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PF: right acronym, wrong name?

Posted by elliott on 5/21/03 at 10:44 (119503)

Article in the latest JAPMA:

http://www.japmaonline.org/cgi/content/abstract/93/3/234

The distinction between fasciitis (inflammation) and fasciosis (tissue disorder) apparently was discussed briefly on these boards a while back. Two questions:

If it really is a fasciosis, would that mean also don't bother with long-term use of oral anti-inflammatories?

If it really is a fasciosis, why does a cortisone shot work great for some?
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Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/21/03 at 21:13 (119580)

Elliott:

Very few posters on this site actually have plantar fasciitis. They have plantar fasciosis. The latter term implies that the tissue is diseased and it is the diseased fascia that fails to respond to conventional conservative treatments and becomes 'intractable' PF. ESWT is a treatment for plantar fasciosis, not PF. Virtually every study except Buchbinder, applied ESWT to patients with plantar fasciosis. That being said, the term 'plantar fasciosis' is a more accurate term but not one in common usage and, as such, confusion may be caused by throwing that term around. I think that, in the long term, for the benefit of all we do need to change the terminology. (One dreads changing the terminology, then waiting for the FDA and third parties to fall in line)

Ed

Re: PF: right acronym, wrong name?

Bev on 5/22/03 at 06:33 (119596)

DR. ED..,
What do you mean by ' the tissue is diseased' in plantar fasciosis , and that it is no longer classified as plantar fasciitis ?

Re: PF: right acronym, wrong name?

elliott on 5/22/03 at 08:28 (119607)

Dr. Ed, you're sarting to sound like another doc on this board absolutely fixated with ESWT. :-) Look, I believe you, but could you at least answer my questions about whether it follows not to bother with anti-inflamms and why cortisone does work for some? Thanks! :-)

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Re: PF: right acronym, wrong name?

john h on 5/22/03 at 09:17 (119617)

Elliott: Obvioulsy I cannot speak with the authority of Dr. Ed but certainly there are at least two reasons whey cortisone shots may work for some and not for others. (1) The shot was not in the correct area (2) There is another underlying problem. Dr. Baxter thinks the pain generator in PF in many cases is caused by the fascia pressing on the Baxter Nerve underneath the fascia.

My first cortisone shot had me pain free for about three days. My second one did not work at all. Having bilaterl PF I asked the Doctor who gave me the shot if I should not get one in both feet. He said that he found in many cases that a shot in one foot for reasons unknown to him actually helped the PF pain in both feet. This made no sense to me but that is actually what happened with the first shot. Some years ago I tried a Medrol Dose Pack (cortisone) and that actually was the only effective medication I ever took for PF but as you know it is not something you want to take long term.

I still think the biggest question to be answered with PF is 'What is the pain generator?'. I do not think anyone with scientific certainity can answer that question and is probably different from person to person. If this is the case then no one treatment is going to work all of us and so our Doctors practice medicine as the Art which it is.

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 09:21 (119619)

Elliott:

Please go back to my use of the treamtent triad since that concept addresses your concerns. There are three 'legs' to the PF treamtent issue -- inflammation, biomechanics and tissue quality. But, those legs are not of equal length and differ with the stage of the disease. Initially, inflammation is the major component and, as such, anti-inflammatories and rest are the key treamtents. If the problem persists, then maintainance of the problem is probably due to biomechanical factors which need be addressed. Longstanding inflammation leads to a decrease in tissue quality. If that decrease in tissue quality is significant, then anti-inflammatories have a negligible effect.

Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 09:24 (119620)

Bev:

Lonstanding plantar fasiciitis which is inflammation of the fascia causes the fascia to become thick, inelastic, filled with scar tissue and with decreased vascularity. That is the stage where the tissue is diseased and where conventional treatments work poorly. That stage is often termed intractable PF. It is not officially re-classified as fasciosis but many, including myself favor that reclassification as it better reflects what is occurring.
Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 09:28 (119622)

JOhn:

The reason that the cortisoned shot did not work well is because cortisone is an anti-inflammatory and you probably did not have a large component of inflammation. Another issue is the location of the injection.
Depending on what is used in the shot, there is systemic absorbtion and as such , a potential systemic effect which can influence inflammation on the other foot or in other parts of the body.
Ed

Re: PF: right acronym, wrong name?

Pauline on 5/22/03 at 09:31 (119623)

Just wondering how many of us may have blood relatives who also suffer or suffered from P.F.?

So far I've only found one in our family, but I'm still checking.

Re: PF: right acronym, wrong name?

elliott on 5/22/03 at 10:22 (119638)

But Dr. Ed, if I'm reading that JAPMA abstract correctly, their point is that just about none having classic PF symptoms have any significant inflammation, seemingly implying that there is little to no chance of NSAIDS working in such circumstances. It certainly would explain why you need to take them for a very long time (since that is not really what's making you better, but taking it for so long means you'll never know for sure). Accepting the implications of the article may also mean that Medicare's recently announced pre-requirements for ESWT you just posted, such as a course of anti-inflammatories, would be misguided.

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Re: PF: right acronym, wrong name?

john h on 5/22/03 at 10:24 (119639)

Ed: Are you aware of any large studies done on cadavers who had PF and what the findings may have been? I guess it would be difficult to make such a study as people do not die form PF and probably the best info we have is just from random cases.

Re: PF: right acronym, wrong name?

Bev on 5/22/03 at 10:50 (119643)

DR. ED. ,

At this stage, then is it the best treatment to do ESWT , when you classify PF as plantar fasciosis? Or is there other treatment that can be done other than ESWT ? I think that I have been through the gammet of everything else there is . Bev

Re: PF: right acronym, wrong name?

Bev on 5/22/03 at 10:52 (119645)

DR. ED.,

PS. If I am at that other stage of PF, then cortisone injections would not even help either anymore, right, as the inflammation has turned into scar tissue?

Re: PF: right acronym, wrong name?

Bev on 5/22/03 at 11:05 (119646)

Pauline,
I do not know if I had any family members that did or not. My father was a police officer and he may have, however our parents did not discuss things with us children. We lived our own lives and they lived theirs , they never really 'talked' to us about things . Now that they are gone, I really am very sad about that, there is so much I will never know about them , and it hurts me deeply. They were always involved in their friends and not their childrens lives, but that is how they were, they were very social people. I surely do not take after them, I have always been very shy and a hermit, my sister was the social one :) So if anyone had PF in the family I do not know of it. Boy, do I get off of the subject or what :D

Re: PF: right acronym, wrong name?

elliott on 5/22/03 at 11:20 (119649)

Bev, I think we're rapidly heading toward a view similar to that of Dr. Kiper's and his SDOs, whereby starting from about age 10, every few years or so we should all get ESWT for preventive maintenance. By so doing we will irradicate PF from our midsts once and for all. :D

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Re: PF: right acronym, wrong name?

Bev on 5/22/03 at 11:40 (119651)

Elliott,
Are you being smug :-/

Re: PF: right acronym, wrong name?

Dr. Z on 5/22/03 at 12:39 (119658)

You are taking NSAID in hopes that the swelling will be reduced. The swelling is causing an impedence on the healing process and possible damaging the micro-circulation to the fibers that are attached to the plantar fascia. Once the micro-circulation is damaged it is very difficult to heal the area. I like to call this a soft tissue mal-union. Very similiar to a boney non-union but we are talking about soft tissue

Re: PF: right acronym, wrong name?

Dr. Z on 5/22/03 at 12:41 (119659)

this is where an ultrasound may be very helpful to elevate any swelling in the plantar fascia before a local steriod injection is given. Right now it give the shot and see what happens

Re: PF: right acronym, wrong name?

elliott on 5/22/03 at 13:34 (119664)

Dr. Z, I'll ask again: are you sure a typical case of PF has swelling? The thesis of the article seems to be that in general there isn't any.

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Re: PF: right acronym, wrong name?

Dr. Z on 5/22/03 at 15:46 (119676)

An acute form of pf has swelling that is where you get the word acute. again you and have a chronic form that has an acute episode. The only way you can see swelling is either with an ultrasound and or mri. Is what you want

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 15:49 (119677)

John:

I am not aware of such studies particlarly as it pertains to the plantar fascia. The significant finding I have seen on almost every cadaver is the atrophy of the intrinsic musculature of the foot -- the small muscles in the foot that run parallel to the fascia. If those muscles could be enlarged/strengthened, then tension would be removed from the plantar fascia. That is why the Russians effectively used 'Russian stim' to treat PF in some studies.
Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 15:51 (119679)

Bev:

I think that the significance of calling it 'fasciosis' is that we are admitting that we must do something to deal with the bad tissue -- improve it with ESWT or surgically release it.

Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 15:59 (119680)

Elliott:

ESWT would have no value in maintainance unless we somehow come up with some way to look for potentially pathologic tissue ahead of time. I think that is 'pie in the sky' for now so I would not worry aabout it.
Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 16:03 (119681)

Elliott:

The problem is that there is still a degree of a shotgun approach. If we really knew exactly how much of the problem was inflammation, how much was biomechanics and how much was a tissue quality issue (fasciosis) then those recommendations could be refined.
Ed

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/22/03 at 16:05 (119682)

Bev:

I think he has been watching Star Trek.

Ed

Re: QUESTION FOR DR. ED about inflammation and tissue damage

Sharon W on 5/22/03 at 16:54 (119685)

Dr. Ed,

I recall your 'treatment triad' concept and I'm quite fascinated by your remarks, above: 'Lonstanding plantar fasiciitis which is inflammation of the fascia causes the fascia to become thick, inelastic, filled with scar tissue and with decreased vascularity. That is the stage where the tissue is diseased and where conventional treatments work poorly. That stage is often termed intractable PF.'

I don't think I've ever seen that explained so clearly and understandably before, and it's something I've wondered about. I have seen comments before that longstanding inflammation (swelling) can cause tissue damage but I didn't understand how that happens... Does the tissue damage caused by longstanding inflammation include NERVE damage? Could the nerves, or at least the nerve endings, in an area constantly filled with inflammation for months on end, begin to die back?

This explanation seems to fit with what happened in my case. My MRI clearly showed inflammation under the PF but after my podiatrist did the TTS surgery she told me my plantar fascia looked healthy -- not bumpy or thickened. (There was a 7 month gap between the MRI and the surgery, and I think my PF had healed considerably during that time, probably because of rest and Vioxx.)

It makes sense. If I understand this correctly, I must have had 'true' plantar fasciitis that probably did NOT turn into 'plantar fasciosis,' or 'Intractable PF'.

Thanks, Dr. Ed - and Elliot, too!

Sharon
:)

Re: PF: right acronym, wrong name?

Sharon W on 5/22/03 at 17:00 (119687)

Dr. Z:

You made some comments that I found quite interesting: swelling is causing an impedence on the healing process and possible damaging the micro-circulation to the fibers that are attached to the plantar fascia. Once the micro-circulation is damaged it is very difficult to heal the area.'

Does this damage to the micro-circulation explain why sometimes people with PF seem to have less heel fat than the average person? Is the heel fat also affected by this problem with the micro-circulation?

Sharon
:-/

Re: Pauline - PF in the family?

Kathy G on 5/22/03 at 18:27 (119692)

Yes, Pauline, my twenty-nine year old son developed PF last year. My mother had osteoarthritis in her feet but no PF and neither did my father. My sister had a Morton's Neuroma (I have one of those, too.) sucessfully removed a few years ago. Interestingly, my twenty-two year old daughter had to have an ingrown toenail removed a few months back and she went to my Pod. He asked her, at the end of the appointment, if she had any questions and she said, 'Yes, what can I do so I don't end up with feet like my mother's?'

He told her not to worry. While there is no guarantee that she won't get it, structurally her feet are not in the least bit like mine. He gave her the usual speil he probably gives all the young women about wearing somewhat sensible shoes, or at least not wearing harmful shoes for any extended period, but that was about it.

And he's right. My son's feet, poor guy, look just like mine and he is built like me. He shares my problems with muscle spasms and back pain. She, fortunately, is built more like my husband and so far, so good.

Re: Oh, and one more thing

Kathy G on 5/22/03 at 18:28 (119693)

He also inherited my terrific good looks and wonderful personality! :'> :))

Re: PF: right acronym, wrong name?

elliott on 5/22/03 at 19:22 (119698)

Hey Docs, I'm starting to wonder if you even clicked on the link I provided. There, some fellow beloved pods, writing not in some lowly orthopod journal, but in your favorite DPM journal, wrote the following:

'The authors review histologic findings from 50 cases of heel spur surgery for chronic plantar fasciitis. Findings include myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. Histologic findings are presented to support the thesis that 'plantar fasciitis' is a degenerative fasciosis WITHOUT INFLAMMATION [caps inserted by elliott], not a fasciitis.'

They are suggesting, based on observations of 50 PF surgeries, that there isn't really any inflammation. It is my feeling that docs who want to stay current with medical advances should at least glance at what's going on in medical journals. Can't you two take a look a the article? If there's weaknesses in it, fine, point them out.

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Re: PF: right acronym, wrong name?

Dr. Z on 5/22/03 at 20:09 (119700)

Fat pad wearing out is caused by repetitive trauma to the area. Excessive Weight will spread the fat pad away from the bottom of the heel. Micro-circulation has no part generally speaking

Re: PF: right acronym, wrong name?

Dr. Z on 5/22/03 at 20:23 (119702)

Sounds like my soft tissue mal-union description. That is why ESWT works but that is all I am tuned into I have observed alot of heel spur pf procedures and found that the ones that didn't respond to conservative treatment have poor circulaton and findings of incomplete healing. I talked before on this board. Not all doctor agree with this but it is my opinon that an avascular event is the cause of chronic pf ( osis)

Re: PF: right acronym, wrong name?

dave r on 5/23/03 at 07:29 (119732)

My twin brother had pf for three years. He was able to get rid of it by wearing cowboy boots. My mother has pf and my father had a nueroma on both feet. All three of them can out run/walk me.

Re: PF: right acronym, wrong name?

john h on 5/23/03 at 10:38 (119738)

Dr Z I would assign the word a-cute to some of of our ladies on the board.

Re: PF: right acronym, wrong name?

Ed Davis, DPM on 5/23/03 at 15:56 (119764)

Elliott:

Yes, we read those journals but we do so critically as they baiscally provide a 'slice' of information that does not present the whole picture.
The take home lesson from that article is the importance of PF as a disease of the tissue in recalcitrant cases. It does support the case for fasciosis. The article focuses on the third leg of the triad that is addressed with ESWT.

PF is not a static process, but like most pathology, a dynamic one which goes through stages. I believe that if progressive biopsies were performed at different stages one would see a progression of pathology consistent with that which I have described. The bottom line is, very few patients, in their right mind are going to let someone cut a chunk of their fascia off (ie. biopsy) unless they are in pretty bad shape, that is diseased fascia or fasciosis.

Ed

Re: PS for Elliott

Ed Davis, DPM on 5/23/03 at 15:59 (119765)

By the way -- I know the author, Harvey Lemont, DPM very well and have some insights into the thinking behind the paper.
Ed

Re: QUESTION FOR DR. ED about inflammation and tissue damage

Ed Davis, DPM on 5/23/03 at 23:18 (119791)

Sharon:

Thank you. I believe that your understanding of the situation is consistent with what I have described. It is critical that the process be described accurately so that we can agree on what treatments are appropriate and how to describe the need for treatment to third parties.
Basic understanding of these concepts shows that the oft quoted Buchbinder study, virtually the only study that failed to support ESWT, was incorrectly done since half of the subjects in the study had short term plantar fasciitis and probably no significant fasciosis.

Ed

Re: QUESTION FOR DR. ED about inflammation and tissue damage

Dr. Z on 5/24/03 at 07:00 (119801)

Ed,

The article by Lemont just came in the mail today. It is excellent. The use of ultrasound before any local steriod injection may help to determine if and when a local steriod injection is indicated. I like to describe this fasciosis as a type of soft tissue non-union . Good point about the Buchbinder study.

Re: Lemont

elliott on 5/24/03 at 22:29 (119849)

Dr. Z, when you have a chance, could you summarize Lemont's article? I mean, if it offers strong evidence that there's a point in time when it pays to take or not take NSAIDS, that would be valuable info. Thanks.

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Re: PF: right acronym, wrong name?

Laura on 6/03/03 at 19:59 (120831)

I have had ESWT that did not work, EPF, and heel spur surgery, all on the same foot and nothing has worked. So I have come to the conclusion that somehow my fasia is damaged and cannot repair itself. It starts to repair and as we start to walk again, and do normal things, it slips back into the same condition. I have good circulation and no problem with healing anywhere else and do the stationery bike 20 to 30 minutes a day. I do believe that PF in many people is a tissue 'disease' and should be treated as such by the doctors. This is a disease that we will probably have to live with the rest of our lives and that compromises the quality of our lives and what we love to do.

Re: PF: right acronym, wrong name?

Pauline on 6/04/03 at 10:08 (120890)

Laura,
The same thoughts about long term p.f. have crossed my mind too.