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MRI, PF

Posted by Jane T on 10/18/02 at 18:57 (097834)

I have had intractable PF in my R. foot since March. I have not worked since the end of July. I am an emergency physician.
The PF in that foot started 2 years ago but cleared up for about 6 months prior to the exacerbation.
The MRI 9/13/02 showed severe edema/inflammation of the muscles deep to the fascia, subjacent , underneath the calcaneous.
The 'flexor and abductor digiti minimi'. The fascia is inflammed, but less so. This puzzles my doctors. I am scheduled for endoscopic release of the medial band of the PF November 7th. Some doctors have said that I should have an open approach to look at that muscle. Does anyone have experience seeing this on MRI? My primary podiatrist says that the finding is simply an extension of bad PF and that I need the endoscopic surgery. My EMG/NCV was negative.
I had ESWT in Canada early August without any help (Siemons, low intensity, 3 treatments). I am on high dose celebrex (800), neurontin , camwalker, orthotic, ice, tape, I have had acupunture and homeopathy to no avail.
Thank you.
Jane

Re: MRI, PF

Dr Zuckerman on 10/19/02 at 09:30 (097872)

Have you though about high energy ESWT. Remember once the pf release is cut it is done. IF you have pain on palpation of the pf fascia at the insertion with pain and or limping after periods of rest especially in the AM with the first step then you have a very good chance of a cure with ESWT. IF you don't have trigger point pain with first step pain then ESWT isn't the first choice and pf release is not indicated. As per the mri the edema on the bottom could be a bursitis/stress fracture , the area around the insertion of the abductor digit could be from gait compensation. I would still rule out a stress fracture. Just had a case where the MRI was negative and the three phase bone scan was positive. I have also learned that an ultrasound is a much better diagnositic tool when determining the thickness and edema in the the pf. IF the pf is thicker then you know that the that is problem. An mri does evaluate that specific characteristic. Good Luck

Re: MRI, PF

pala on 10/19/02 at 09:41 (097874)

jane when you say a cam walker did not help do you mean it did not resolve it or did you mean that it eases the pain when in it but does not heal it when not in it? have you tried physical therapy? my pt put foam pad in my cam walker and it helped me some. have you tried night splint?

Re: MRI, PF

Dr. David S. Wander on 10/19/02 at 15:49 (097915)

Jane,

In addition to all your past treatments and suggestions by Dr. Zuckerman and Pala, has anyone attempted to place you in a non-weightbearing cast with serial castings to gradually increase dorsiflexion?? This can serve two purposes. Obviously, complete rest may be the only answer for a chronic/recalcitrant plantar fasciitis. Additionally, serial casting may allow for slow passive stretching of the plantar fascia, similar to a night splint. In the interim, if you are going to try a night splint, my personal preference is the Strassburg Sock. A recent study in the Journal of Foot & Ankle Surgery reported significant relief with this product vs. weightbearing stretching exercises. I would be hesitant to recommend plantar fascia release until all avenues have been explored. Have any blood tests been performed to rule out a rheumatological cause? Was your MRI read by a radiologist with significant experience in musculoskeletal MRI, specifically the foot and ankle? Are there any major teaching hospitals in your area with a radiology department well versed in diagnostic ultrasound? Just thought I'd give you as much information as possible to attempt to help you. Good luck.

Re: MRI, PF

BrianG on 10/19/02 at 17:45 (097924)

Hi Jane,

Have you looked at the 'foot surgery' section of this forum? If not, I think you should take some time, and read the results. More and more doctors are getting away from the EPF method. Although the healing period may be a little quicker, it really appears the success rate is much less than the 'open' method. We have many people who have posted here, that not only had failed EPF surgery, they also developed TTS. I think your one of the fortunate few, that made it to heelspurs.com before your surgery.

Good luck
BrianG, not a doc

Re: MRI, PF

pala on 10/19/02 at 19:42 (097928)

i'm also not a doc and i think that reading the surgery section is a good idea brian. it convinced me to keep plugging away at this with conservative methods. good luck jane please keep us posted. we all care here.

Re: MRI, PF

Jane T on 10/19/02 at 20:03 (097930)

I spent $3000 out of pocket for the low intensity,because I was told that it was not only less expensive but 5% better results--both around 70%. The high intensity would be $4000 out of pocket--no insurance coverage. The surgery is covered.
Since the first low intensity failed, I am reluctant to spend more money.
The bone scan was somewhat postitive but Dr Mann seemed to ignore that finding (wasn't sure of it) and focused on the MRI.
I do have pain at first step. I wear a night splint, and usually before my first step I am pain free.
Thanks for the input. Jane

Re: MRI, PF

Jane T on 10/19/02 at 20:16 (097932)

Thanks for your comments. I do wear a night splint (for months), and that is the only stretching that I do. Any other kind of stretching seems to exacerbate the condition. I swim. I wear a camwalker/boot. I asked them to cast me in a real cast but they said that it was not better than a camwalker. In addition, I would not be able to swim or drive. I have had 3 opinions that the camwalker is 'casting', although I am not sure that I agree.
I had two different radiologists who specialize in this area of the body look at the report. They both said the same thing: some PF but Marked edema in the muscles deep to the PF.

Re: MRI, PF

pala on 10/19/02 at 20:24 (097934)

i'm also not a doc and i think that reading the surgery section is a good idea brian. it convinced me to keep plugging away at this with conservative methods. good luck jane please keep us posted. we all care here.

Re: MRI, PF

Jane T on 10/19/02 at 22:55 (097942)

I use a night splint. It is not clear to me if the camwalker helps at all. Dr Roger Mann (foot and ankle specialist) told me that I should wear it in order to immobilize the area. The Pedorthist who made my orthotics said that I needed to be in good supportive shoes to wear in conjunction with the orthotics--so as usual two different opinions
Jane

Re: MRI, PF

pala on 10/20/02 at 08:05 (097950)

i've had a dozen or more different opinions. they go like this. you must have an operation on both feet now or you will be a cripple for the rest of your life, you would be insane to let anyone operate, you are just simply insane, stop whining, it can't hurt that much. i either have plantar faciitis, posterior tibial tendon dyfunction, mild, m edium or the most advanced case ever seen, ankle insuficiency, metatarsalgia, achilles tendonitits, or nothing is wrong with my feet at all and i am making it all up. i think my favourite is the doctor who thought that all divorced middle aged women complain for no reason and he told me i should not have gotten divorced. i'd remarry the abusive ex if this foot pain would go away. seems about as scientific as the other diagnoses.

Re: MRI, PF

Dr Zuckerman on 10/20/02 at 11:20 (097964)

We use the dornier high energy treatment and our fee is $2500 per one foot. Where do you pay $3000 for a low energy treatment? Are you sure of this?

Re: MRI, PF

Jane T on 10/21/02 at 18:10 (098039)

It was $1000/foot, $2000 both feet but $1000 in travel expenses since I had to go to Toronto, Cananda for several days.

Re: MRI, PF

Ed Davis, DPM on 10/21/02 at 22:17 (098054)

The going rate at the Sonorex treatment center in Vancouver, B.C. is $750 Canadian for three treatments or about $530 US. I thought you lived on the west coast???
Ed

Re: MRI, PF

Jane T on 10/22/02 at 16:46 (098093)

I was not able to find this information. I looked for a place in Vancouver to no avail. The main place I found was Toronto--farther and more money. Too late now. It's over.
My bone scan shows uptake at the origin of the PF 'consistent with PF'. My podiatrist still thinks that I should have the endoscopic scheduled for early November,but I am going to talk to the person who would do this Friday. I am a little better, although I had the bone scan done less than a week ago showing the inflammation.

Re: jane T

Pete on 10/23/02 at 12:28 (098149)

Doesn't Sunny Jacobs at Bayshore, Canada do it cheaper than that ?

Re: MRI, PF

Dr Zuckerman on 10/19/02 at 09:30 (097872)

Have you though about high energy ESWT. Remember once the pf release is cut it is done. IF you have pain on palpation of the pf fascia at the insertion with pain and or limping after periods of rest especially in the AM with the first step then you have a very good chance of a cure with ESWT. IF you don't have trigger point pain with first step pain then ESWT isn't the first choice and pf release is not indicated. As per the mri the edema on the bottom could be a bursitis/stress fracture , the area around the insertion of the abductor digit could be from gait compensation. I would still rule out a stress fracture. Just had a case where the MRI was negative and the three phase bone scan was positive. I have also learned that an ultrasound is a much better diagnositic tool when determining the thickness and edema in the the pf. IF the pf is thicker then you know that the that is problem. An mri does evaluate that specific characteristic. Good Luck

Re: MRI, PF

pala on 10/19/02 at 09:41 (097874)

jane when you say a cam walker did not help do you mean it did not resolve it or did you mean that it eases the pain when in it but does not heal it when not in it? have you tried physical therapy? my pt put foam pad in my cam walker and it helped me some. have you tried night splint?

Re: MRI, PF

Dr. David S. Wander on 10/19/02 at 15:49 (097915)

Jane,

In addition to all your past treatments and suggestions by Dr. Zuckerman and Pala, has anyone attempted to place you in a non-weightbearing cast with serial castings to gradually increase dorsiflexion?? This can serve two purposes. Obviously, complete rest may be the only answer for a chronic/recalcitrant plantar fasciitis. Additionally, serial casting may allow for slow passive stretching of the plantar fascia, similar to a night splint. In the interim, if you are going to try a night splint, my personal preference is the Strassburg Sock. A recent study in the Journal of Foot & Ankle Surgery reported significant relief with this product vs. weightbearing stretching exercises. I would be hesitant to recommend plantar fascia release until all avenues have been explored. Have any blood tests been performed to rule out a rheumatological cause? Was your MRI read by a radiologist with significant experience in musculoskeletal MRI, specifically the foot and ankle? Are there any major teaching hospitals in your area with a radiology department well versed in diagnostic ultrasound? Just thought I'd give you as much information as possible to attempt to help you. Good luck.

Re: MRI, PF

BrianG on 10/19/02 at 17:45 (097924)

Hi Jane,

Have you looked at the 'foot surgery' section of this forum? If not, I think you should take some time, and read the results. More and more doctors are getting away from the EPF method. Although the healing period may be a little quicker, it really appears the success rate is much less than the 'open' method. We have many people who have posted here, that not only had failed EPF surgery, they also developed TTS. I think your one of the fortunate few, that made it to heelspurs.com before your surgery.

Good luck
BrianG, not a doc

Re: MRI, PF

pala on 10/19/02 at 19:42 (097928)

i'm also not a doc and i think that reading the surgery section is a good idea brian. it convinced me to keep plugging away at this with conservative methods. good luck jane please keep us posted. we all care here.

Re: MRI, PF

Jane T on 10/19/02 at 20:03 (097930)

I spent $3000 out of pocket for the low intensity,because I was told that it was not only less expensive but 5% better results--both around 70%. The high intensity would be $4000 out of pocket--no insurance coverage. The surgery is covered.
Since the first low intensity failed, I am reluctant to spend more money.
The bone scan was somewhat postitive but Dr Mann seemed to ignore that finding (wasn't sure of it) and focused on the MRI.
I do have pain at first step. I wear a night splint, and usually before my first step I am pain free.
Thanks for the input. Jane

Re: MRI, PF

Jane T on 10/19/02 at 20:16 (097932)

Thanks for your comments. I do wear a night splint (for months), and that is the only stretching that I do. Any other kind of stretching seems to exacerbate the condition. I swim. I wear a camwalker/boot. I asked them to cast me in a real cast but they said that it was not better than a camwalker. In addition, I would not be able to swim or drive. I have had 3 opinions that the camwalker is 'casting', although I am not sure that I agree.
I had two different radiologists who specialize in this area of the body look at the report. They both said the same thing: some PF but Marked edema in the muscles deep to the PF.

Re: MRI, PF

pala on 10/19/02 at 20:24 (097934)

i'm also not a doc and i think that reading the surgery section is a good idea brian. it convinced me to keep plugging away at this with conservative methods. good luck jane please keep us posted. we all care here.

Re: MRI, PF

Jane T on 10/19/02 at 22:55 (097942)

I use a night splint. It is not clear to me if the camwalker helps at all. Dr Roger Mann (foot and ankle specialist) told me that I should wear it in order to immobilize the area. The Pedorthist who made my orthotics said that I needed to be in good supportive shoes to wear in conjunction with the orthotics--so as usual two different opinions
Jane

Re: MRI, PF

pala on 10/20/02 at 08:05 (097950)

i've had a dozen or more different opinions. they go like this. you must have an operation on both feet now or you will be a cripple for the rest of your life, you would be insane to let anyone operate, you are just simply insane, stop whining, it can't hurt that much. i either have plantar faciitis, posterior tibial tendon dyfunction, mild, m edium or the most advanced case ever seen, ankle insuficiency, metatarsalgia, achilles tendonitits, or nothing is wrong with my feet at all and i am making it all up. i think my favourite is the doctor who thought that all divorced middle aged women complain for no reason and he told me i should not have gotten divorced. i'd remarry the abusive ex if this foot pain would go away. seems about as scientific as the other diagnoses.

Re: MRI, PF

Dr Zuckerman on 10/20/02 at 11:20 (097964)

We use the dornier high energy treatment and our fee is $2500 per one foot. Where do you pay $3000 for a low energy treatment? Are you sure of this?

Re: MRI, PF

Jane T on 10/21/02 at 18:10 (098039)

It was $1000/foot, $2000 both feet but $1000 in travel expenses since I had to go to Toronto, Cananda for several days.

Re: MRI, PF

Ed Davis, DPM on 10/21/02 at 22:17 (098054)

The going rate at the Sonorex treatment center in Vancouver, B.C. is $750 Canadian for three treatments or about $530 US. I thought you lived on the west coast???
Ed

Re: MRI, PF

Jane T on 10/22/02 at 16:46 (098093)

I was not able to find this information. I looked for a place in Vancouver to no avail. The main place I found was Toronto--farther and more money. Too late now. It's over.
My bone scan shows uptake at the origin of the PF 'consistent with PF'. My podiatrist still thinks that I should have the endoscopic scheduled for early November,but I am going to talk to the person who would do this Friday. I am a little better, although I had the bone scan done less than a week ago showing the inflammation.

Re: jane T

Pete on 10/23/02 at 12:28 (098149)

Doesn't Sunny Jacobs at Bayshore, Canada do it cheaper than that ?