Just prior to this patient’s 2 week follow-up appointment, I looked out one of the windows in the back of the office only to see the patient sitting in his car with the door open, grafted foot down on the ground while he smoked the last of a cigarette.  I was struck by the moment.  Here I was trying my darnedest to get this patient to heal.  And the image of him smoking really threw me.

Is all smoking bad?  To be honest, I’ve had a few smokes in my life.  But smoking is just one of those social activities that you have to look at as a treat.  Chronic smoking has such a detrimental effect on bone and soft tissue grafting.

What to do in the future?  I think the only thing is to speak to my patients before the surgery and tell them this simple story.  What would the conversation accomplish?  I’m sure I’m not going to reform any smokers.  But my job as their surgeon is to be sure they understand the risks of their surgery and the consequences of their lifestyle.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

The front and back porch is by far the single most common place that I hear patients describe injuries.  Why?  I think there’s actually a number of reasons for this phenomenon.  As we’re leaving the house, we’re typically preoccupied with a task.  So we’re looking for the car keys or carrying a bundle of laundry t hang on the line.  And there’s the threshold of the door.  Another big factor is the surface of the porch.  In fact I saw a patient this morning that said that she had on gardening shoes and slipped on the dew on her porch.  She broke her ankle.  And lastly, there’s a change in lighting.  You’re going from the dark house to the bright sunshine.  Each of these factors seem to contribute to porch injuries.

I know this may seem like a simple post, but it is striking how many injuries that I see that are porch injuries.  So go slow.  And be careful out there.  It’s not the big ol’ world that will get you.  You don’t have to go any further than your front porch to find problems.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

She presented to me with right lateral midfoot pain.  The pain had been present for several weeks but was aggravated by a 3 mile benefit walk 3 days ago.  Since the walk, she described acute pain of the 5th metatarsal base.  No history of injury (inversion sprain or fall) was described.  Physical exam noted mild erythema and no edema of the lateral right foot.  Palpable pain was present and specific to the 5th metatarsal base.  Pain with resistance to forced eversion was present.

X-rays showed an atypical fracture, consistent with a Jones fracture of the 5th metatarsal.  The reason this x-ray was atypical was the fact that the fracture margins were smooth and rounded.  Comparison films of the left foot were taken and the findings were just the same.  This patient had an incomplete closure of the growth plate of the proximal 5th metatarsal bilat.  This proximal or secondary growth plate is called the apophysis.

Apophysitis, or inflammation of the growth plate is a common foot problem.  Apophysitis can occur at a number of different growth plates in the foot, but when it does occur at the 5th metatarsal base, it’s called Iselin’s Disease.  But Iselin’s Disease is considered self limiting meaning that once the growth plate is closed (15-18 y/o) an the patient has reached skeletal maturity, there is no way that Iselin’s Disease can occur.  Simply put, no growth plate, no Iselin’s Disease.

This particular patient had clearly reached skeletal maturity at the age of 26 y/o.  Yet on both the left and right x-rays, she clearly had showed evidence of a complete lack of closure of the 5th metatarsal apophysis. 

We discussed treatment options and opted for rest and a shot of cortisone.  We’ll wait and see what comes of this treatment, but additional methods of care might include an OTC insert with a reversed dancer’s pad to create a valgus post on the forefoot.  And lastly, grafting and fusion of the apophysis is indicated when conservative care fails.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

For sake of discussion, let’s break down the non-fasciotomy treatment into two categories; neuroablation and treatment of fasciosis.

The term neuroablation describes techniques that are used to ablate, or destroy the nerve that supplies sensation to the plantar (bottom) heel.  This nerve goes by several names including the first branch of the posterior tibial nerve, the recurrent calcaneal branch of the posterior tibial nerve and Baxter’s nerve.  At first glance, neuroablation is a bit counterintuitive.  The technique does nothing for the primary mechanical problem we call plantar fasciitis.  It doesn’t address the pulling of the fascia.  What neuroablation does is that it deadens (ablates) the pain felt by those folks with plantar fasciitis.

Neuroablation can be performed in a number of ways.  Radio frequency ablation employs the use of a radiofrequency probe that uses heat (thermal ablation) to destroy the contents of Baxter’s nerve.  Cryoablation (cold) is also used to destroy the nerve.  In either case, the primary objective with the ablation procedure is to destroy the contents of the nerve, leaving the nerve sheath intact.  This is an important subtlety of this procedure.  If we were to simply cut the nerve, the contents of the nerve would attempt to grow back.  This is true for any peripheral nerve.  When the nerve is cut, the the sheath is no longer present to guide the direction of the growth of the nerve.  With ablation, the sheath of the nerve is left in place.  As the contents of the nerve regenerate, the sheath is there to guide to direction of regrowth.  This simple concept helps to eliminate one of the complications of nerve surgery called a stump neuroma.

That description begs the question; so we destroy the contents of the nerve and the nerve is going to then grow back?  Doesn’t that mean that the heel pain is going to recur?  And the answer is yes.  It can.  Regeneration of the nerve may take up to a year.  And in many cases, patients have complete restoration of sensation of the heel with no heel pain.  But it is true that in some cases, heel pain will recur over time following neuroablation.

Moving on to plantar fasciosis.  What is plantar fasciosis?  There’s a school of thought that says that after a period of months, inflammatory conditions like plantar fasciitis change to non-inflammatory conditions.  So the acute inflammation (itis) changes to a chronic condition (osis).  Histological studies have proven this to be true.  Biopsies of patients with chronic heel pain greater than 6 months show a significant decrease in inflammatory cells at the site of the insertion of the plantar fascia.

The logic applied to treating plantar fasciosis is this;   if there is no inflammation, then how does the body know to send the mediators of inflammation to the site to help begin and manage the repair process?  These mediators of inflammation include chemical and cellular components that are our primary step in healing any injury.  Without these mediators of inflammation, there will be no healing.

Simply put, doctors who subscribe to this theory act to induce inflammation.  This can be done in a number of ways.  Old school techniques include dry needling.  The heel is anesthetized and a hypodermic needle is inserted multiple times into the insertion of the plantar fascia in an attempt to ’stir things up’.  Newer methods include Topaz radiofrequency surgery and injection of growth factor called PRP (platelet rich plasma). 

Lastly, another non-fasciotomy technique is called shock wave therapy.  Shock wave therapy employs a pulsed ultrasound wave that also stimulates an inflammatory response at the insertion of the fascia.

Many doctors are drawn to these non-faciotomy techniques due to the fact that these techniques do not involve cutting the fascia.  And non-fasciotomy techniques are simple to perform and heal quickly.

The down side of these procedures is that they have a lower success rate when compared to fasciotomy.  Data published in the journals varies based upon the technique chosen for use.

What’s the best method for you?  Once you’ve failed conservative care for plantar fasciitis, be sure to have a long talk with your doc.  Each of the methods described in parts 1 & 2 of these articles have their merits and possible problems.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

 The first consideration is to listen to your doc.  Your doctor is going to recommend the procedure that he or she has used with success.  So regardless of the method described, be sure to listen to the pros and cons of what your doc has to offer.  Personally, I’ve had a number of surgeries and have always found that the method or technique chosen by my doc was chosen with my best interests in mind.

The fundamental question regarding plantar fasciitis surgery is whether or not to transect or cut the plantar fascia.  Cutting the fascia is a procedure called a fasciotomy.  Let’s break this discussion into two sections; fasciotomy vs non-fasciotomy procedures.

Fasciotomy -

A plantar fasciotomy can be performed in a number of different ways.  A fasciotomy can be performed through a plantar stab incision, with an open medial incision or performed endoscopically (called an EPF) with a single or double portal approach.  Which is the best method?  It really depends upon who you speak with.  My preference is a two portal procedure performed with an endoscope.  But again, that’s just my preference. 

What’s the benefit of performing a plantar fasciotomy?  The advantage of a fasciotomy is that it’s a permanent correction.  By performing a fasciotomy, you’re correcting the primary contributing factor to plantar fasciitis.

What’s the down side of a plantar fasciotomy?  Many doctors will argue that they steer away from performing a plantar fasciotomy due to the temporary biomechanical instability created by the procedure.  Their primary fear is a post-operative complication known as lateral column syndrome (LCS).  I find LCS to occur in less than 10% of my patients who undergo endoscopic plantar fasciotomy.  The key to treating LCS is good patient communication.  The first time I start to introduce EPF surgery to a patient, I also start the conversation about LCS.

Most of us tend to think of surgical recovery in a linear fashion; the first week is most important, followed by a little less vigilance on the second week.  A plantar fasciotomy is a bit different though.  Patients are usually careful for 3-4 weeks and as soon as the incisions are healed, they feel they can get back to full activities.  Nope.  Not ready yet.  It really take 4-6 months for the fascia to heal in a lengthened position.  During that 4-6 month period, post-op patients are susceptible to LCS.  So it’s the 2-4 month period that I monitor closely, not the 2 weeks immediately following surgery.

Is an EPF a bad choice of procedures?  No.  Not at all.  But you have to be sure to understand the pros and cons of EPF surgery.  Patients often just hear the pros; small incisions, 10 minute surgery, back to a regular shoe and showers in 2 days.  That all sounds pretty good.  But be sure to understand the cons, like LCS, also.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

Several years ago, several class actions suits were filed against shoulder surgeons alleging that the pain pumps had caused permanent damage to the cartilage of the shoulder.  At first glance, the suits sounded frivolous.  How could such a great invention be labeled as something that would not help, and actually hurt the patient.

Well, last month in The Journal of Bone and Joint Surgery (JBJS), two studies were published that did indeed identify damage to chondrocytes (cartilage cells) with prolonged exposure to Marcaine.  Wow.  To me, that was really and eye opener.

The On-Q pumps may have worked well, particularly when placed adjacent to the joint and not directly in the joint.  And they may still.  But can they be used anymore?  No in my practice.  Based on the JBJS articles, the medical malpractice risk  just got to be too big.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

Lisfranc’s dislocations and fractures are often missed in an ER setting.  It’s common to see patients in the office that complains of midfoot pain only to find that the pain is secondary to an old Lisfranc’s dislocation.  In these cases, x-rays show signs of osteoarthritis specific to Lisfranc’s joint.

In the acute setting. Lisfranc’s fractures and dislocations can be difficult to treat.  Many of these cases require open reduction and pinning.  Arthritis is inevitable in most cases. 

How can we predict the success or failure of treatment of Lisfranc’s fractures?  First, I think from the get-go we have to lower our expectations just a bit.  These fractures are notorious for their less than optimal outcomes.  Other factors that may be considered include the success of reduction of the fractures during surgery, the complexity of the fracture or dislocation and the general health of the patient.  Each of these factors will be significant in the overall healing of the injury.

Smokers do poorly with fracture healing, particularly in the extremities.  Therefore, smokers with Lisfranc’s fractures should be counseled regarding the less than optimal outcomes of these surgeries.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

PVS is categorized as localized or diffuse.  Diffuse is most common.  Diffuse refers to proliferation of the tumor along the course of the tendon sheath or joint.

These images show a diffuse pattern of PVS.  This patient had sustained a Lisfranc’s fracture 12 years ago when she fell into a hole in her yard.  The Lisfranc’s fracture was undiagnosed at the time of injury.  Several years following the injury she noticed a proliferation of nodules surrounding the site of the previous injury.  Over time these nodules proliferated up the anterior aspect of the ankle (Image 1).   Although the size of the dissection was quite large, the site healed uneventfully at the anterior ankle.  Image 2 (right) shows the ankle following excision of the PVS.

Dissection at the midfoot was incomplete due to adherence of the PVS to the joint structure. 

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

But on the other hand, there are many patients who suffer with lateral column pain.  Their pain is real.  But this pain, often described as cuboid syndrome, cannot be defined with plain x-ray.  MRI and CT scans are not able to identify cuboid syndrome.  So if we can’t quantify it and we can’t see it with contemporary testing techniques, again, we have to question the legitimacy of cuboid syndrome.

To answer this question, we decided to take a closer look at the definition of cuboid syndrome.  To accomplish this, we’re searching for patients who fit the following criteria;

• Have been diagnosed with lateral column pain or cuboid syndrome within the past 2 years.
• Have had x-rays and and MRI of the foot for this problem.
• Live in the United States.

Our hypothesis is that cuboid syndrome may be a more than one condition.  Our goal is to aggregate data on lateral column pain to identify trends in MRI findings for those patients who have been diagnosed with lateral column pain and cuboid syndrome. 

 If you fit this criteria or are interested in this study, please contact melissa@drjoster.com.  For additional information on this research project, please go to http://www.drjoster.com/research.htm.

Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio

Dr. Oster cannot answer medical questions or provide medical care through this blog.

In cases of mononeuritis that have failed to respond to conservative care, selective transection of the nerve may be indicated.  Transection results in the permanent loss of motor and sensory function of the nerve.  My question is when do you suggestion selective neurectomy? 

CRPS can be a nasty and unpredictable problem.  Management of CRPS should only be performed by a pain management specialist.  But when surgical care is indicted, a team approach is required.  The case that I’m currently participating in was a referral from pain management for a problem of recalcitrant pain specific to the sural nerve.  The sural nerve originates in the posterior calf and ultimately supplies sensation to the lateral foot.  In this case, the sural nerve was damaged following a surgical procedure.

My role in this case was to perform the sural nerve transection.  Leading up to the procedure, I met with the patient several times to assess the problem. But I also used these visit to assess the patient and his ability to undergo this procedure.  CRPS is often found in depressed, agitated and angry patients.  This patient certainly met each of these three criteria but seemed motivated to move forward with the procedure.  He seemed psychologically stable enough to work as a partner in this kind of procedure.  Fortunately, the sural nerve is a purely sensory nerve, so transection of the sural nerve would result in no motor loss.

The procedure was completed in about 30 minutes.  The sural nerve was transected (cut) and buried in the soleus muscle.  The reason that we bury the nerve is that peripheral nerve has a tendency to grow.  Its’ growth is simply an attempt to reattach to the opposite side of the cut nerve.  If it cannot complete this bridge, the nerve forms a stump neuroma.  The image at left shows the sural nerve buried in the soleus muscle.

What can we expect in this case?  It’s hard to say.  CRPS is not predictable.  And your expectations cannot be too high. 

But the question remains, when do you recommend transection?  This particular case was a comparatively easier decision in that loss of sensation on the lateral side of the foot would be a blessing to this patient.  But what about transection in nerves that supply motor sensation?  Or what about cutting the nerve that supplies the sensation to the bottom of the foot?  Step on a nail and you wouldn’t feel it? 

In each instance mentioned above, the trade offs have to be thoroughly discussed with the patient prior to surgery.  Patient expectations need to be realistic.  And often, the expectations when treating CRPS with surgical care should be low.

I’ll post again in the future to update on this post.  I think only time will tell whether I made the right decision of not.

Jeffrey A. Oster, DPM

The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio