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Doctors any input on the following article?

Posted by Carmen H on 2/28/02 at 09:00 (075266)

http://www.physsportsmed.com/issues/2000/05_00/khan.htm

Could there be people out there being treated for Tendinitis instead of Tendonosis? (sp?)

Re: Doctors any input on the following article?

Glennx on 2/28/02 at 11:05 (075280)

Carmen: Super illiminating! Perhaps too for wrist soreness.

Wonder also if fibroblasts and/or myofibroblasts are present with PF, and what that may (or may not) mean? [As in 'Cellularity results from the presence of fibroblasts and myofibroblasts, not inflammatory cells. Thus, in patients who have chronic overuse tendinopathies, inflammatory cells are absent.'] from the article

Re: Doctors any input on the following article?

AmyM on 2/28/02 at 17:19 (075319)

Everyone has fibroblasts and myoblasts whether they have PF or not. Fibroblasts are cells that make up the fibrous tissues of the body and myoblasts make up muscle. (there are also loads of sub categories of these cell types)
There are loads (at least 30-40) different types of 'inflammatory' cells so that term is pretty meaningless.
I've never heard of 'cellularity' before. Your cells make up your body so of course there is 'cellularity'!

This has probably confused the issue, but their scientific reasoning seems pretty vague to me.

Re: Could it be Plantar Fasciosis?

Glennx on 2/28/02 at 20:01 (075331)

The article Carmen points us to makes a case for most tendinitis actually being tendinosis. ('itis' has to do with inflammation. 'osis' seems to refer more to degeneration) Until today I didn't know there was such a thing as tendinosis. Now I also learn there is a term, 'fasciosis,' as in 'Plantar Fasciosis.' And which may also suggest some subtle different treatment directions.

See, for instance:
http://partners.golfserv.com/apps/fitness/askexperts/more.asp?qid=2
http://www.allina.com/Allina_Journal/Spring1997/lutter.html

And a search for 'fasciosis' here on heelspurs brings up an interesting dialogue from last summer.

Re: Doctors any input on the following article?

Glennx on 2/28/02 at 21:27 (075342)

Amy: Do you know? Are fibrous tissues made BY, or made OF fibroblasts? i.e., builders of fibrous tissues or ingredients?

Re: Fibroblasts make fibrous tissue

AmyM on 3/01/02 at 15:39 (075417)

Fibroblasts build fibrous tissue. 'blast' cells can divide and create new tissue.
Fibroblasts create fibrous tissue where as osteoblasts create bone.
Connective tissue is made up of three types of fibres 1)collagenous 2)elastic 3)reticular.
Fibroblasts are capable of remodelling and forming all three types of fibre, therefore they can both produce and breakdown collagen. Fibroblasts also create the 'ground substance' referred to in the article. Ground substance is a clear fluid/gel that surrounds the fibres. It contains proteoglycans and glycans.
Myofibroblasts are a subtype of fibroblasts the contain actin and myosin, two proteins that are commonly found in muscle cells and allow muscle to contract. Myofibroblasts are often found in healing wounds.

So the article says that tendonopathies have....

a loss of collagen continuity (figure 1):
This means that instead of being nice and flat and in straight rows the collagen fibres are all curled up and mashed together

an increase in ground substance,
increase in the amount of fluid in each cell, this seems logical as this would increase pressure on surrounding cells and produce pain. It might also explain why massage helps as it would promote the movement of fluid

an increase in vascularity,
This means an increase in blood vessels. Possibly because the body is trying to heal itself ?

an increase in cellularity (figure 2: not shown)
Cellularity means the number and quality of cells in a tissue. Possibly more cells if dead cells aren't cleared efficiently ?

Cellularity results from the presence of fibroblasts and myofibroblasts (figure 3: not shown), not inflammatory cells.

Myofascial releasehas helped some PF/AT sufferers. Practitioners of this therapy claim that ground substance can change from a gel to a liquid state. They say (I don't know how much scientific evidence there is for this) that heating or streching causes ground substance to become liquid and during this time the collagen fibres can unwind and adhesions break. They claim that fast massage does not allow enough time for this to happen.

For a nice picture of fibroblasts check out this link. Scroll down to 'Ordinary Connective Tissue Types',the green picture with the heading 'Loose' has fibroblasts http://www.uoguelph.ca/zoology/devobio/210labs/ct1.html

For more information on myofascial release look at http://www.deeptissue.com/learn/systems/fascia/fascia.htm

Re: Fibroblasts make fibrous tissue

Glennx on 3/01/02 at 18:07 (075423)

Amy: Fascinating and very helpful stuff. It makes such a difference seeing, and beginning to understand things at the cellular level. I'd done searches on fibroblasts but hadn't been able to find anything so lucid and concise. Your links were insightful as well. For the first time I understand MFR.

Puts this exerpt in better perspective too:
The Stages of Healing
There are characteristically three stages of ligament and tendon healing: inflammatory, proliferative, and remodeling.

1. During the initial inflammatory phase, the immune system increases circulation to the injured area, which produces the classic redness and warmth, which typifies soft tissue injury. The increased circulation also helps produce edema (swelling) and the accompanying pain. Unfortunately, many athletes, trainers, and team physicians see pain and heat after an injury as bad and prescribe treatments such as RICE and anti-inflammatories. Pain should signal to the athlete that the immune response to injury is working correctly. Stopping the above inflammatory reaction to any degree decreases the likelihood of, or delays complete healing.

2. During the proliferative phase, type I collagen is being laid down by the fibroblasts to increase ligament and tendon strength. After about four weeks, about 60 percent of the tensile strength of the tissue may be restored. This obviously depends on the amount of tissue damage and the ability to mount an inflammatory response after injury. The healthier the immune system, the quicker the ability to heal.

3. The remodeling phase of healing occurs for up to one to one and a half years after the original injury, when the body attempts to restructure the injury and restore the body to a pre-injury state.

Thank you!
Glenn

Re: Fibroblasts make fibrous tissue

AmyM on 3/02/02 at 08:58 (075458)

Thats interesting, I'm starting to think that icing chronic injuries may not be the best plan. I've found heat to be better, I think I've been stuck in Stage 3 for about a decade!!!!
It might be interesting to see if people prone to chronic PF/AT and related conditions have a defect in firbroblasts.

Re: Fibroblasts make fibrous tissue

Glennx on 3/02/02 at 11:22 (075468)

I'm recently not-icing as well, and have started monitoring how warm my injured area is to the touch, particularly after about an hour of rest in the evening. If warm in comparison, say to my other foot, my guess is some tissues are at stage 1 responding to micro injuries in that, or previous days. Since the fascia is fairly large, probably likely that portions of it can be in different stages, perhaps all three simultaneously. And perhaps month after month.

Chronic situations may suggest that tissues really need remodeling, maybe by massage, more likely via ESWT. A search here on heelspurs on 'remodeling' brings up some helpful thinking, as in:

Re: Bilateral PF View Thread -- Posted by Ed Davis, DPM on 8/12/01 at hrmin
There was a good post about 3 weeks ago concerning 'fasciosis' vs. fasciitis. Getting a bit theoretical but fasciosis implies that the problem or at least some of it is due to intrinsic 'disease' of the tissue itself. That is, there is a loss of normal elasticity in the tissue, excess fibrosis (scar tissue) and possibly the improper remodeling or regeneration of tissue in the area by the body.

My gut feeling is that this area is going to be looked at more closely in the future and may have more relevance than we now think. ESWT, by 'traumatizing' the fascia probably results in increased remodeling or tissue turnover time by the body, that is, induce the body to replace 'diseased' tissue with healthier tissue at a faster rate.

We often see patients who have all the right set of conditions, biomechanical and occupational, to develop plantar fasciitis. Will they develop it? When? The answer may lie in how the tissue responds to the abnormal forces.
Ed
Message Number 56959

Re: Fibroblasts make fibrous tissue

Glennx on 3/02/02 at 11:27 (075470)

I believe I've heard osteoblast numbers can be determined in blood. One would think the same is possible for fibroblasts.

Re: WOW Amy and Glenn

Carmen H on 3/03/02 at 07:31 (075522)

You two have really done some talking! Great! I am saving your conversation for future discussion with the doc. I am gettting ESWT done in the near future and will talk to him about this stuff as well just to see his input!

Re: Carmen

Carole C in NOLA on 3/03/02 at 07:48 (075524)

Carmen, you are getting ESWT done? That's wonderful!

My memory is not the best, but as I recall your pain is in the 1-2 area. Is that right? I guess that is why I am surprised you are getting ESWT. Not because it's not worth the money, since I think it would be even at a pain level 1, but I didn't think they'd do it on someone with pain level 1-2.

Carole C

Re: Fibroblasts make fibrous tissue

AmyM on 3/03/02 at 12:12 (075532)

Hi
I'll look into blood tests for fibroblasts, trouble is its very hard to study in people. You can't give someone ESWT and then open up their foot a few months down the line to see whats happened! A blood test would only give an indication of fibroblasts in the whole body and as most people with pf only have trouble in their feet that might not be so informative.
As for heating, well as long as its not hot enough to activate your cells heatshock pathways then all its doing is promoting blood to flow into the area. An increase in blood flow increases oxygen and this can only be a good thing.
I don't think feeling the temperature on the outside of your foot could really give much indication of the amount of healing that is actually going on, because our hands and feet are the parts of our body that experience the most temperature change. For example, if you're really cold, then your body puts all its energy into maintaing your core body temperature (around your heart and lungs)which is why explorers in arctic conditions experience gangarene in their toes and hands. (the body is sparing the heart and to a certain extent the brain at the expense of your hands and feet)

Re: Fibroblasts make fibrous tissue

Glennx on 3/03/02 at 13:06 (075542)

I agree. Fibroblast counts are probably not informative since tissue re-building is ongoing even without injury.
Because my right foot is more troublesome than my left, I have a point of comparison. An hour into rest of an evening, my right foot, particularly around the ball of my foot, is noticeably warmer than my left, which is cool. A month ago my RF was even warmer there, at that time of day. I otherwise have no trouble with the ball of my foot and ascribe this to increased blood flow (inflammatory work) to the foot region in general. I'm looking forward to when it remains cool.
I agree with you though that other factors influence. At best it's indicative, not definitive. For me however, even small suggestions of progress are encouraging.
I much appreciate you're curiosity to this area.

Re: Carmen

Carmen H on 3/03/02 at 13:10 (075543)

It's been stuck at this level (sometimes going to a 5-6 one looong days) for MONTHS. The tendon is VERY tight....the Pod and PT recommended it b/c even though my pain lessened the tightness is still extraordinary.
Can't hurt. I am ready to have a family with my husband but NOT until these feet are under control. I can NOT go through pregnancy with BAD feet.....it will be tough enough already to gain weight, have raging hormones etc...much less with PF!
I am not mentally equppied to handle that kind of trauam. ;-) little humor for ya on that last one.
Thanks for your interest as always Carole...you are so kind to inquire!

Re: Carmen

Carole C in NOLA on 3/03/02 at 15:58 (075563)

Sorry to hear about those 5-6 days, and the very tight tendons, Carmen!

Definitely it can't hurt, and I'm happy for you that they are going to do it. I am feeling really really good this week, perhaps a 0.5 (grin)(hi fives to all here!) so with any luck I will heal without needing it. Still, it's good to know that they do not automatically rule people out who aren't in excruciating agony constantly. A 1-2 is already too much! :)

Carole C

Re: Doctors any input on the following article?

Glennx on 2/28/02 at 11:05 (075280)

Carmen: Super illiminating! Perhaps too for wrist soreness.

Wonder also if fibroblasts and/or myofibroblasts are present with PF, and what that may (or may not) mean? [As in 'Cellularity results from the presence of fibroblasts and myofibroblasts, not inflammatory cells. Thus, in patients who have chronic overuse tendinopathies, inflammatory cells are absent.'] from the article

Re: Doctors any input on the following article?

AmyM on 2/28/02 at 17:19 (075319)

Everyone has fibroblasts and myoblasts whether they have PF or not. Fibroblasts are cells that make up the fibrous tissues of the body and myoblasts make up muscle. (there are also loads of sub categories of these cell types)
There are loads (at least 30-40) different types of 'inflammatory' cells so that term is pretty meaningless.
I've never heard of 'cellularity' before. Your cells make up your body so of course there is 'cellularity'!

This has probably confused the issue, but their scientific reasoning seems pretty vague to me.

Re: Could it be Plantar Fasciosis?

Glennx on 2/28/02 at 20:01 (075331)

The article Carmen points us to makes a case for most tendinitis actually being tendinosis. ('itis' has to do with inflammation. 'osis' seems to refer more to degeneration) Until today I didn't know there was such a thing as tendinosis. Now I also learn there is a term, 'fasciosis,' as in 'Plantar Fasciosis.' And which may also suggest some subtle different treatment directions.

See, for instance:
http://partners.golfserv.com/apps/fitness/askexperts/more.asp?qid=2
http://www.allina.com/Allina_Journal/Spring1997/lutter.html

And a search for 'fasciosis' here on heelspurs brings up an interesting dialogue from last summer.

Re: Doctors any input on the following article?

Glennx on 2/28/02 at 21:27 (075342)

Amy: Do you know? Are fibrous tissues made BY, or made OF fibroblasts? i.e., builders of fibrous tissues or ingredients?

Re: Fibroblasts make fibrous tissue

AmyM on 3/01/02 at 15:39 (075417)

Fibroblasts build fibrous tissue. 'blast' cells can divide and create new tissue.
Fibroblasts create fibrous tissue where as osteoblasts create bone.
Connective tissue is made up of three types of fibres 1)collagenous 2)elastic 3)reticular.
Fibroblasts are capable of remodelling and forming all three types of fibre, therefore they can both produce and breakdown collagen. Fibroblasts also create the 'ground substance' referred to in the article. Ground substance is a clear fluid/gel that surrounds the fibres. It contains proteoglycans and glycans.
Myofibroblasts are a subtype of fibroblasts the contain actin and myosin, two proteins that are commonly found in muscle cells and allow muscle to contract. Myofibroblasts are often found in healing wounds.

So the article says that tendonopathies have....

a loss of collagen continuity (figure 1):
This means that instead of being nice and flat and in straight rows the collagen fibres are all curled up and mashed together

an increase in ground substance,
increase in the amount of fluid in each cell, this seems logical as this would increase pressure on surrounding cells and produce pain. It might also explain why massage helps as it would promote the movement of fluid

an increase in vascularity,
This means an increase in blood vessels. Possibly because the body is trying to heal itself ?

an increase in cellularity (figure 2: not shown)
Cellularity means the number and quality of cells in a tissue. Possibly more cells if dead cells aren't cleared efficiently ?

Cellularity results from the presence of fibroblasts and myofibroblasts (figure 3: not shown), not inflammatory cells.

Myofascial releasehas helped some PF/AT sufferers. Practitioners of this therapy claim that ground substance can change from a gel to a liquid state. They say (I don't know how much scientific evidence there is for this) that heating or streching causes ground substance to become liquid and during this time the collagen fibres can unwind and adhesions break. They claim that fast massage does not allow enough time for this to happen.

For a nice picture of fibroblasts check out this link. Scroll down to 'Ordinary Connective Tissue Types',the green picture with the heading 'Loose' has fibroblasts http://www.uoguelph.ca/zoology/devobio/210labs/ct1.html

For more information on myofascial release look at http://www.deeptissue.com/learn/systems/fascia/fascia.htm

Re: Fibroblasts make fibrous tissue

Glennx on 3/01/02 at 18:07 (075423)

Amy: Fascinating and very helpful stuff. It makes such a difference seeing, and beginning to understand things at the cellular level. I'd done searches on fibroblasts but hadn't been able to find anything so lucid and concise. Your links were insightful as well. For the first time I understand MFR.

Puts this exerpt in better perspective too:
The Stages of Healing
There are characteristically three stages of ligament and tendon healing: inflammatory, proliferative, and remodeling.

1. During the initial inflammatory phase, the immune system increases circulation to the injured area, which produces the classic redness and warmth, which typifies soft tissue injury. The increased circulation also helps produce edema (swelling) and the accompanying pain. Unfortunately, many athletes, trainers, and team physicians see pain and heat after an injury as bad and prescribe treatments such as RICE and anti-inflammatories. Pain should signal to the athlete that the immune response to injury is working correctly. Stopping the above inflammatory reaction to any degree decreases the likelihood of, or delays complete healing.

2. During the proliferative phase, type I collagen is being laid down by the fibroblasts to increase ligament and tendon strength. After about four weeks, about 60 percent of the tensile strength of the tissue may be restored. This obviously depends on the amount of tissue damage and the ability to mount an inflammatory response after injury. The healthier the immune system, the quicker the ability to heal.

3. The remodeling phase of healing occurs for up to one to one and a half years after the original injury, when the body attempts to restructure the injury and restore the body to a pre-injury state.

Thank you!
Glenn

Re: Fibroblasts make fibrous tissue

AmyM on 3/02/02 at 08:58 (075458)

Thats interesting, I'm starting to think that icing chronic injuries may not be the best plan. I've found heat to be better, I think I've been stuck in Stage 3 for about a decade!!!!
It might be interesting to see if people prone to chronic PF/AT and related conditions have a defect in firbroblasts.

Re: Fibroblasts make fibrous tissue

Glennx on 3/02/02 at 11:22 (075468)

I'm recently not-icing as well, and have started monitoring how warm my injured area is to the touch, particularly after about an hour of rest in the evening. If warm in comparison, say to my other foot, my guess is some tissues are at stage 1 responding to micro injuries in that, or previous days. Since the fascia is fairly large, probably likely that portions of it can be in different stages, perhaps all three simultaneously. And perhaps month after month.

Chronic situations may suggest that tissues really need remodeling, maybe by massage, more likely via ESWT. A search here on heelspurs on 'remodeling' brings up some helpful thinking, as in:

Re: Bilateral PF View Thread -- Posted by Ed Davis, DPM on 8/12/01 at hrmin
There was a good post about 3 weeks ago concerning 'fasciosis' vs. fasciitis. Getting a bit theoretical but fasciosis implies that the problem or at least some of it is due to intrinsic 'disease' of the tissue itself. That is, there is a loss of normal elasticity in the tissue, excess fibrosis (scar tissue) and possibly the improper remodeling or regeneration of tissue in the area by the body.

My gut feeling is that this area is going to be looked at more closely in the future and may have more relevance than we now think. ESWT, by 'traumatizing' the fascia probably results in increased remodeling or tissue turnover time by the body, that is, induce the body to replace 'diseased' tissue with healthier tissue at a faster rate.

We often see patients who have all the right set of conditions, biomechanical and occupational, to develop plantar fasciitis. Will they develop it? When? The answer may lie in how the tissue responds to the abnormal forces.
Ed
Message Number 56959

Re: Fibroblasts make fibrous tissue

Glennx on 3/02/02 at 11:27 (075470)

I believe I've heard osteoblast numbers can be determined in blood. One would think the same is possible for fibroblasts.

Re: WOW Amy and Glenn

Carmen H on 3/03/02 at 07:31 (075522)

You two have really done some talking! Great! I am saving your conversation for future discussion with the doc. I am gettting ESWT done in the near future and will talk to him about this stuff as well just to see his input!

Re: Carmen

Carole C in NOLA on 3/03/02 at 07:48 (075524)

Carmen, you are getting ESWT done? That's wonderful!

My memory is not the best, but as I recall your pain is in the 1-2 area. Is that right? I guess that is why I am surprised you are getting ESWT. Not because it's not worth the money, since I think it would be even at a pain level 1, but I didn't think they'd do it on someone with pain level 1-2.

Carole C

Re: Fibroblasts make fibrous tissue

AmyM on 3/03/02 at 12:12 (075532)

Hi
I'll look into blood tests for fibroblasts, trouble is its very hard to study in people. You can't give someone ESWT and then open up their foot a few months down the line to see whats happened! A blood test would only give an indication of fibroblasts in the whole body and as most people with pf only have trouble in their feet that might not be so informative.
As for heating, well as long as its not hot enough to activate your cells heatshock pathways then all its doing is promoting blood to flow into the area. An increase in blood flow increases oxygen and this can only be a good thing.
I don't think feeling the temperature on the outside of your foot could really give much indication of the amount of healing that is actually going on, because our hands and feet are the parts of our body that experience the most temperature change. For example, if you're really cold, then your body puts all its energy into maintaing your core body temperature (around your heart and lungs)which is why explorers in arctic conditions experience gangarene in their toes and hands. (the body is sparing the heart and to a certain extent the brain at the expense of your hands and feet)

Re: Fibroblasts make fibrous tissue

Glennx on 3/03/02 at 13:06 (075542)

I agree. Fibroblast counts are probably not informative since tissue re-building is ongoing even without injury.
Because my right foot is more troublesome than my left, I have a point of comparison. An hour into rest of an evening, my right foot, particularly around the ball of my foot, is noticeably warmer than my left, which is cool. A month ago my RF was even warmer there, at that time of day. I otherwise have no trouble with the ball of my foot and ascribe this to increased blood flow (inflammatory work) to the foot region in general. I'm looking forward to when it remains cool.
I agree with you though that other factors influence. At best it's indicative, not definitive. For me however, even small suggestions of progress are encouraging.
I much appreciate you're curiosity to this area.

Re: Carmen

Carmen H on 3/03/02 at 13:10 (075543)

It's been stuck at this level (sometimes going to a 5-6 one looong days) for MONTHS. The tendon is VERY tight....the Pod and PT recommended it b/c even though my pain lessened the tightness is still extraordinary.
Can't hurt. I am ready to have a family with my husband but NOT until these feet are under control. I can NOT go through pregnancy with BAD feet.....it will be tough enough already to gain weight, have raging hormones etc...much less with PF!
I am not mentally equppied to handle that kind of trauam. ;-) little humor for ya on that last one.
Thanks for your interest as always Carole...you are so kind to inquire!

Re: Carmen

Carole C in NOLA on 3/03/02 at 15:58 (075563)

Sorry to hear about those 5-6 days, and the very tight tendons, Carmen!

Definitely it can't hurt, and I'm happy for you that they are going to do it. I am feeling really really good this week, perhaps a 0.5 (grin)(hi fives to all here!) so with any luck I will heal without needing it. Still, it's good to know that they do not automatically rule people out who aren't in excruciating agony constantly. A 1-2 is already too much! :)

Carole C