Frequently Asked Questions
Are there orthotics for dress shoes?
I advise my patients 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.
When I perform ultracryo on 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.
Are Ultracryo, Cryomax and Cryoplantalis the same thing?
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 radically 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 for complete resolution of the symptoms, 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.
Can cryo procedure be repeated? If so, how many times?
The UltraCryo procedure and 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 UltraCryo can be repeated as many times as is necessary. Because of the nature of the procedure, it has no true longterm 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 painfree. 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.
Does my medical insurance cover the UltraCryo procedure?
The procedure is covered by most insurance plans. Some insurance plans choose not to cover ultracryo. This should not be misconstrued as an indication that there is something medically wrong with the procedure. As ultracryo is such a new procedure, some insurance companies use that as a reason to deny payment. There are also those insurance companies that say they cover the procedure, but then offer a very low payment. For this reason, arizona family podiatry has elected to no longer be a provider on such plans. This procedure is very expensive to perform. The things that need to be factored into the cost of the procedure include the cost of the equipment needed to perform the procedure correctly and the time it takes to perform the procedure. The various equipment and instrumentation needed are very expensive. The cost of the equipment is never taken into consideration by the insurance company when determining a fee. Additionally, this is one of the few surgical procedures that are strictly timed. Time to perform the procedure does not vary very much from patient to patient. The procedure requires the cryosurgeon’s attention from the beginning to end of the procedure. This has to be factored into the cost of the procedure.
For Heel Pain and Neuroma Pain- Cortisone injection or UltraCryo (Cryoanalgesia)?
Given the extremely high rate of complete pain relief seen in UltraCryo and the ease with which patients tolerate the procedure, Dr. Rampertab offers UltraCryo as an option for treatment early in the treatment course. Cortisone injections have many side effects, especially when there are several injections in the same area. These side effects include but are not limited to loss of fat and fibrofatty tissue, localized bone loss, water retention, hyperactivity, abnormalities in blood sugar control in Diabetics, etc. The loss of fat padding can actually worsen the symptoms seen in Plantar Fasciitis and Neuromas. For more on this, visit the section "What are the side effects commonly associated with cortisone injections?"
In Plantar Fasciitis, the heel pain is actually from the tearing/repairing of the ligament causing localized inflammation. There is an area of inflammatory tissues around the site of injury and this is the source of pain when the patient steps down on the heel in the morning or after sitting for a while. When repeated cortisone injections cause Fat Pad Atrophy, there is less padding around the heel bone. This causes even more pressure on the area of inflamed tissues. Additionally, as we walk the heel bone has a lot of pressure and impact on it with every step. The fat padding around it acts to absorb the shock. When there is atrophy of that padding, there is more shock into the heel bone. This commonly leads to bone pain in the heel and less commonly leads to fracture or stress fracture of the heel bone. These are much more difficult conditions to treat.
As for Neuroma pain, this is due to inflammation of the nerve as it courses between the bones. With inflammation comes enlargement of the nerve. With repeated cortisone injections, we will see atrophy of the tissues between the bones. This leads to less cushioning of the enlarged nerve and more continuous pain.
As one can plainly see, the temporary pain relief of a cortisone injection is not worth the long-term adverse effects associated. Dr. Rampertab tries to avoid these adverse effects by offering real pain relief without bad side effects. At azcryo, Dr. Rampertab has over 97% success rate with UltraCryo. That means that over 97% of patients got complete relief of their original symptoms. This is not partial relief. These patients were not almost pain-free. They no longer had any of their original symptoms. As for the procedure, it hurts as much or less than having a cortisone injection. The only real pain associated with the procedure is the first local anesthetic injection. The second injection does not hurt because the area is already numb. As the procedure (freezing of the nerves) is performed, there is rarely pain. Less than 10 out of almost 4000 patients said they felt any pain from the procedure. There is a very short, uncomplicated post-op period and the patient is back to full activity in 2-3 days. They are back to light exercise in a week. When a procedure is this successful and this well-tolerated, why would anyone deal with the possible side effects of cortisone injections? The answer is plain to see-UltraCryo brings more long-term pain relief than cortisone injections without the bad side effects.
How is UltraCryo different from the conventional cryosurgery?
The conventional cryo procedure 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.
UltraCryo 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.
Is there numbness after the procedure?
It depends on the nerves on which the procedure is being performed. In most of the cases we have performed here at azcryo, 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, just pain relief. 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 ultracryo, 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.
What if my insurance does not cover the procedure?
Because of the contractual obligations we have with the insurance providers that we accept at azcryo, we cannot offer a private pay discount of less than we are reimbursed by those insurance carriers. Doing so would void our contract or require us to accept that lower rate from the insurance company. As such, patients whose insurance does not cover the procedure or those without insurance are charged a reasonable and customary fee equivalent to that which we are reimbursed by those carriers.