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Helping Your Practice and
Helping Your Patients
While Limiting Risks
2015
Michael C. McGlamry DPM, FACFAS
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Conservative Care• When
• Why
• Who
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When to Apply Conservative Care
• Conditions that predictably respond to CC
• Non emergent conditions
• Conditions with substantial recovery
• High risk/difficult patients
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Why Conservative Care?
• It works
• Minimal risks
• Allows you to get to know the pt.
• Medical/legal implications
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Who?
• All
• Non emergent conditions
• High risk pt’s
– Medical
– Social
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Conditions
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Plantar Fasciitis
• Statistically responds well to CC
• Google search 3.7M
• Complications of surgical treatment
– CC syndrome
– Nerve entrapment
– Other nerve injuries
– Persistent heel pain
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Plantar Fasciitis CC Treatments
• Injections
• NSAID’s
• OTC/custom inserts
• Night splints
• PT (home and Rx)
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Plantar Fasciitis Escalated CC
• PRP
• Stem cell treatment
• Laser therapy
• ESWT
• Cryo
• Nerve ablation
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Financial Considerations
• Conservative Care
– IOV $109.15
– Xrays $29.07
– Injection(2) $59.42
– OTC inserts $40
– Night splint $161.53
– Follow up (2) $73.09
Total $531.68
Risk 0
ESWT $1250/231.17
Ultrasound $25.03
• Surgical care
– EPF $441.08
– Instep etc $302.01
– Boot $263.29
Total $629.95-704.37
90 day global
Risk $53,737
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Claims
• 28060 Instep or other open
• 28062 Complete
• 28250 Steindler stripping
• 29893 EPF
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Insertional Achilles Tendonitis/
Retrocalcaneal Exostosis
• Responds fairly well to CC
• Google => 759,000 results
• Postop
– 1 month NWB cast
– 1 month fracture boot
– Gradual return to activities
– Lengthy rehab for “typical pt”
• Total recovery 1 year
– **Informed Consent**
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Insertional Achilles Tendonitis/
Retrocalcaneal Exostosis
• Complications
– Weakness
– Persistent pain
– Achilles tendon rupture
– Other injuries from falls while NWB (High BMI
pt’s
– DVT/PE
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Insertional Achilles Tendonitis/
Retrocalcaneal Exostosis CC
• Immobilization
• Oral steroids
• NSAID’s (oral and topical)
• Alteration shoe gear
• Heel lifts
• Bracing (Achillotrain, AFO etc.)
• PT (treatment and evalution for NWB ability)
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Insertional Achilles Tendonitis/
Retrocalcaneal Exostosis
Escalated Conservative Care
• PRP injections
• Stem cell
• Topaz
• ESWT
•NO STEROID
INJECTIONS!!!!!!
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Financial Considerations
• Conservative Care
– IOV $109.15
– Xrays $29.07
– Heel Lifts $20
– Boot $263.29
– Follow up (2) $73.09
Total $567.64
Risk 0ESWT $1250/231.17
Ultrasound $36.52
Casting $150
• Surgical care
– Resection exostosis
$424.71
– Repair Achilles $675.65
– Boot $263.29
Total $
90 day global
Risk $62,118
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Posterior Tibial Tendon Dysfunction
• Moderate response to CC dependent on stage
and underlying structure
• Google => 239,00
• Postop
– 6-8 weeks NWB in cast
– 4 weeks PPWB in boot
– 3-6 months swelling/soreness
– 12 month full recovery
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Posterior Tibial Tendon Dysfunction
• Complications
– Delayed or nonunion
– swelling
– DVT
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Posterior Tibial Tendon Dysfunction
Conservative Care
• Medications
• Orthotics
• Bracing
• Immobilization* (dual role)
• PT
• ?Injections?
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Procedures
• 28238 Kidner
• 28300 Calcaneal osteotomy
• 28715 Triple arthrodesis
• 18 claims
• Average payout $101,389
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Other Procedures
• 28725 Subtalar fusion $98,625
• 28740 Isoltated midtarsal $225,000
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Charcot Neuroarthopathy
• Conservative care success based on severity of
deformity
– Midfoot vs ankle
– Stable vs instable
– Ulcer vs closed
• Google => 264,000
• Postop
– 10-16weeks NWB Cast (Ex Fix)
– CROW 12 mo – life
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Charcot Neuroarthropathy
• Surgical Complications
– Wound dehiscence
– Nonunion
– Infection (+/- 30%)
– Ampution
– Death
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Charcot Neuroarthropathy
Conservative Care
• EARLY DX!!
• Offloading
• Ulcer care when present
• Bracing
• TCC
• Bone stimulation
• Bisphophonate therapy
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When is Surgery Indicated?
• Failure/lack of response of conservative care
• Imaging/other findings to support that CC will
likely be unsuccessful
• Patient has already had extensive conservative
care elsewhere
– Caution!
– Obtain records
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Consent
• Detailed discussion about procedure as well as
normal expected recovery
• Alternative conservative treatment options
• Risks
– Common
– Catastrophic
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Summary
• Conservative care is often succesful
• Risk factor near “0”
• Time=>Rapport
• Trust
• Rewarding
• Decreases stress
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