QUESTION: I am a 62 year old male who was diagnosed with plantar fasciitis in February of this year. I have been seen by DPM’s, pedorthotists, osteopaths, and a physiatrist who all concur that this was plantar fasciitis. The x-rays show a bone spur and the recent ultrasound scan shows inflammation of the plantar fascia resulting in irritation of the nerve. Immediately after the injury, we instigated a conservative treatment plan which has included rest, oral anti-inflammatories, custom orthotics, topical anti-inflammatories, night splints, ultrasound treatments, stretching exercises, strengthening exercises, icing, contrast baths, strapping, cortisone injections, etc.
I researched additional treatment options and found out about cryosurgery. I live in
If our conservative plan of action does not produce results, I’d like to be considered as a cryosurgery candidate by your office. Thank you in advance for your time. JG
ANSWER: Dear JG, You sound like the typical out-of-state patient that we treat. In general and ultracryo (cryoplantalis, cryomax) in particular are procedures that are not widely used. The main reason for the scarcity of the machines in each state is the fact that each physician must pay for the training for the procedure. Once the physician/surgeon learns the procedure, he must then purchase the equipment needed to perform the procedure. For those of us that are doing the procedure, it is quite gratifying. Those of us doing ultrasound-guided cryosurgery boast a more than 98% success rate with success being patients who rate their post-procedure pain level as 0-1/10 compared to 10/10 prior to the procedure.
As for the course of treatment you have already instituted, it sounds like a typical conservative course. At this point in treatment, if you have not seen significant enough improvement, cryo is your best available option.
Typically since you already have a podiatrist in your state, I would recommend scheduling a consultation followed by the procedure the following day. As the typical patient has done as much research (internet or otherwise) by the time they find us, this is usually enough pre-procedure work-up. The pre-op teaching and post-op instructions are available on the website. As the incision is only 2-3 mm in length and should heal uneventfully in 3-7 days, there is no need for follow-up with me. If you have questions afterward, we can always offer advice.
As you will be leaving
Response to Wall Street Journal article on Cryosurgery:
Dear Ms. Johannes,
I read your piece in the WSJ online and felt I had to write. I am a podiatric surgeon in private practice for the past 14 years. I consider myself a sports medicine and biomechanics specialist. I have a moderately busy established practice seeing 30-35 patients per day. At this time, my practice population is comprised of 50% plantar fasciitis sufferers. I see patients ranging from those who have never seen a podiatrist for the problem before to those that have seen many specialists of various types.
I will not bore you with the details, but prior to my performing the cryo procedure; I was performing 2-3 open plantar fasciotomies per week. This was costing the insurance companies between $3750-5000 per patient in an outpatient facility.
I have been performing cryo since 2004. Since that time, I have performed over 800 procedures for plantar fasciitis. The average loss to the insurance company for this in-office procedure is $600. Since 2004, this procedure has been so successful that I have only performed 4 open plantar fasciotomies.
I understand that many of the studies and interviews include only anecdotal evidence, but when treatment protocols include night splints that cost the insurance company $250-300 for something that costs $20 or less to make and is generally accepted by biomechanics and plantar fasciitis specialists as something that does not work, I feel cryo is an acceptable treatment prior to open plantar fasciotomy.
I lost almost all faith in fair journalism when in the last paragraph you included an interview with a physician at mass general who authored a study on shock wave treatment funded by the manufacturer of the shock wave machine. That would be the last person and study I would quote as a rebuttal for the cryo procedure.
I am now in the process of building the most comprehensive website on cryoanalgesia. You would be well-informed to visit the site for a better idea of how and why cryo works. We who are performing the procedure are not quacks. Although Dr. Fallat was a pioneer in the procedure, many of us including Dr. Cavazos and Dr. Marc Katz in
Most of the resistance to this procedure is caused by the insurance companies. In most states the procedure is viewed as experimental by the insurance companies. This is their effort to not cover the cost of the procedure. This leads to resistance of physicians to elect to learn and perform the procedure. Additionally, the physician must then purchase the equipment in order to perform the procedure. We are never reimbursed for this cost.
I hope you will take the time to visit our websites. If you have any questions, please feel free to call or e-mail.
Highest regards
QUESTION: Dear Dr., Fifteen years ago I had a neuroma removed from my right foot, between the 2nd and 3rd toes rather than the more typical 3rd and 4th. The nerve was sent to pathology and it was determined to be degenerative. I have been totally pain free in that area until about 2 months ago and now I have pain and it seems to be increasing. I have a recent history of plantar fasciitis. The pain in the ball of the foot feels like I have a rock in my shoe directly under the scar, it can burn, can ache, can sting, and can tingle, and simply hurt to walk. My family doctor and pedorthotist believe the nerve stub has been irritated. I will be seeing a foot specialist next week. If this issue is not resolved, is it possible this could be treated with cryo? Thank you for your time.
ANSWER: Scar tissue entrapment of nerve and recurrent stump neuromas are ideal indications for ultracryo/cryoplantalis/cryomax. After hearing your description, I cannot help but think that if it has been 15 years the likely cause is a completely new nerve entrapment of the 3rd intermetatarsal space nerve. If it were 3-5 years after the previous surgery, I would lean toward 2nd intermetatarsal space stump neuroma due to scar tissue, but this far out, it is less likely. However, if you can definitely tell that the burning pain is directly under the scar, it is possible.
Given the history of plantar fasciitis for the past 3-4 months and possibly favoring the affected heel may have caused an increase in forefoot weight bearing or instability. This could lead to a new neuroma or irritation of the scar tissue around the old nerve trunk. It could also be that the problem was slowly progressing and when the plantar fasciitis worsened, the neuroma became more evident.
Ultrasound would give us a definitive diagnosis. In my practice, we try not to perform a heel procedure at the same time as a forefoot procedure except in very rare circumstances. We can discuss it during the consultation visit. I would probably deal with the more painful problem first as it is quite possible that if you stopped favoring the affected heel, the pain from the neuroma may lessen. During the consultation for ultracryo of the heel, we would visualize the neuroma as well.
QUESTION: How is ultracryo different from the conventional cryosurgery, I read about it all over the internet? Note: ultracryo, cryomax and cryoplantalis are similar procedures.
D.G.,
ANSWER: The conventional cryo procedure made well-known by Dr. Fallat involves the use of a very small incision in the skin. The area(s) of most pain are elicited prior to local anesthesia. The plan is to freeze the tissues in the area(s) of most pain. In the conventional procedure, a small bit of local anesthesia is placed in the area of the proposed incision. A small 3mm incision is placed into the skin and the cryoprobe is placed into the incision and is slid into the marked areas of most pain. In some instances, a neurostimulator attachment may be used to localize the nerves in this area. The use of the neurostimulator has been shown to cause significant pain to the patient and most physicians have stopped using it. With an experienced cryosurgeon, good results may be achieved without the use of the neurostimulator.
Ultrasound-guided cryo takes the procedure to new levels of accuracy. The exact placement of the probe is more accurately achieved with the use of a highly sensitive digital ultrasound in pulsed Doppler mode. The cryosurgeon takes advantage of the fact that all nerves follow the path of the similarly-named artery and vein. If we are able to exactly locate the small artery, the nerve is in close proximity. We use the ultrasound to locate and perform the reversible prolonged conduction nerve block on those nerves that carry the signal for pain from the inflammation in the area. When the procedure is performed on the proper combination of nerves, a significant decrease in pain is seen. The underlying biomechanical problem must still be addressed and this is usually done with orthotics. The pain remains gone as full activity is regained and the use of orthotics minimizes the chance of recurrence of the pain.
QUESTION: Dear Dr., I have been reading the postings on heelspurs.com and have seen that there are three doctors performing the same procedure, but they all have different names for their procedures. Are these procedures truly the same?
H.A., NYC
ANSWER: Dear H.A., Dr. Cavazos, Dr. Katz and I have all been performing procedures for the indications of heel pain and neuroma pain for several years. We were some of the first cryosurgeons to undergo training. Separately, we started changing and tweaking the procedures we learned and all came to realize the same things about the procedure, its advantages and disadvantages as we learned it. We were able to change it to allow it to work better. We considered the chronology of the pain and the change in symptoms over time. We used this information to come to the conclusion that, in the case of plantar fasciitis, there is a gradual progression of nerve symptoms that masks the original symptoms and may appear to be a separate problem when in fact it is the same problem, only more advanced. In short, the longer the patient waits or complete resolution of the symptoms takes, the more nerve related the symptoms become. What may have started out as a biomechanical problem becomes a nerve problem. That is why you will see us saying that the cryo procedure (ultracryo, cryomax and cryoplantalis) can be used to treat a variety of foot/heel/arch conditions.
Deo Rampertab, DPM
QUESTION: Dear Dr., My neuroma is killing me. I have read everything on this site about neuroma treatments. My podiatrist has tried everything except orthotics. I work in a bank and have to wear dress shoes all day every day. I cannot fit orthotics into my dress heels. Would cryo help my condition?
D.M.,
ANSWER: Dear DM. The ultrasound-guided cryo procedure would give you significant relief of symptoms within a few days. The problem is that you need to wear custom orthotics in your shoes to prevent recurrence. I advise my patients in your situation to wear their dress shoes with special, thinner orthotics most of the time and orthotics specially made for sport sandals or tennis shoes the rest of the time. Modern, computer generated orthotics are very exacting and thin. They are able to fit well in shoes up to 1 ½ inches in heel height. If we performed ultrasound-guided cryo on your neuroma, I would insist that you wore orthotics during at least 40% of your standing and walking. The recurrence rate we have seen with this particular condition has been due to patients not wearing the orthotics. It is only in a few rare cases that we have seen the neuroma symptoms recur when the patient has been wearing orthotics on a regular basis. I hope that answers your question.
QUESTION: Dear Dr., I have had pain on the outside of my ankle for several months. I wear orthotics and have now resorted to an ankle brace. The pain is still present, but it is less. I work 4 10-hour shifts per week on my feet. My doctor told me, after exhausting everything he could, that I have sinus tarsitis. He has changed my orthotics several times. Each time it brings temporary relief, and then the pain comes back. Any answers?
S.T.., Mustang, OK
ANSWER: Dear S.T., Sinus tarsitis is commonly started by a biomechanical condition of the foot and/or ankle. This is usually corrected by orthotics. When the pain persists, it is usually due to impingement/compression of the nerve to the sinus tarsi. When patients present with this problem, I perform a diagnostic block of this nerve. I use a very small amount of local anesthetic directly on the nerve. I then allow them to perform normal activities for the remainder of the day. If the pain does not come back during that day’s activities, this is a successful test and I recommend ultracryo of the nerve to the sinus tarsi. It is an easy procedure from the patient’s standpoint. There is very little pain during and after the procedure and the pain relief is significant. Most patients are doing much more than their normal activities within days of the procedure. You will still need to wear orthotics and possibly the ankle brace, but the pain would be essentially gone.
QUESTION: Dear Doctor, I read that the cryo procedure can be repeated. How often can it be repeated and how often is that necessary?
-unsigned
ANSWER: The ultrasound-guided cryo procedure and other cryo procedures in general are classified as reversible prolonged conduction blocks of peripheral nerves. By their nature, the procedure freezes sections of nerves and causes a localized defined area of cell degeneration (axonal degeneration). The section of nerve degenerates after the procedure and this process goes on for 4-6 weeks varying from patient to patient. Almost immediately following this degeneration begins a regeneration of the nerve trunk. This also takes 4-6 weeks. The pain is usually gone by the end of this time.
The ultrasound-guided cryo can be repeated as many times as is necessary. Because of the nature of the procedure, it has no true long-term side effects. If the pain comes back 2 or 3 years later, we can repeat the procedure.
In the almost 2000 procedures at various sites that we have performed, less than 50 patients have needed to have a second procedure performed. Some have had to have it repeated for continued pain. More than 20 of those patients had the procedure repeated after 2 years of being pain free. Less than 10 of those patients have had to have the procedure repeated 3 or more times over a 4 year period. These have been rare and exceptional cases and they know who they are.
QUESTION: Dear Dr., Is there numbness after the procedure?
ANSWER: It depends on the nerves on which the procedure is being performed. In most of the cases we have performed the nerves associated are not sensory nerves to the skin. In the procedure for plantar fasciitis, the nerves are sensory nerves to deep tissues. There is no skin numbness after the procedure in many cases, just pain relief. However, there is that possibility. In the procedure performed for neuroma, the nerve affected is a skin sensory nerve. When a patient has conventional neuroma excision surgery, we let the patient know that they should expect permanent numbness between the affected toes. In the patients who have cryo, there is a transient period of numbness in between the affected toes. This numbness may last 12-16 weeks. When the nerve regeneration is complete, the numbness resolves. I have had one patient in the past 4 years that had a one-inch area of numbness remain on the bottom of the foot behind the toes. There was no pain.
QUESTION: I have heel pain and a neuroma in my left foot, I have been through many conservative therapies and have seen many Podiatrists. My Dr recommended RF - radiofrequency ablation. It sounds similar to cryosurgery except one uses heat and one uses cold. Please enlighten me.
ANSWER: That is an excellent question which we commonly need to clarify. Neuroablation can be accomplished in many ways. RF is one method and uses heat to burn the nerve or tissue. The downside to RF compared to cryosurgery is that heat has much greater potential to damage surrounding tissue, there is much less control. And the biggest issue with RF is that it can lead to the dreaded stump neuroma. Cryosugery is really the only neuroablation method that does not cause a stump neuroma. With cryo we preserve the outer portion of the nerve so that the nerve has a pathway for regeneration. This is a huge advantage. Also, with ultrasound-guided cryo we do not use a grounding pad or stimulation. RF can lead to grounding pad burns and stimulation can make the procedure much more painful than cryosurgery.
