Plantar plate repairs & the pre-dislocation syndrome: what the f$@% (Part 1)

God bless the Beverly Hillbillies. Doubtlessly one of the best scenes depicting their countryfied ignorance was when the doorbell would ring and Jethro would say to Jed, “Uncle Jed, there goes that bell again, next thing you know someone’s gonna come a knockin’ at the door.” Classic.

angry orthopod upload Plantar Plate Repairs

Well, the way my colleagues, both fellowship trained foot and ankle orthopaedic surgeons and my step brothers, podiatrists, are approaching the spectrum of 2nd MTP synovitis, eventual hammertoe formation, and even more eventual second MTP dislocation is really no different than Jethro and Jed on the doorbell.

Most everyone is waiting for the knock at the door because they don’t know what the doorbell is about. Not a clue!

They are waiting way too long to deal with this problem, but they don’t know it. Pity…for you. In the case of foot and ankle orthopods, they at least are not waiting until the MTP joint dislocates. Currently most of us have gone on a rampage of doing a Weil osteotomy combined with repair of plantar plate ruptures, the precursor to dislocation and part of a hammertoe. In fact there are whole systems developed by both Smith & Nephew, and Arthrex for this purpose. All I have to say about these innovations is “If you build it they will come.”

Angry Orthopod & pre-dislocation syndrome

The “pre-dislocation syndrome,” a term used by many, is full of mystery and intrigue.

How would one pose this concept to a patient anyway? Doctor says to patient: “The pain, swelling and hammertoe you have is called pre-dislocation syndrome. We don’t know what it is or what caused it (which means we don’t know how to treat it), but we do know what will eventually happen, your toe is going to dislocate.” Speaking of letting the cat out of the bag.

Here is another favorite line I hear way too often from my patients: “They told me the reason for my problem is that my 2nd metatarsal has grown too long, so it has to be shortened.” And this is said with a straight face. Seriously, a 2nd metatarsal that has grown too long? Believe me when I say something has changed to force this situation, but it is definitely not the magical growth of ones 2nd metatarsal midlife.

By the way, the podiatrists have gotten fully on board and are performing these procedures with reckless abandon. Everybody is joining in on the party.

…letting the cat out of the bag.

Unfortunately this whole issue is where medicine and technology goes haywire all to often today.

Systems and techniques like this are developed mostly because we can.

They seem like a good idea on paper. But do they really work?

In our profession these same docs continually yell out the mantra “where’s the evidence?” Well, I’m going to call them on this one and say, “where’s your evidence?” That would be a big Blutarsky, zero point zero. If and when the evidence comes forth it will be mostly about semi-straight toes and little about patient satisfaction or problem resolution.

…where’s your evidence


I would estimate that in excess of 1000 of these reconstructive procedures are being done every day in the U.S…based on nothing. I am also going to go out on a limb and say this concept is doomed and in time will not be the answer. That is, if we ever get any clinical evidence to tell us how they are doing.

So all the while we will continue to merrily cut away…until we find out it was not a good idea.

“Okay Mr. AO smarty pants, what is the reason we develop 2nd MTP synovitis and a hammertoe?” Stay tuned while I think about it and I will be back with an answer in a few days.

Stay tuned.

Stay healthy my friends,

AO

Why I Don’t Promote Plantar Fascia Stretching- (Part 2)

Click here to see what we discussed in Part 1.

The science backing plantar fascial stretching (PFS) is not convincing to say the least. So, how about a little common sense if you’re not convinced yet. Let’s make the isolated gastrocnemius contracture and calf stretching sexy, what do you say?

First, let’s examine the act of PFS. It is not easy to do and requires one to be barefoot and sitting. Awkward! Yet calf stretching is so easy to do: anywhere, anytime, and done with your shoes on.

F1.large

Pure collagenous structures like the plantar fascia and the Achilles tendon really don’t stretch much, if any. Let me be even more clear, they don’t stretch unless we use a knife.  Certainly they do not “move” compared to muscle and it’s surrounding weaker, less substantial connective/collagenous tissue. Spending ones time stretching the plantar fascia is like moving a mountain. But I digress. The plantar fascia is not even the problem, so even if one could stretch it, why do it?

Here are two repeatable and simple daily occurrences that show the plantar fascia being tight is not the problem, thus PFS is misguided.

“So much of what we do everyday is habit based on what we saw someone do or what we were told to do in the past.”

  1. Why does wearing higher heels (yes, I said higher, not high) like Dansko’s or mild wedges, so often give temporary relief?  Joanie-Black-Full-GrainGo ahead, be honest, release your guilt and admit that these type shoes feel better. I know that you have been categorically told to never wear those shoes and wear flats/supportive shoes, but that does not make it right. So much of what we do everyday is habit based on what we saw someone do or what we were told to do. But could this ‘any heel is bad’ concept be wrong? Damn right it could be. Go ahead and wear those higher heels if you want, they just might make you feel better. One would think that the windlass effect in the foot would place the plantar fascia under an acute, increased tensile strain and incite immediate pain, not relief, with the use of any heel. windlass-foot-designThis would happen because the toes are dorsiflexed (raised up), which places more tension on the plantar fascia. Look it up! What higher heels actually do is immediately relax the gastrocnemius a bit, which in turn reduces the linked tension on the plantar fascia. If someone has a better explanation, bring it.
  2. Have you ever noticed the diagrams of the foot and the tearing and the inflammatory fire representing plantar fasciitis. They always show the heel up in the air near toe off when the toes are dorsiflexed and the plantar fascia is under maximal strain or tension. OUCH! See! It’s so obvious, yet so utterly wrong. Plantar_Fasciitis11 This is where misperception and urban myth runs amuck. The plantar fasciitis pain experienced during walking gait is not when your heel strikes the ground and it is definitely not after the heel raises and the toes roll up as you toe off. The pain is always experienced at a precise time in the gait cycle giving the characteristic shortened gait of plantar fasciitis, as well as many other problems that result from an isolated gastrocnemius contracture. It is the brief time just before the heel raises, not after. This is because the gastrocnemius reaches it’s length limit and runs out of room and the stride is shortened to subconsciously avoid the pain produced as the plantar fascia comes under intense tension over a very short time. This is also why going downstairs and walking uphill is routinely more difficult: it requires more dorsiflexion.

The evidence abounds and is growing everyday as to the association between the isolated gastrocnemius contracture and plantar fasciitis as well as many other foot and ankle problems. Why do we (doctors, patients, physical therapists. trainers, etc.) categorically deny what is right there in front of us? The literature is finally catching up to this fact. Just sit back and watch over the next 5 years as the powerful, damaging effects that the isolated gastrocnemius contracture exerts upon the human foot and ankle becomes common knowledge.  Who knows, calf stretching might even rise to sexy status.

 

-AO

Why I Don’t Promote Plantar Fascial Stretching

Plantar fascial stretching for plantar fasciitis is the rage, but it’s not effective. Here is why! (Part 1 of 2)

Plantar fascial stretching (PFS) is definitely hot right now. It is all over the internet. In fact, it has attained sexy status. People want to talk about it almost as much as they want to talk about their orthotics.  What a shame, because PFS (and orthotics for that matter) does little, if anything, at least to fix the real problem that needs fixing. Yes, I am saying that if you are pinning your hopes on PFS you are likely wasting your time. I am not saying you will not improve, I am saying your PF may improve, but only by luck. This is blasphemy no doubt,(for who would question something that has attained sexy status) but hear me out.

“Plantar fascial stretching…has attained sexy status”

Let’s first examine why PFS might have some success, because it does. PFS also stretches, albeit poorly, your soleus and a bit of your gastrocnemius at the same time. So PFS might inadvertently do a little bit of good where it counts, but it is serendipitous and collateral at best. It also takes up time and we all know time can be beneficial for plantar fasciitis and so many other things.

I am not saying that PFS is bad, because it is not. What I am saying is you are putting your eggs in the wrong basket if that is all you are doing.

high-cholesterol-foods-eggs-in-a-basket

 

PFS is untenable for several good reasons.

Foremost, as I stated above, PFS does not even address the underlying cause of plantar fasciitis: an isolated gastrocnemius contracture. I can’t state it any more direct or simple than this.

“PFS does not even address the underlying cause of plantar fasciitis: an isolated gastrocnemius contracture”

Let’s examine the two articles that put PFS on the map. These originating PFS works were published in the Journal of Bone and Joint Surgery in two successive parts in 2003 and 2006. While these well intentioned studies basically attained Level I status, they were not well designed or executed.  There were significant protocol inequities and bias towards the PFS group. For instance Group A, doing the PFS, was instructed to perform their PFS exercises prior to getting out of bed, while Group B, doing the Achilles stretching, were to stretch “sometime” after getting out of bed. The timing of the stretching in the two groups does not seem like a big difference until one looks at the significant data.  While the two groups were basically equivalent as to overall results (which is the goal, right?), including overall pain reduction and quality of life, the most significant differences were found in reduction of pain experienced upon the first few steps out of bed in the morning. Go figure that the most striking claim and difference between the two groups was that Group A experienced significant reduction of pain arising out of bed first thing in the morning just after they had stretched their plantar fascia (and their calves a bit also).

F1.large

In the second edition of this two part series in 2006 these authors unwittingly fessed up to an addition to the PFS Group A protocol that was omitted from the 2003 article. “The patients were instructed to follow the assigned protocol three times per day, and those in the plantar fascia-stretching group were encouraged to perform it prior to any weight-bearing.” This means they were doing the PFS potentially many more times per day, while Group B did not perform any additional calf stretches. Folks, this is a serious bias, but it is Evidence Based Medicine!

In their 2 year follow-up article in 2006 the bias continued. Basically they took Group B, deemed to be a failure, stopped the Achilles stretching, and started PFS. Yet no reciprocal longitudinal study was done and in neither study was there any control group. The two groups converged somehow showing that PFS still triumphs. Interestingly, David Porter’s 2002 Level I study in Foot and Ankle International “The Effects of Duration and Frequency of Achilles Tendon Stretching on Dorsiflexion and Outcome in Painful Heel Syndrome: A Randomized, Blinded, Control Study” was left off the references on both JBJS articles as well as many other articles.

In the end, Groups A and B where not actually statistically different, yet we are enamored by PFS regardless. Did anyone actually read these two articles or did we just look at the pictures? Just because something is popular or sexy does not mean it is true, which brings me to the next point.

The very same senior author promoting PFS finally saw the light in 2011 publishing again in JBJS “Association Between Plantar Fasciitis and Isolated Contracture of the Gastrocnemius”. The association of the isolated gastrocnemius contracture and plantar fasciitis is given it’s due by the very same author who denounced Achilles (gastrocnemius) tendon stretching as ineffective when compared to PFS in 2003 and 2006. Please, make up your mind.

Check back Tuesday, April 28th for Part 2 of this article.

 

AO

56 Year Old Female

A couple of years ago in our clinic a rotating 29 year old female orthopaedic resident started to present a new patient to me out in the hall and before she could get much out I interrupted her and said “let me guess, a 56 year old female?”. She reacted a bit like I was patient profiling, which I was, making such a bold statement with little, if any information. She responded as politely as possible in her heavy Tennessee accent “now Dr. AO, how can you say something like that?”. “Because I am probably right” I responded. She then had to reluctantly admit that it was indeed a 57 year old female.

“…in her heavy Tennessee accent ‘now Dr. AO, how can you say something like that?'”

Fast forwards, after this same resident has been around for a couple of weeks in my world and back in the same hallway with another new patient. I ask “what do you have?” referring to the patient on the other side of the door. She responded with a resigning attitude “Another 56 year old female!”.

Clueless Doctor

 

BOOM, told ya!

The scientific evidence has existed for years and is mounting by the day that the isolated gastrocnemius contracture is here and it is real and it is casing the majority of non-traumatic acquired foot and ankle pathology we see. This is the very thing I have promoted for all 30 years of my practice and on this site. But I digress. Back to the 56 year old.

Not to sound creepy, but I could make and sustain a busy orthopaedic practice by seeing only women in their fifties and sixties. Why? Around 45 and increasingly thereafter is when the cumulative effects of long standing and increasing isolated gastrocnemius contractures start to become noticeable and symptomatic in many forms, more in women than men in general. And 56 seems to be the perfect age.

The two most common problems I see in the 56 year old female, without question, are second MTP synovitis and midfoot arthritis. Other problems resulting from an isolated gastrocnemius contracture and general start up pain and stiffness, plantar fasciitis, Sever’s disease, shin splints, posterior tibialis tendon rupture (PTTR) acquired flatfoot deformity, second MTP synovitis which leads to plantar plate rupture and ultimately a hammer toe, Morton’s neuroma, insertional Achilles tendinosis/Haglund’s deformity, Achilles tendinitis, musculotendinous Achilles ruptures, calf cramps at night/Charley horse, anterior ankle spurs, Jones/Fifth MT stress fracture, diabetic Charcot anthropathy, diabetic malperforans ulcer formation, and many metatarsal stress fractures.

Here is the problem. People, including the majority of my doctor colleagues, either don’t know or don’t believe, even though the evidence is there and is solid. It is too bad because the secondary foot or ankle problem naturally becomes the focus of treatment, which might make a person feel somewhat better, but it will not fix the primary problem, the isolated gastrocnemius contracture. Ever wonder why plantar fasciitis seems to just linger on or mysteriously returns when you have “done everything”?

Let me be clear on the next point: WE ARE TREATING THE WRONG THING. And it is wasting loads of money and time for all you out there suffering.

Wrong Target

“WE ARE TREATING THE WRONG THING”

On a final note, of my few colleagues who get that the isolated gastrocnemius contracture is the problem, want to guess what their solution is?  Surgery to lengthen the Achilles or the gastrocnemius of course. Don’t get me wrong, I surgically lengthen the gastrocnemius as well, but only after clear cut failure of dedicated daily gastrocnemius stretching, which works just fine most of the time.

Why would somebody take on the expense and obvious risk of any surgery when it can be avoided in most cases. All it takes is ONE simple exercise, daily calf stretching and some patience.

This is for all you lovely 56 year olds. I love ya.  Now stretch!

Be a believer,

AO

 

Employed Physicians and facility fees: I’m as mad as hell and I’m not going to take this anymore- Part 2

Here is the question that must be asked. Where is all this new money coming from?

The Answer: The money is coming from all the employed physicians FACILITY FEES charged by their employers!

And the docs are oblivious to it happy they are making more money.

The hospital systems perpetrating this power play are capitalizing on a longstanding crevice in the system, but this one is actually the size of Grand Canyon that is wildly increasing their profit. And this loophole is costing all of us except for the beloved non-profit hospital systems. In fact, they are making out like never before, but they don’t want you to know about it.

Non profit has the ring of “we are on your side”, and we protect the little people who can’t take care of themselves. In most cases this non-profit concept might actually be true, but not in the case of the non-profit hospital employers. Everyone, especially you, gets screwed except for these longstanding institutions. Even the docs are getting screwed, they just don’t know it.

Forget the ACO (Accountable Care Organization) implemented by Obamacare as the source of all these shenanigans. What we are talking about is across the board, blatant greed.

I want everyone of you to ponder this as long as it takes for the truth to settle in, because it needs to settle in loud and clear for all our sake. Once you get it, you need to get mad as hell.

So here is a simplified example of how it works. Today I see you in my private practice and I charge you for a simple visit ($150) and a set of xrays($50). The insurance company will pay me, after adjustments, etc., $100 for the visit and $35 for the xrays. That is the entire charge, no additional “facility fees” or other random charges. Please keep in mind the numbers I use here are very rough and for demonstration purposes, but close enough. 

Next week I become a hospital employee – smarter, happier, richer – and now I work out of the exact same office where I just saw you, but now it is a facility because I am employed, right? Magic! Now my salary has doubled because my loving, caring, big brother hospital will pay me more because I am important to them and their benevolent cause. But how can they pay me double, build all these new buildings, and do all this advertising? Get ready because here it comes. The increased revenue is not because there is more business or more effective billing practices as they would have you believe. Nope!  It’s because of facility fees charged for employed doctor office visits.

Now, as a hospital employee I see you in my facility office (again, same digs) and I charge you for the same visit ($150). However, the X-ray charge and other things I can charge for can be as much as 2 to 5 fold increase. In addition, you are likely to get stuck with an additional “facility” usage fee amounting to hundreds of dollars to pay for the overhead. In other words you have to pay a lot extra now for breathing the air and walking on the floor of the “facility”. And believe me, we all pay for it.

“The root of these increases are controversial charges known as “facility fees,” …. routinely tacked on to patients’ bills….because they’ve [physicians practices] been purchased by hospital-based health care systems.”

Fred Schulte of The Center for Public Integrity wrote it brilliantly, “One family accustomed to paying about $120 in out-of-pocket costs for doctor visits and other medical services was outraged when they ended up forking over more than $1,000 for similar visits, Mullin [Senator Kevin Mullin, VT] said, mostly for seeing doctors whose practices had been bought out by a local hospital.”

Furthermore he wrote “The panel noted that hospitals buying up medical practices in recent years have been tacking on facility fees that increase the patient’s bill even when the doctor is working from the very same office.” 

By one estimate, under its current reimbursement system, Medicare is paying in excess of a billion dollars a year more for the same services because hospitals, citing higher overall costs, can charge more when the doctors work for them. 

With the rapid migration of doctors from private practice to hospital employment, the percentage of outpatient visits eligible for facility fees is soaring. More employed docs, more facility fees, more money. Here is the thing: the facility fees charged for these doctor visits have been possible since 2000, but they are NEW because the more recent implementation of the ACO and hospitals luring these docs in like a dog chasing the rabbit at the dog races. Just to make sure this point is clear, this is a completely new and extra source of revenue for these hospital systems.

To be fair I must look at the other side of the argument. What is the hospitals excuse for all these new charges? Schulte wrote “The American Hospital Association argues that phasing out the payments “threatens patient access to care.” The group said that hospitals tend to treat “sicker, more complex patients” and are better equipped than doctors’ offices and should be paid more.” These same hospitals were doing quite well before they discovered the facility fee Holy Grail; they are just making a lot more now. All the while their expenses really never changed.

How do you feel about paying for luggage when you fly? Facility fees for doctor office visits are no different. 

Currently the battle to help control these facility fees is waged in the form of “transparency”. What great political wordsmith; transparency. The ACO’s are increasingly being forced to inform the patient/consumer up front about the facility fee for an office visit that has never existed before . Connecticut HB 5337 was passed this past spring with pressure brought by CT Attorney General George Jepsen. It will be implemented into law October 1, 2014.  At least this is a start. 

Alas!  In the end there may be justice. The US Office of the Inspector General (OIG) is on to this facility charge shell game and when the off-campus facility fees are stopped, Katy bar the door, because the exodus of these employed physicians will be like yelling fire in a theater. In the words of Jeff Foxworthy, it will be pandelerium. Doctors will patted on the back and told to move on to life’s work just as end-of-career professional athletes are told to do when their usefulness has ended. They might be wandering around the streets pondering what just happened with no place to go. Everybody looses except for the hospital systems!

Dr. Scott Gottlieb painted a very grime future for my colleagues, and ultimately you, in Forbes over a year ago, “If these new doctor-hospital marriages fail again, then this time around the doctors may not been able to go back to what they were doing. They will be financially stuck in these relationships. They will be unable to even raise the capital to re-start their own offices. They may have trouble getting bank loans…………The doctors will get squeezed but the real misfortunate will befall patients. We will increasingly be getting our medical care out of busy, hospital-run clinics. Our doctors will be salaried employees, more beholden to the rules that hospitals erect to manage their activities than the medical practices that they once owned.”

http://www.kansascity.com/news/special-reports/_news_special-reports_doctors-inc_/article334895/Day-2-‘Facility-fees’-add-billions-to-medical-bills.html

Gottlieb Forbes

http://www.theatlantic.com/health/archive/2014/05/should-doctors-work-for-hospitals/371638/

http://www.wakehealth.edu/outpatient-clinics/

http://www.heritage.org/research/reports/2014/08/how-the-affordable-care-act-fuels-health-care-market-consolidation

http://www.ctnewsjunkie.com/archives/entry/attorney_generals_report_on_hospital_facility_fees_encourages_legislative_a/

http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

https://www.youtube.com/watch?v=xtwPS4X41r4

http://www.cga.ct.gov/2014/SUM/2014SUM00145-R01HB-05337-SUM.htm

http://www.nejm.org/doi/full/10.1056/NEJMp1101959

http://well.blogs.nytimes.com/2011/04/14/what-big-medicine-means-for-doctors-and-patients/?_php=true&_type=blogs&_r=0

http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=all

http://www.mondaq.com/unitedstates/x/205782/Healthcare/8+Key+Issues+For+Hospitals+And+Health+Systems+2013

Employed Physicians and facility fees: I’m as mad as hell and I’m not going to take this anymore. Part 1

This gallery contains 5 photos.

Every weekday I drive down a 13 mile stretch of interstate to get to my office right next to my hospital, or should I say facility. Over the last few years I couldn’t help but notice during my drive to … >> full post

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