy.       Given Dr. Barrett’s position as a member of Podiatry Today’s Editorial Advisory Board, we would have expected such an article to be less biased and more balanced in opinion.       — Martin Woodhouse       Sales Director       CryoTech LLC

Another Perspective On In-House Billing

      I read the article by Steven Peltz, CHBC, entitled “In-House Billing: Assessing the Pros and Cons” with great interest (see page 40, October issue). As a practicing podiatrist of 33 years and a partner in a billing business, your points are more critical than most podiatrists realize.       First, this disclaimer: my company only bills for podiatrists in the state of Florida. I know how easy it is to loose control of your money. It is important to have continuous access to your account information. I disagree that the client should be allowed to enter data. The client’s responsibility is to supply the billing company with accurate data so claims can be processed to completion without errors. The most critical issue is who handles your money. The answer should be only the client. No lock boxes or bulk check transfers. The monies should go directly to the client. If the billing business is everything it purports to be, the client’s A/R days, the average amount of money generated each day divided into the total A/R, should be less than 30 and the cash flow continuous.       — Philip Adler, DPM       Podiatry Billing Services, Inc.       Mr. Peltz Responds       I appreciate your comments. Most physicians do not have the scope or depth of knowledge that you do. The article does not say this is the only way to do billing. It is only one way to address the concept of billing as it applies to new or established practitioners.       — Steven Peltz, CHBC       President       Peltz Practice Management and Consulting Services       Editor’s note: To read the original Podiatry Today articles referenced in these letters, please visit the archives at www.podiatrytoday.com.       For a continuing debate on the article by Stephen Barrett, DPM, as well as Dr. Barrett’s response to the letters, check out the “Letters” section of the forthcoming February 2007 issue.