The most common foot and ankle deformity
“Oh, my aching feet,” is a common lament. Just how common a complaint is revealed in the PearlDiver Patient Record Database. While “bunion” is among the top ten diagnoses within the lower extremity region, Plantar Fascial Fibromatosis (ICD-9-D-728.71)—painful feet—is the number one diagnosis in the PearlDiver database. Plantar Fascial Fibromatosis is right up there in frequency with the other headliners—pain in shoulder joint, degeneration of lumbar intervertebral disc, pain in lower leg joint and carpal tunnel syndrome.
Between three and four million patients go to a physician every year complaining of sore feet. Most are suffering from plantar fascial fibromatosis problems—a condition that presents with firm bumps or nodules in the plantar fascia—the tough, fibrous band of tissue that runs from the heel bone to the base of the toes. Plantar fasciitis is an inflammation of the plantar fascia. Tears in the plantar fascia can cause acute pain and make it difficult for a patient to walk.
Females are diagnosed with plantar fasciitis from 1-½ to 2 times as often as males. Plantar fasciitis is a common complaint, affecting not just runners, tennis players, and joggers but non-athletes as well. Conservative treatments for plantar fasciitis are the most in demand, although the majority provides only short-term relief. These treatments include proscribing stretching exercises, arch supports, appropriate shoes, orthotics, corticosteroid injections, arthrocentesis, and strapping. When conservative treatments fail, patients in search of long-term relief have opted for surgical release of the plantar fascia.
Endoscopic or fasciotomy procedures are performed only when all conservative and non-surgical treatments have failed. These are minimally invasive treatments that cut away the fascia for the release of the proximal medial of the fascia which relieves the tension and pressure on the foot.
Chart 1, which includes both conservative and surgical procedures, shows the leading treatments for plantar fascial fibromatosis. Among the most innovative is extracorporeal shockwave therapy. This treatment is still regarded as controversial and patients have reported mixed results.
Chart 1: Top Associated Procedures Following Plantar Fascial Fibromatosis
Source: PearlDiver Patient Record Database January 2004 – June, 2007
According to the PearlDiver database the following procedures are the most commonly used surgical treatments for problems in the plantar fascia. Among them, endoscopy plantar fasciotomy is the most preferred surgical treatment recommended by doctors and surgeons for patients who fail the conservative treatments.
1. Endoscopy plantar fasciotomy(CPT-29893)Table 1 shows the number of patients who have undergone the traditional conservative treatment of injection and/or arthrocentesis procedures compared to those who have experienced surgical plantar fascia release treatments.
Table 1: PearlDiver Patient Counts for Plantar Fascial Treatments
According to a PearlDiver longitudinal study, 25% of the patients who have plantar fascia are treated with an injection (procedure codes CPT-20550 and CPT-20551). What is interesting within this study is that 3 to 4% of the patients who had been injected for plantar fascia also had an endoscopic or fasciotomy procedure. Surgical procedures for plantar fascia are relatively uncommon but endoscopy and fasciotomy are growing in popularity.
The continuum of care for Plantar Fascia is fairly straight forward—less expensive conventional treatments leading, over time to more expensive surgical release procedures. According to the PearlDiver study, all those patients who had injection procedure and then later had endoscopic surgery in average had a total charge of $2,285. The following list shows each procedure mentioned above in Table 1 with its average charges per procedure. The most expensive treatment for plantar fascia problems is endoscopic plantar fasciotomy with charges reported well above $2,000.
Conventional Treatment Charge per Procedure
1. CPT-20550 --------› $140 Avg.Surgical Release Treatment Charge per Procedure
1. CPT-29893 --------› $2,145 Avg.According to PearlDiver Patient Record Database, surgical release treatments have experienced a relatively steady growth rate of 35% since 2004. Though podiatry still dominates the market with lower cost products such as anti inflammatory medicine and cortisone injections, we estimate that from 70,000–90,000 patients are presently undergoing surgical release treatments every year.
Instratek Incorporated is one of the leading companies distributing endoscopic instruments, especially for carpal tunnel release and plantar fascia release. The Endotrac™ System from Instratek is one of the pioneer products for plantar fascia release. AM™ Surgical Endoscopic Soft Tissue Release from Wright Medical is another product that has been an asset to the company since its acquisition of foot and ankle products from AM Surgical, Inc. These products have been available since October 2007. Conventional treatments are still being preferred because of the low cost and simple mechanism. “However, the surgical side of the market is growing with a steady pace and better results, providing a competitive market potential for other foot and ankle associated companies with which to get involved.”