November 2016 Journal Club

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SLCpod

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Journal club overview:
- An article will be selected and posted each month. Please PM me an article you are interested in and I will select one. Please keep them as recent as possible.
- We will discuss how we can use what we learned from the selected article in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.


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Interesting.

Acetycholine Gq protein antagonist, preventing vesicle presynaptic membrane fusion and release.

Would get rid of the pain. No transmission.

Didn't know it could be used clinically.
 
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good on them for including a control group that received a placebo since their results were just self reported outcomes. They should have had a 3rd group that received a steroid injection OR excluded patients who had failed the other conservative therapies they mention in the introduction. ie including only patients that would be at the stage of getting surgery/fasciotomy otherwise. I want to know if their new, proposed treatment works any better than what I do now OR if this is an effective last ditch effort before surgery. Especially since a 100u injection will cost your clinic $400-500...

I understand why the BT injection would improve a patient's symptoms, what I don't understand is why rely on a therapy that doesn't address the etiology or what, in my opinion, is the primary cause of a patients pain (though it probably has some anti inflammatory effect on the fascia itself according to some cited studies)?

Is anyone else having problems with their fasciotomy patients? I feel like I only end up doing them on folks who aren't real compliant with their conservative care (stretches/home exercises/inserts/etc) so I don't do a ton, but I don't see problems post-operatively (almost exclusively EPFs). And I'm very certain it's not because they went somewhere else, since our facility is their only option 99 times out of 100.
 
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good on them for including a control group that received a placebo since their results were just self reported outcomes. They should have had a 3rd group that received a steroid injection OR excluded patients who had failed the other conservative therapies they mention in the introduction. ie including only patients that would be at the stage of getting surgery/fasciotomy otherwise. I want to know if their new, proposed treatment works any better than what I do now OR if this is an effective last ditch effort before surgery. Especially since a 100u injection will cost your clinic $400-500...

I understand why the BT injection would improve a patient's symptoms, what I don't understand is why rely on a therapy that doesn't address the etiology or what, in my opinion, is the primary cause of a patients pain (though it probably has some anti inflammatory effect on the fascia itself according to some cited studies)?

Is anyone else having problems with their fasciotomy patients? I feel like I only end up doing them on folks who aren't real compliant with their conservative care (stretches/home exercises/inserts/etc) so I don't do a ton, but I don't see problems post-operatively (almost exclusively EPFs). And I'm very certain it's not because they went somewhere else, since our facility is their only option 99 times out of 100.

Any loss of function with fasciotomies? Decreased ROM? Complications at all?
 
good on them for including a control group that received a placebo since their results were just self reported outcomes. They should have had a 3rd group that received a steroid injection OR excluded patients who had failed the other conservative therapies they mention in the introduction. ie including only patients that would be at the stage of getting surgery/fasciotomy otherwise. I want to know if their new, proposed treatment works any better than what I do now OR if this is an effective last ditch effort before surgery. Especially since a 100u injection will cost your clinic $400-500...

I understand why the BT injection would improve a patient's symptoms, what I don't understand is why rely on a therapy that doesn't address the etiology or what, in my opinion, is the primary cause of a patients pain (though it probably has some anti inflammatory effect on the fascia itself according to some cited studies)?

Is anyone else having problems with their fasciotomy patients? I feel like I only end up doing them on folks who aren't real compliant with their conservative care (stretches/home exercises/inserts/etc) so I don't do a ton, but I don't see problems post-operatively (almost exclusively EPFs). And I'm very certain it's not because they went somewhere else, since our facility is their only option 99 times out of 100.
I agree with the faults that you pointed out in the article. I also find it difficult to understand how the therapy is effective. BT is not going to address the acute on chronic problems that is usually the cause of long lasting pain in our patients. The article suggests that by paralyzing the EDB there may be some pain relief. I just don't believe the EDB would be the cause of plantar heel pain.
 
Any loss of function with fasciotomies? Decreased ROM? Complications at all?
What complications do you think could arise from this procedure? What is the function of the plantar fascia?
I ask this so you might learn a little about the anatomy of the foot and get an idea of how the surgery is preformed. You've got some good questions.

A typical fasciotomy procedure is explained here:
http://www.podiatryinstitute.com/pdfs/update_1994/1994_07.pdf
 
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I've been meaning to add to this. I've been busy.

Interesting study. It's funded by Merz, the maker of the botulinim toxin. I found it interesting that they used MRI on every patient, something I don't think I've ever done for plantar fasciitis. They only had patients try conventional therapy for 6 weeks before they enrolled them in the study. I don't think that they had a specific initial treatment course. I'm a bit surprised that the placebo group didn't really improve much even though all of the patients received physical therapy. I would have expected them to improve more than they did.

I see a fair amount of heel pain in practice, probably 3-5 new patients a week. I've done exactly 1 plantar fasciotomy in practice. I find that most patients that don't respond to stretching, anti-inflammatories, and good shoes/inserts are either not doing it consistently or have some other etiology for their pain, often neurogenic. I find a lot of patients with Baxters neuritis, tarsal tunnel, or some sort of neuropathy. In a patient that I really do think has plantar fasciitis and is not responding to a good non-operative treatment course (including immobilization), a plantar fasciotomy is a quick procedure with what I feel are minimal negative consequences. I certainly don't think that I will add this to my treatment regimen. I just don't see enough patients that don't get better conservatively and I think that the downsides of a plantar fasciotomy are minimal.
 
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Is anyone else having problems with their fasciotomy patients? I feel like I only end up doing them on folks who aren't real compliant with their conservative care (stretches/home exercises/inserts/etc) so I don't do a ton, but I don't see problems post-operatively (almost exclusively EPFs). And I'm very certain it's not because they went somewhere else, since our facility is their only option 99 times out of 100.
I haven't seen many problems with post-fasciotomy patients, either as a resident or in practice. To be honest, I don't do them enough to make that mean much. This might be one more thing to try before doing surgery, but to be honest, how many things are you going to try before surgery? How long are your patients going to stick with you while you run through a million things before recommending a fasciotomy?
 
I've been meaning to add to this. I've been busy.

Interesting study. It's funded by Merz, the maker of the botulinim toxin. I found it interesting that they used MRI on every patient, something I don't think I've ever done for plantar fasciitis. They only had patients try conventional therapy for 6 weeks before they enrolled them in the study. I don't think that they had a specific initial treatment course. I'm a bit surprised that the placebo group didn't really improve much even though all of the patients received physical therapy. I would have expected them to improve more than they did.

I see a fair amount of heel pain in practice, probably 3-5 new patients a week. I've done exactly 1 plantar fasciotomy in practice. I find that most patients that don't respond to stretching, anti-inflammatories, and good shoes/inserts are either not doing it consistently or have some other etiology for their pain, often neurogenic. I find a lot of patients with Baxters neuritis, tarsal tunnel, or some sort of neuropathy. In a patient that I really do think has plantar fasciitis and is not responding to a good non-operative treatment course (including immobilization), a plantar fasciotomy is a quick procedure with what I feel are minimal negative consequences. I certainly don't think that I will add this to my treatment regimen. I just don't see enough patients that don't get better conservatively and I think that the downsides of a plantar fasciotomy are minimal.

Are you doing Baxter nerve releases? And at what point do you recommend it?

Back to the topic of Botox in general, I wonder if some of the results is due to paralysis and atrophy of the muscles which surround the nerve, thus leading to a "decompression" of potential superimposed baxters neuritis. I heard a lecture by a radiologist who made me rethink the potential of Botox in compression syndromes. I know this is a discussion about plantar fasciitis but I wonder how often when we evaluate heel pain is there really a component of neuritis underestimated and disregarded as "atypical plantar fasciitis".

Here is that radiologist's paper. He's working on publishing his results of 100+ cases
http://www.sciencedirect.com/science/article/pii/S2352667X15000223
 
I would probably try Topaz before going for the EPF because of the deceased risk of biomechanical dysfunction and it'seems a low risk high reward procedure. My sample size isn't great but pts seem to be doing well at ~1 year.
 
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Are you doing Baxter nerve releases? And at what point do you recommend it?
I have done quite a few nerve releases but I don't think I've ever just released Baxters nerve. In residency I was much quicker to recommend surgery, but in practice I typically try a few more things before recommending surgery. I am typically getting nerve conduction studies on most of them, not really for proof of nerve compression but more to evaluate for concomitant peripheral neuropathy that may be muddying the water. I typically will try a steroid injection, both for diagnostic and therapeutic purposes. If they respond well to the injection and have complete or near-complete pain relief, I feel pretty comfortable diagnosing a nerve entrapment. At that point, I will bring up the surgery. I explain that the injections are a temporary fix, but surgery could be a permanent fix. If they don't want surgery but want to continue conservative treatment, I would consider a trial of gabapentin, especially if the NCV shows a generalized neuropathy. I have suggested physical therapy for a few patients with nerve entrapments, but I haven't had much success with it. I don't try to rush people to surgery, but I do usually present surgery as a viable option for a long-term solution.

And I do agree with the comments about a lot of heel pain having a neurologic component. There are a lot of podiatrists who treat all heel pain as plantar fasciitis and don't look for any other possibilities. If you see 100 heel pain patients and diagnose 99 with plantar fasciitis, you're missing a lot of neuritic heel pain.
 
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I would probably try Topaz before going for the EPF because of the deceased risk of biomechanical dysfunction and it'seems a low risk high reward procedure. My sample size isn't great but pts seem to be doing well at ~1 year.
I did a few Topaz as a resident and heard (but didn't directly see) decent results. I think it's certainly a viable option. I personally see a plantar fasciotomy as a relatively low-risk/high-reward procedure. I certainly wouldn't say doing Topaz was wrong, but I would say that a Topaz procedure and a fasciotomy offer about the same risk/benefit profile in my opinion
 
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