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Question about atypical PF

Posted by BrianJ on 5/30/03 at 17:49 (120447)

Many on the board have spoken of 'atypical PF,' which does not cause 'first step' pain, but does cause increasing pain as the day progresses. This is the kind of PF I have. When I get up in the morning, my feet don't hurt much at all; it's only after walking around or standing in one place that my feet begin to hurt (and they hurt badly!). Further, my feet often hurt and burn AFTER I sit down (by the way, I've confirmed that I don't have nerve issues or systemic issues such as arthritis)

Here's my question: What treatments have proven best for atypical PF? Has anyone with atypical PF benefitted from ESWT, surgery, or other treatments?

Re: Question about atypical PF

SteveG on 5/30/03 at 19:32 (120458)

Brian - sounds a lot like my PF. Do you have pain at the insertion point? Although I have the symptoms you mentioned, I also have pain that is quite localized at the insertion. I have had two rounds of ESWT and I would say that I am definitely better than I was prior to the treatment.

Re: Question about atypical PF

monte on 5/30/03 at 21:49 (120468)

sounds like mine too!

Re: Question about atypical PF

Pauline on 5/30/03 at 21:51 (120469)

I've been told the Ossatron because of it's larger focal area. I've not had the treatment, however, it can be used in the arch area. They would move it around and adjust the power level.

The condition you are describing was similar to what I was experiencing.

Re: Question about atypical PF

BrianJ on 5/30/03 at 22:13 (120472)

SteveG --

Yes, I do have localized pain at the insertion, and slightly distal to the insertion. The thing that is really strange is how the whole plantar aspects of my feet feel so fragile, and how I often have aching pain that will radiate both down toward my toes and up through my ankles. I suspect (pure speculation) that if the insertional pain could be reduced, the radiating pain would be reduced proportionally.

Re: Question about atypical PF

Pauline on 5/30/03 at 22:40 (120474)

Brian & Steve,
Do your tendons stick out when you flex you foot forward or does it lie flat? Do you notice a difference in this tendon on either foot or are they both the same?

Re: Question about atypical PF

SteveG on 5/30/03 at 23:05 (120480)

Interesting - mine is also slightly distal to the insertion. I also have pain through different parts of my fascia -- arches, metatarsals. I think the whole fascia is damaged. Occasionally I will get pain in my ankles. I suspect this may be the tendon that runs down the inside of the ankle, but I am not sure about that. I did, however, notice that after my first round of ESWT the bottom of my foot started to feel lighter and more supple. According to Dr. Davis, this is a sign that the fascia is stretching out a bit and returning to a more normal width. It's hard to characterize, but even with the pain, I am pleased that my foot feels more 'normal'. I had more second round at the beginning of May, and I hope to see even more improvement.

Re: Question about atypical PF

Dr. Z on 5/30/03 at 23:11 (120482)

I have only heard this on this board . Could you please direct Dr. Z to who told you and who is using the ossatron in this way.
Very interesing comment about its larger local area. I have been trying to find out for four years the size of the focal area for the ossatron and the relationship between KV output and focal area size for the ossatron.
I still remember the training session when I asked this same question.
I received a strange look and no answer. The use of KV is useless when talking about ESWT.

Re: Question about atypical PF

monte on 5/30/03 at 23:11 (120483)


are you saying taht you had the heel AND arch pain and are better now? I am not familiar with your case


Re: Question about atypical PF

Kathy G on 5/31/03 at 09:53 (120509)

My symptoms are very similar to Brian J.'s. Way down these boards, below all the discussion about disappearing threads, I posted to ask Dr. Z if he thought ESWT would work for me. Based on what I told him, he said he didn't think so. If you go way back, it says something about 'non traditional PF.' Unlike Brian, I do have some arthrtis beginning in my big toes and I guess I have fibromyalgia. No other lower extremity arthritis, however, or any neuropathy, thankfully.

It just seems, from what I've read over the last two years on these boards, that our type of PF, Brian, doesn't seem to respond to ESWT as well.

I might add that I seldom come to the ESWT boards, mostly just the Treatment, Support and Insert boards so maybe I've missed some success stories.

Re: Question about atypical PF

BrianJ on 5/31/03 at 13:23 (120520)

I have two more thoughts for atypical PF sufferers. First, just because we sometimes have pain in the arch and forefoot doesn't necessarily mean those areas are damaged. The primary 'damage' in the heel could cause pain to radiate to other parts of the fascia, couldn't it? Second, do we really know that ESWT doesn't work well on atypical PF, or might it just take more treatments? It seems to me that few patients are willing (or able) to get more than two ESWT treatments because the costs are high. If two treatments don't help much, patients rarely go back for more (with the obvious exception of Mohez).

Re: Question about atypical PF

Pauline on 5/31/03 at 13:27 (120522)

Yes. Third time and three years later.

Re: Question about atypical PF

john h on 5/31/03 at 13:28 (120523)

Pauline tendon on both of my feet clearly stick out when I dorsiflex my feet. Even the foot that had PF surgery sticks out as much as the other.

Re: Question about atypical PF

BrianJ on 5/31/03 at 13:31 (120525)

Not sure how scientific these measurements are, but mine stick out.

Re: Question about atypical PF

Pauline on 5/31/03 at 13:52 (120527)

Interesting John. Mine do not. I was wondering in those people who stated they had atypical P.F. how their tendon looked when they dorsiflex.

My husband has never had P.F. and his are flat and smooth when he dorsiflexes. I was trying to compare people who never had P.F. and those that had atypical cases.

John from the location of your pain would you consider your case atypical or not?

Re: Question about atypical PF

Dr. Z on 5/31/03 at 14:17 (120528)

I consider John H's pf not classic only because he doens't have the first step pain when first getting up after sitting. He has the classic trigger point insertional pf pain on examination

Re: Question about atypical PF

Dr. Z on 5/31/03 at 14:20 (120530)

I have seen and felt that post-eswt sensation that I think you are describing. It is a VERY good sign that things can get better ( less pain)

Re: Question about atypical PF

monte on 5/31/03 at 15:25 (120540)

my feet feel more softer and less stiff to the touch now too. they are softer than they were a year ago. i think the ESWT helped and think another round would help more, but the ultrasound only shows inflammation at 4mm, which is deemed to be in the normal range.

From what I feel in my feet, I think that if I had more treatments ( or at least another one) I would get more relief. I noticed the most relief after my last treatment.

Re: Question about atypical PF

Pauline on 5/31/03 at 15:30 (120542)

If you strongly feel that way why not try another ESWT instead of the treatment you have scheduled? Your in charge and if you want another ESWT I'd do it. It's certainly safe enough and others like John have had three and even 4 treatments.

Re: Question about atypical PF

monte on 5/31/03 at 15:35 (120543)

I know....I just get so confused. I have to do some thinking and maybe talk to Dr Z again. To tell the truth. I have to lay out money for the surgical center that is not covered by my insurance....I would rather give that towards more ESWT.

I really should think about it so that I don't drive the doctors crazy as well as myself


Re: Question about atypical PF

Dr. Z on 5/31/03 at 16:04 (120544)

Do you know if John and others had a completely normal ultrasound reading.
If the ultrasound readings are normal there is no place to treat the plantar fascia at the insertion

Re: Question about atypical PF

Pauline on 5/31/03 at 17:33 (120552)

Dr. Z,
In atypical P F. I was told by Dr. Zingas he would treat the entire
arch area not the insertion point. He's using the Ossatron. Different docs must treat differently.

Re: Question about atypical PF

SteveG on 5/31/03 at 18:36 (120553)

Brian - That's a difficult call. I know that when Dr. Davis pressed on the point where the fascia inserts into my toes it was tender. Like you say, he did, however, state that when the fascia returns to a more normal width that will take some of the pressure of the metatarsal area. He also urged me to continue to work on my stretches, since that will also take some of the stress off the fascia. I have not been as good about stretching and wearing my nightsplint and I should be. We have also discussed the possibility of using low energy to treat the distal parts of the fascia. I will wait a few months and see how I am doing before I consider that option.

Re: Question about atypical PF

Dr. Z on 5/31/03 at 18:42 (120554)


I remember you telling us this. From my understanding of the ossatron I just don't understand how this is possible. Sometimes the posterior tibial tendon is referred to as the arch area. Maybe this is what Dr. Zingas was referring to when he told you this. I have no idea. All ESWT in the World
from what I have learned, seen, and read is for INSERTIONAL chronic tendonitis of the human/horse bodies,except for the achilles tendon. I have performed ESWT for non-insertional achilles tendonitis. I have used ESWT for insertinal peroneal Brevis tendonitis, insertional posterior tibial tendonitis.
I am not saying this can't be done. There is a few cases where some of our Excellence Shockave Therapy Physicians have used the dornier for distal plantar fasciitis in a very small area. You need an outline ultrasound to do this safely. When I first saw the dornier used, I asked an experienced Dornier Tech . Could you treat other areas of the fascia and here was his answer. YES if you can place the head in the area and you can see pathology it can be done. The problem is placing the head in the area. The dornier delivers ESWT from the side.
In summary most of the research, treatments are for insertional pf. There is an old saying that if someone is thinking of it can be done ( Something like that).
If I would to do this I would go with the dornier in a low energy mode and do three sets of treatment each week. Wait twelve weeks and then go at it again, but this is assuming there isn't a wide area of pathology and if you can SEE patholoy on the ultrasound as a diagnostic evaluation.
I also was told that if you are treating more then one site of trigger point pain then the results are less sucessful.
This is assuming that the problem in the arch are is due to fasciosis .
There can be biomechanical problems, nerve problem that are the real reasons. So there must be in my mind a problem with the fascia in the area
that there is pain.

For example. I see patients that have pain at the pf insertion, there is pain on palpation BUT the ultrasound is completely normal. I don't do ESWT in those cases. Dr. Gordon told me he would never do ESWT unless there was an ultrasound performed to show disease.
This is a difficult situation that needs further discussion. ESWT can do harm if you hit a nerve or blood vessel so we must be very sure we don't do any harm . There is a risk with the ossatron due to the lack of ultrasound attachment and the method of moving the head around in circles when treating the human foot. This is just my opinion.
I haven't written off the use of ESWT for distal or mid pf disease if in fact the ultrasound shows pathology.

Re: Question about atypical PF

Pauline on 5/31/03 at 22:01 (120577)

I don't think Dr. Zingas as an Orthopedic Surgeon would perform a treatment he didn't think would be effective or do damage to his patients. He does have a quality reputation in the field of foot and ankle. Like Dr. Manoli he is no fly by night doctor.

By performing the FDA studies and putting his name as Dr. Gordon has done on several published papers on ESWT, I think most of the medical field feel they know what they are doing.

If you have questions you certainly can contact them or Healthronics to see if they can provide you with more satisfactory answers.

I don't believe your concerns can be answered on this board.

Re: Question about atypical PF

Dr. Z on 6/01/03 at 09:15 (120595)

It is much easier for you to contact Healthronics to see if they are doing Arch pain ESWT. As a patient you would get much better .

Re: Question about atypical PF

Pauline on 6/01/03 at 09:24 (120598)

I got my answers already, your the one with ????'s No need for me to check any farther.

Re: Question about atypical PF

Dr. Z on 6/01/03 at 09:28 (120601)

Ok So any patient on this board that has arch pain that they want treated with ESWT should call Dr. Zingas, who is using ESWT on arch pain. Fair enough thanks for providing this new treatment tot he board

Re: To Dr. Z. Question about atypical PF

Pauline on 6/01/03 at 10:18 (120606)

Hay what every you say Dr. Z. As far as I know, people are free and have always been free to contact any doctor they want for their opinion. Maybe you just always assumed you controlled people more than you do.
We're in America.

Re: Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Jen L on 6/01/03 at 10:37 (120607)

Sunny, if you could comment on the thread and give us some info about your critera in assessing a patient for ESWT, we would really appreciate it.

Based on some of the doctors on the board, three things may qualify a heel pain patient for ESWT treatments:
1. Morning pain or pain when you get up after resting;
2. Insertional/trigger point pain;
3. Fascia thickness is measured about 5mm or more by Ultrasound.
If I missed something, doctors please correct me.

If you have only one of the three it may or may not convince a doctor that ESWT will be helpfull.

That is exactly my case, and it seems a number of people on the board fall in this catergory. Does anyone know how many heel pain sufferers out in the world are not typical PF patients.


Re: Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Dr. Z on 6/01/03 at 10:41 (120608)

Just one more thing.

There are no other lower extremity conditions or systemic conditions that maybe be contributing to heel pain. Good question. Sunny will have some good insight . If you get no answer just e-mail his clinic

Re: To Jen Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Pauline on 6/01/03 at 10:42 (120609)

How did your orthotic deal play out?

Re: To Jen Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Pauline on 6/01/03 at 10:47 (120611)

How come you never posted about your atypical P.F. before??? Surely you would have gotten the help you needed earlier than this.

Re: To Dr. Z. Question about atypical PF

Dr. Z on 6/01/03 at 10:49 (120612)

I am just trying to have an informative dialogue in hopes that someone may be helped.

Re: Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Jen L on 6/01/03 at 11:47 (120614)

Thank you Dr.Z for pointing that out -finding the cause of the heel pain should be the fist step.
Here I am still not clear about how TTS come into play in deciding whether ESWT is needed. From what I read from the TTS board, a patient with a history of PF for a year or two is very likely to get TTS. On the other hand I was told by my doctor that PF symptoms can be caused by TTS and in that case patient may not notice any thing about the never problem until going to see a doctor for heel pain. If TTS is confirmed to be the cause, of course the treatment plan should be focused on TTS. While if TTS is a complication of chronic PF, do you go ahead to treat him with ESWT?
I think more comments from doctors and Sunny will help more than one patient here.

Re: Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Dr. Z on 6/01/03 at 12:00 (120615)

This is a judgement based on experience and the doctor's gut feelings.
Alot of patients that have the atypical Pf ( no pain when first getting up in the AM etc) may have the beginning of TTS that can't be pick up on nerve testing or clinical examination. However they still have that trigger point pain when examining the pf at the insertion.
The use of ultrasound has helped to determine if you should go ahead with ESWT in the presence of some level of TTS.
If a patient has pain on examination , no first step morning pain, abnormal ultrasound reading, no abnormal nerve testing, but signs of TTS with examination then ESWT may help that person. I have treated patients
with this exact problem . I have also not treated patients with these same signs. This is where the gut feeling comes into play. Anoter factor is what is the goal of that patient and what is the level of disability etc. The patient's goals are very important when chosing to perform ESWT on them

Re: To Jen Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Jen L on 6/01/03 at 12:22 (120617)

Hi Pauline,
I posted several times in the past months. It's been a long story, although my heel pain has been there for shorter than two years. As I recall I started to have the pain when I was standing for some time on a hard floor like kitchen's. That was only several times a month. Then I started to have the 'typical' pain -first step in the morning and after sitting to watch TV in the evening on one foot. I wish I knew what it signaled at that time. A few months later I got the sudden onset of sever and constant heel pain. Now the classic morning pain disappeared! Then docotr's visits, medication, heel injections, deep massage, custom othotics, P.therapy, plus all kinds of home therapy did not bring satisfactory relief. Then 2nd foot followed up. During the doctors's visits I was told that my pf is not typical, so ESWT is not in the treatment plan. But nothing else worked and I will not consier surgery.
On my last vist to my doctor, thank god he confirmed I do have the insertional pain and I may proceed with low intensity ESWT, which is my intuition shared by docotr.
My story may sound very similar to many other people's, and that's why I posted above question. Actually I've passed the phase to get green light from doc. for ESWT. I know it's very frustrating when you don't know what to do next.
I am on my way to decide on a location and time for ESWT.


Re: Question about atypical PF

john h on 6/01/03 at 15:24 (120639)

Dr. Z. can you not treat the area where you feel the pain by pressing with your thumb regardless of ultra sound. that is what we did with the Orby.

Re: Question about atypical PF

Dr. Z on 6/01/03 at 16:18 (120642)

Yes you can. The ultrasound does a few things. If proves to you that the tissue is indeed damaged, and it keeps the shockwave in the area that you want to treat. It is possible to have pain in an area at the insertion and the cause of the pain is nerve and not pf. This is rare but it is possible. The use of ultrasound eliminated the mistake of treating normal fascia. There is a chance with or without first step morning pain to be caused by nerve and not pf.

Re: Does Bayshore Pain Clinic treat atypical PF wh ESWT?

Sunny Jacob on 6/02/03 at 06:33 (120688)

Jen, - re your message about atypical PF:
Dr. Z. has already given a clearer answer than I cold.
As far as the treatment decision is concerned, it is a judgement based on experience of the provider and a reasonable expectation of the patient.
Based on your description of the insertional point, your doctor's advice for low intensity ESWT seems appropriate. If I were you, my choice would be to get bilateral treatment.

Re: Question about atypical PF

HilaryG on 7/04/03 at 19:52 (123602)

Did Mohez have atypical PF? I just want to know because my PF is atypiccal in that I have no morning pain or pain after resting. Mohez' story is inspiring.

Re: Question about atypical PF

john h on 7/05/03 at 09:07 (123617)

If my memory is correct (?) Mohez did not have first step morning pain. I never have and that is why I followed his progress for all this time.