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PF/ poss TTS tx-please advise

Posted by Carol E. on 9/01/02 at 09:47 (094121)

I've probably provided too much history, so if you just want the questions, they are at the end, after the asterisks! Thanks!

I had a desk job a year or two ago and developed PF when I started a walking program. It was treated by a podiatrist I really liked with orthotics, ultrasound and NSAIDs, and responded pretty well. I also took the advice to cut out the walking program for awhile (never really got back to it).

Changed jobs in February (having completely forgotten about the foot stuff). Went to work as nurse in hospital ICU. Feet got really bad, to where I had to ice them mid (12-hour) shift. No health insurance now, but I went back to podiatrist, who told me that it wasn't caused by work. Got it settled down as long as I was not working, but as soon as I went back, it was back with a vengeance.

Visited local urgent care one day when it was really bad and I'd hurt my knee at work, doctor determined feet were work-related and referred to the only podiatrist in town that accepts Workers' Comp. This helps, due to lack of insurance. I really like the new podiatrist, too. He told me that my current orthotics were useless, because they were too flexible, told me to continue Naprosyn, ice feet, and do some (non-weight bearing) stretches.

Returned in two weeks, he gave me a steroid injection in the worse foot. I got out to the car and put the seat back before I passed out (OK, I'm a wimp), so I didn't think to ask about work. He had told me to take it easy for a couple days. I only work 2-3 12 hour shifts per week, and the first would have been that night. I didn't work.

Returned in one week. When he heard about my reaction to the shot, he decided not to repeat that. Taped the worse foot. When I asked about working, he told me I could have gone to work after the steroid injection and that I could go now, with tape in place.

I cannot walk through the grocery store for more than an hour without having severe pain. Two years ago, at age 40, I was told that I was osteopenic (sort of 'pre-osteoporosis,' I guess). Dr. tapped my ankle and I felt a sort of twitch in the bottom of my foot - he says maybe TTS. I have stayed off work since I hurt my knee and feet were so sore (Aug 4), but did that on my own, no doctor has 'covered' this for me. (I work through an agency - being off work just means I don't schedule shifts; I don't need a note to use sick time or anything because I don't get sick time. All I can get is WC coverage if doctor puts me off, and it is less than I would make working).

*********************************

Questions:

1. Are one or more steroid injections 'conservative management' within the 1st 3 weeks of treatment?

2. Does my osteopenia raise any contraindication to local steroid injections (I've heard that long-term systemic steroids can further weaken my bones)?

3. Is it realistic for me to continue to work as a nurse while I am symptomatic? There is no 'light duty' option; lifting adult patients is part of a normal shift.

4. Are there other treatment options that should be considered prior to repeating a steroid injection?

I want to treat this actively, but I don't want treatments that may cause more harm down the road. The steroids do worry me.

Please help!

Re: PF/ poss TTS tx-please advise

Dr. Z on 9/01/02 at 10:35 (094125)

Hi

Local steriod injections have very little effect on general osteoporosis.
They can damage local tissue and in some rare but real cases cause rupture of the plantar fascia.

Yes rest is key and if you are on your feet alot you have to change or modify your nursing job. Long 12 hour standing shifts aren't going to heel your feet.

There are many treatment that can and shoule be used in conjunction with a local steiord injection. Physical Therapy, NSAID, taping, boot cast if only one foot.

ESWT is an option if there is a tear and you aren't responding to conserative treatment.
The fact that you due have a heel spur or what is called a calcification tells me that you did have some degree of tearing of the plantar fascia fibier. The quesion is are they healed and to what degree

Re: PF/ poss TTS tx-please advise

J. King on 9/01/02 at 17:52 (094154)

Don't scorn the workers compensation! If you can get a doctor to say it is work- related go for it. It may be less than what you make working but it may save your financial situation if it gets worse. That would give you a long rest if you could collect for a while.

John K

Re: PF/ poss TTS tx-please advise

Carol E. on 9/02/02 at 21:20 (094304)

Please don't think I am scorning the WC! It is income, besides covering the cost of treatment. Both are WAY better than nothing. I just meant that I don't need a 'note from my doctor' for missing work. I don't get any sick time when I miss work. But if the doctor does officially put me off work to heal, I can get comp. No doctor bothered to do that until I'd been off for nearly a month without pay. Even though WC will pay less than working, it would have been a help for the past 3-4 weeks!

Thanks for your thoughts.

Re: PF/ poss TTS tx-please advise

Carol E. on 9/02/02 at 21:29 (094307)

Dr. Z. - Thank you for your comments. Not to dwell on the subject, but can the local tissue damage from steroids extend to bony damage, like weakening calcaneous? I have read about rupture of plantar fascia, that didn't sound good, either. I'm just real nervous about this 'low bone mineral density' stuff.

Thanks for validating my concerns about being on my feet. It just got so much worse the last time or two that I worked, I couldn't imagine that it would get better if I kept it up.

Is the physical therapy mostly non-weight-bearing stretches? Is there a 'typical' duration for a boot cast? I've seen information about 'night splints' as well, are they helpful?

I looked at ESWT sites and it looks like I would have to travel some distance for that kind of treatment. I appreciate that it is an option, but, as you suggest, I am guessing that I will work with conservative treatment first and see how I respond.

I didn't realize that the heel spurs were indicative of tearing. I understood that they were associated with tightness, but it also looks like they don't cause the pain?

Thanks again for your help.

Re: PF/ poss TTS tx-please advise

Dr. Z on 9/03/02 at 22:16 (094409)

Hi

I woujldn't be real concerned about the local steriod injection causing changes in your bone density. Try the classic treatment . Each treatment such as nite splint depend on your specific degree of plantar fasciitis. I don't use the nite splint but it appears can help your first step morning pain or tight heel cord ( achilles Tendon)

Re: PF/ poss TTS tx-please advise

Dr. Z on 9/01/02 at 10:35 (094125)

Hi

Local steriod injections have very little effect on general osteoporosis.
They can damage local tissue and in some rare but real cases cause rupture of the plantar fascia.

Yes rest is key and if you are on your feet alot you have to change or modify your nursing job. Long 12 hour standing shifts aren't going to heel your feet.

There are many treatment that can and shoule be used in conjunction with a local steiord injection. Physical Therapy, NSAID, taping, boot cast if only one foot.

ESWT is an option if there is a tear and you aren't responding to conserative treatment.
The fact that you due have a heel spur or what is called a calcification tells me that you did have some degree of tearing of the plantar fascia fibier. The quesion is are they healed and to what degree

Re: PF/ poss TTS tx-please advise

J. King on 9/01/02 at 17:52 (094154)

Don't scorn the workers compensation! If you can get a doctor to say it is work- related go for it. It may be less than what you make working but it may save your financial situation if it gets worse. That would give you a long rest if you could collect for a while.

John K

Re: PF/ poss TTS tx-please advise

Carol E. on 9/02/02 at 21:20 (094304)

Please don't think I am scorning the WC! It is income, besides covering the cost of treatment. Both are WAY better than nothing. I just meant that I don't need a 'note from my doctor' for missing work. I don't get any sick time when I miss work. But if the doctor does officially put me off work to heal, I can get comp. No doctor bothered to do that until I'd been off for nearly a month without pay. Even though WC will pay less than working, it would have been a help for the past 3-4 weeks!

Thanks for your thoughts.

Re: PF/ poss TTS tx-please advise

Carol E. on 9/02/02 at 21:29 (094307)

Dr. Z. - Thank you for your comments. Not to dwell on the subject, but can the local tissue damage from steroids extend to bony damage, like weakening calcaneous? I have read about rupture of plantar fascia, that didn't sound good, either. I'm just real nervous about this 'low bone mineral density' stuff.

Thanks for validating my concerns about being on my feet. It just got so much worse the last time or two that I worked, I couldn't imagine that it would get better if I kept it up.

Is the physical therapy mostly non-weight-bearing stretches? Is there a 'typical' duration for a boot cast? I've seen information about 'night splints' as well, are they helpful?

I looked at ESWT sites and it looks like I would have to travel some distance for that kind of treatment. I appreciate that it is an option, but, as you suggest, I am guessing that I will work with conservative treatment first and see how I respond.

I didn't realize that the heel spurs were indicative of tearing. I understood that they were associated with tightness, but it also looks like they don't cause the pain?

Thanks again for your help.

Re: PF/ poss TTS tx-please advise

Dr. Z on 9/03/02 at 22:16 (094409)

Hi

I woujldn't be real concerned about the local steriod injection causing changes in your bone density. Try the classic treatment . Each treatment such as nite splint depend on your specific degree of plantar fasciitis. I don't use the nite splint but it appears can help your first step morning pain or tight heel cord ( achilles Tendon)