07/29/2016    Michael M. Rosenblatt, DPM

Posterior Tibial Injection

Injecting the Posterior Tibial Tendon with
Cortisone in Inflammatory Acquired Medial Column
Failure?

A question was asked by a DPM, when his/her
patient secured an apparently (un-requested)
second opinion for severe posterior tibial
tendonitis from an orthopedic surgeon. The
orthopedic surgeon injected the area (tendon?)
with cortisone. Cortisone is rarely injected into
the Achilles tendon, even in severe cases of
tendonitis, due to fear of weakening and
detachment. The DPM quite reasonably asked about
comparative "risk" of injection of the PTT with
cortisone.

I think there is less fear of traumatic/functional
detachment of the Ptt than say the Achilles tendon
after a cortisone injection, because of the
difference in comparative "work-load." But that
does not rule-out permanent-weakness resulting
from the injection. When a doctor directly injects
a tendon (rather than say the tendon sheath or
surrounding tissues), a physical change in the
tendon may occur as the fibers are forcefully
separated longitudinally. This separation may
cause weakness and decreased reliability. You
probably would have difficulty finding out if the
tendon itself was injected or just surrounding
tissues/tendon sheath. If traumatic/functional
rupture of that tendon occurs, the orthopedic
surgeon will deny direct intra-tendon injection.

The importance of a thorough biomechanical
examination cannot be overstated. It is very
important to "categorize" the deformity you are
dealing with before you start treatment. For
example, if the patient has concomitant
gastrocnemius or Achilles equinus, almost anything
you do to alleviate the inflammation is doomed to
fail, up to and including local surgery..unless
the equinus is also dealt with.
A diagnostic MRI should be added to the work-up
and should also be read by a radiologist to
further dilute medical-legal risk. A contrast dye
injection can also be performed, but I would first
order the MRI to avoid another injection. If you
can visualize the posterior tibial tendon, and it
is showing as "split" or fragmented, that might
suggest the orthopedist directly injected the
tendon. Knowing that in advance will certainly
affect the type of surgery you do. For example,
that might suggest a better choice would be a
fusion procedure. The patient should also be
informed of this.

In evaluating what most orthopedic surgeons do to
treat this condition, cortisone injection is NOT
specified on a brief web analysis. So what the
orthopedic surgeon did for your shared patient
appears "atypical."

If you continue to "share" treatment of that
patient and a traumatic/functional detachment
occurs, you will be "blamed" even though you
didn't inject that patient. It is possible to
explain that risk to the patient, without
necessarily "blaming" the orthopedist outright.
Local treatment with casting, bracing, oral or
applied anti-inflammatory medications (Voltaren
cream), clinical rest and inactivity, ORTHOTICS,
etc. are the usual routes to take prior to
surgery.

Most DPM's consider biomechanics seriously and
will want to fully R/O posterior equinus for this
patient. You may decide it is in your best
interests to no longer treat this patient. The
patient made the decision for the second opinion.
Let the patient live with that decision. When and
if you decide this, you must be very careful to
exit properly, so you will not be charged with
"patient abandonment" which is very serious. The
decision of whom will be the patient's doctor is
the patient's decision, unless you bow-out, which
is your decision. Be sure to present the patient
with written opportunities to see other doctors,
and certainly include other DPMs.

No matter what the DPM does or does not do, the
orthopedist and plaintiff's attorney will blame
the DPM for any and all failure, including
permanently weakening the posterior-tibial tendon.
It is best to keep that in mind in case you get a
"less than perfect result," whether you do surgery
or not. Sometimes complex and disputed patient
care is best left to hospitals and large clinics
that have the ability to absorb complications,
lawsuits and patient complaints more easily than
you.

Michael M. Rosenblatt, DPM, San Jose, CA

Other messages in this thread:

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03/14/2006    Adam Klein, DPM

Medicare: Posterior Tibial Injection for Gout

Query: Medicare: Posterior Tibial Injection for
Gout

How would you bill Medicare for a patient with
an acute gouty attack
that you treated with a posterior tibial nerve
block (lidocaine
only) for hyperemia?

Adam Klein, DPM , Lynbrook, NY

Response: The code that best describes what was
done was CPT 64450
(peripheral nerve block, therapeutic). The
question, however, when
it comes to reimbursement is whether a posterior
tibial nerve block
(with lidocaine) administered proximal to the
site of complaint is

1) medically necessary and reasonable in the
treatment of an acute
gout attack;

2) the standard of care in the treatment of an
acute gout attack; or

3) performed to temporarily control the pain of
an acute gout attack
without any significant proven benefit to
the treatment of an acute gout attack.

Tony Poggio, DPM ,Alameda, CA

Additional responses can be found at
http://www.codingline.com