Summar of APMA article ( fasciosis)Posted by Dr. Z on 5/25/03 at 17:53 (119898)
The main thrust of this article is to show with microscopic evaluations the lack of inflamatory cells that were present with post heel spur specimens submitted to a podiatric pathological lab.
The conclusion was that surgical specimens show a fasciosis instead of a fasciitis. The article sites other journal sources documenting pf rupture with local steriod injections. The author concludes that the re-thinking of local steriod injections in pf cases of fasciosis should be re-evaluated
due to the potential dangers of rupture.
There is no mention of nsaid and the lack of effectivess in the treatment of plantar fasciosis. One can conclude that the use of nsaid may also have to be re-evaluated in the treatment of cases that lack inflamation. One doesn't know if the use of nsaid has only an analgesic effect but logical dictates that this is why some patient feel better but return to pain after stopping the use of nsaid.
It is my opinion the use of ultrsound may help to determine now and in the future the stage of fasciitis or fasciosis that is present in the patient. The physician then be able to prescribe a better course of treatment and
this one is just for Elliott ( smile) prescribe ESWT sooner then six months if indicated. This article should make the physician re-think the
typical routine treatment
Re: Summary of APMA article ( fasciosis)elliott on 5/25/03 at 22:28 (119922)
Thanks, Dr. Z! I really appreciate the summary, as such things keep us up to date on some current thinking.
Dr. Z, let me ask for a bit of clarification on the article's implications for ESWT. Are you saying ESWT is more appropriate during the inflammation stage (assuming there is one) or the fasciosis stage?
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/25/03 at 22:42 (119925)
No. I am saying that one has to use clinical judgement with ESWT or any other treatment and not just use try this if this doesn't work ty that.
ESWT is for chronic insertional pf( fasciosis) It is what I call soft tissue mal-union of pf at the insertinal. Now to determine fasciosis is in my opinion a art and not exactly a science. The physician needs to make a decision based on the patients response to previous therapy, time, degree of pain, ultrasound reading and just plain experience.
The idea of trying using routine protocol instead of clincial judgement is what is important and this article points in that direction with the question when to give a local steriod injections.
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/25/03 at 22:47 (119928)
One more point . I really don't like the criteria of six months and three failured conservative treatments MUST be followed before ESWT can be used. Insurance company can do whatever they want with payment but the criteria should be written stone. These are rare cases but they do exists. There are patients that have tried many treatment and are in severe pain at four months
Re: Summary of APMA article ( fasciosis)elliott on 5/25/03 at 23:58 (119931)
Dr. Z, if ESWT is, as you say, for chronic insertional PF (fasciosis), i.e., no inflammation, what did Monte mean in a recent post,
where he said,
'Dr Z says that I cannot get another treatment at this time because there is no abnormal inflammation present'?
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/26/03 at 00:01 (119932)
He had normal plantar fascia thickness which means no fasciosis.
Re: Summary of APMA article ( fasciosis)elliott on 5/26/03 at 00:09 (119933)
Dr. Z, I'm not surprised you don't like the 6-month criteria; again, it is convenient for you not to like it. I'm not so petty as to argue that one who has failed to respond at all to numerous other treatments should be refused ESWT at 4 months and 2 weeks simply because it's not yet 6 months. It's just that you can't blame such criteria when someone else, like an ins. co. (and not so indirectly, those insured by it who are paying for that coverage in prems, deducs, and co-pays) is footing the bill--the key point here, cuz no one's stopping the patients if they want to pay out of pocket--when a large portion even of this group still has good chances of ultimate recovery without ESWT.
Re: Summary of APMA article ( fasciosis)elliott on 5/26/03 at 00:14 (119934)
Dr. Z, I'm not questioning your reasoning here, I'm just not sure I understand from a medical point of view. 'He had normal plantar fascia thickness which means no fasciosis.' Does fasciosis imply abnormal thickness? Is thickness equated with inflammation?
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/26/03 at 00:50 (119937)
Tell it to the patient that has insurance coverage, in pain, limping has tried multiple conserative treatment and only has had the condition for four months. The insurance Co. doesn't want to hear anything about the human being behind the foot just the fact that there is two months to go before approval . Now that is what I call convenient !
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/26/03 at 00:53 (119938)
Do you want to learn ultrasound.? I can send you to a web site that is very good. It has pictures of normal and abnormal fascia. It even shows what inflamation looks like from when viewing an ultrasound
Re: Summary of APMA article ( fasciosis)Jeff W. on 5/28/03 at 09:04 (120124)
I am that person you describe.. I have gone through the 6 months plusof conservative treatment and have now been denied ESWT due to 'lack of medical necessity'.I can't shop at a food store without people thinking I suffer from tourette's (spelling) syndrome because of my swearing from the pain of a hot pocker being shoved into the bottom of my foot about 10+ times a day. I am going to give the insurance co. 1 appeal information and put them on notice for legal action. I want to thank you Dr. Z for your input the other day as well.
Re: Summary of APMA article ( fasciosis)Dr. Z on 5/28/03 at 09:15 (120126)
This is very frustrating. There is plenty of literature especially from the this site that support the medical need for chronic insertional ESWT. The procedure is FDA approved so is the first place to start. What insurance company are we talking about
Re: Summary of APMA article ( fasciosis)Ed Davis, DPM on 5/28/03 at 16:00 (120186)
The six month criterion will probably need to stand until we have developed a more intelligent criterion to dtermine eligibility.