11/22/2024    Allen M. Jacobs, DPM

My Surgical Experience as a Patient (Ivar E. Roth, DPM, MPH)

Dr. Roth expresses his "disgust" at the treatment
of plantar fasciitis by a colleague. He opines
that the "younger podiatrists" are motivated by
money rather than patient well-being. He states
that the patient consulted with an insurance
covered podiatrist rather than "me", (that is) Dr.
Roth. What was most disconcerting to me was the
statement that Dr. Roth reviews anything for the
purpose of making a judgment on the necessity of
care and, hopefully not, standard of care.

Dr. Roth is critical of the critical of the
utilization of ECSWT for the treatment of plantar
fasciitis. In point of fact, while I personally do
not employ ECSWT due to the general difficulty in
obtaining insurance coverage for this modality, it
is an acceptable and not-infrequently utilized
modality for the management of plantar fasciitis.
There is reasonable literature support for this
modality in the management of plantar fasciitis,
some of which was authored by Dr. Roth's own
residency directors. The standard of care
generally is inclusive of many approaches to any
particular pathology, including plantar fasciitis.
ECSWT is non-invasive, and may be helpful or
curative for plantar fasciitis. The fact that Dr.
Roth in his show me the money practice would
choose not to employ ECSWT doe not make this
treatment regimen inappropriate or "disgusting".
Nor does it provide a license to impune the
motivation of the treating podiatrist.

X-rays? Why would you not obtain radiographs in
some cases of heel pain ? There is Dr. Roth a
differential diagnosis in some patients who do not
present with seemingly textbook plantar fasciitis.
Similarly, orthotics are frequently not a covered
service for the treatment of plantar fasciitis.
The literature supporting the need for functional
orthotics in the management of plantar fasciitis
is supportive from a theoretical standpoint.
However, practically speaking from the clinical
standpoint the majority of the patients whom I
have treated for almost 50 years have successfully
resolved symptoms of plantar fasciitis without the
need for true custom orthotics, and have done
quite well with prefabricated pronation limiting
or shock-absorbing inserts.

Stretching The role of equinus and effort to
stretch the gastrocnemius and/or soleus muscles
and plantar facia are frequently an essential
component in the treatment of plantar fasciitis.
There is ample supportive literature advocating
the incorporation of stretching in the treatment
of plantar fasciitis. There has been increasing
employment of gastrocnemius recession in the
treatment of planta fasciitis. There are studies
indicating that stretching alone may resolve some
cases of plantar fasciitis. How many night splints
are dispensed by podiatrists for this purpose ?
Many I suspect.

Dr. Roth is critical of the failure to employ an
injection as a primary treatment. Why ? Injections
are invasive, they can be uncomfortable to the
patient, and may often provide only temporary
relief of pain. Furthermore, although uncommon,
potential complications such as infection, fat pad
atrophy, fascia rupture may occur. Personally, I
seldom find the need for injection therapy as
initial treatment for plantar fasciitis.

nti-inflammatories? There are potential side
effects such as renal, cardiac, gastrointestinal
to be considered. Personally I frequently utilize
steroids or NSAIDS for the treatment of plantar
fasciitis.

My point is this. WHAT YOU DO OR CHOOSE TO DO DOES
NOT DEFINE THE STANDARD OF CARE Dr. Roth. In
medicine, for any given pathology, there are
frequently many correct answers. Yes there are
some incorrect answers. If a patient tells you
they had an anaphylactic reaction to penicillin
you do not give them penicillin.

The fact that the patient failed to respond to
initial acceptable treatment by the treating
podiatrist does not lead to a conclusion that the
podiatrist was motivated only by money. What PM
readers can state 100% cure rate in the on-
operative treatment of plantar fasciitis?

In reviewing any chart with concern over prior
care, the question is was the treatment acceptable
under the circumstances. NOT WHAT YOU WOULD DO.
Hopefully, others reviewing medical records for
potential malpractice claims or payment reviews
maintain a greater understanding of the standard
of care than you appear to have. Suggesting that a
colleague was motivated by profit only because
they failed to management a patient in the same or
similar manner as you would have is a good reason
that individuals with such distorted thinking
should not be allowed to participate in legitimate
medical record reviews.

Allen M. Jacobs, DPM, St. Louis, MO

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11/22/2024    Adam M Budny, DPM

My Surgical Experience as a Patient (Ivar E. Roth, DPM, MPH)

I read this post earlier today and quite honestly
I was perplexed, as I am one of the "insurance
podiatrists" who I believe represent the majority
of the profession, as opposed to a boutique/
direct pay" podiatrist (which seems to be Dr.
Roth's implied practice model?) I see nothing
wrong with billing a new patient visit or x-ray as
a diagnostic study.How else would a practice run
if you did not bill new/established visits of one
sort or another?

Specifically, in my experience and clinical
practice, stretching exercises are actually the
mainstay of management for plantar fasciitis and
all of my patients are given literature and HEP
for performing this at their initial visit.
Regarding shockwave therapy, this is also a well
accepted treatment option per the American College
of Foot and Ankle Surgeons Clinical Consensus
Document (Available at
https://www.acfas.org/research/clinical-consensus-
documents)

Specifically, regarding the treatments offered by
the podiatrist who saw this patient before you,
the panel reached consensus that the statements
for both stretching and extracorporeal shockwave
therapy (ESWT) are "safe and effective in the
treatment of plantar fasciitis” were appropriate.
Regarding Stretching from this document:

They found that "patients performing plantar
fascia-specific stretching exercises had superior
results in reducing the pain with their first step
in the morning and their highest level of pain.
Kamonseki et al (98) compared the effects of
stretching with and without muscle strengthening
of the foot alone or foot and hip on pain and
function in patients with plantar fasciitis. At 8
weeks, they found that all patients experienced
improvement in function and stability (98).
Equinus is quite common in patients with plantar
fasciitis; therefore, a strict stretching exercise
program will be beneficial."

Regarding ESWT from this document:
"A general observation across all studies was that
approximately 70% of patients with chronic or
subacute plantar fasciitis who underwent ESWT had
experienced meaningful improvement in their heel
pain at 12 weeks." And, "Because ESWT has few
negative consequences and the recovery time is
short, with patients typically walking and
returning to full activities within a few days,
the panel thought that ESWT is a valuable option
for providers treating heel pain"

In fact, I offer all of the options mentioned in
your clinical summary to my patients and some
individuals may still take months to get better.
The reason for bringing these counterpoints to
light is that there is NO treatment in my
experience (and as outlined in the Consensus
Document) that is 100% successful, and there is no
"cookie cutter" approach to treatment regardless
of your practice model being paid by an insurance
company or directly by the patient. Each patient
may react differently to these treatment
modalities and I do not believe there is a
specific order you are mandated to follow in
recommending management to the patient.

It also seems reasonable to suggest that after
failing all of the other options, surgery could be
considered as a legitimate choice. That being
said, do you charge patients when you offer a
steroid injection or fabricate orthotics? Are
these not ancillary sources of income for your
concierge type practice? I am not familiar with
how you would otherwise keep the lights on?

Adam M Budny, DPM, Altoona, PA