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Complete tear of PF

Posted by Monica K on 11/20/03 at 21:30 (138173)

Pain in L foot x 3 yrs. No known injury to foot. Symptoms started after taking a position in a medical office. Probably due to amount of walking/standing.

MRI findings: There is a marked severe thickening of the PF approx. 2.3 cm distal to the calcaneal attachment. there is fluid in this region with a complete tear of the fascia and retraction on the proximal and distal fragments. The distal fragment is thickened over approx. 4.3cm. There are surrounding mild inflammatory changes within the soft tissues and deep plantar musculature.

Sinus tarsi is within normal limits.

The posterior tibialis, flexor digitorum and flecor hallucis longus tendons are normal. There is a corticated ossification adjacent to the navicular at the posterior tibialis insertion consistent with an os tibiale externa.

There is fluid within the peroneus longus and brevis tendon shealth which is somewhat lobulated in contour and extends from the distal to the lateral malleolus distally to the calcaneal cuboid joint level. Underlying tendons are intact.

Achilles tendon is intact.

Anterior tendons are normal.

The anterior talofibular is not visualized consistent with complete tear. There is a relatively large amount of flrid within the lateral gutter. The anterior and posterior tibiofibular are intact. The posterior talofibular ligament is intact.

In short - I have seen 4 ortho's. 2 being foot and ankle spec. I have been told by all of them to 1-stay off my feet, 2-find a sitting job, 3-deal with it! Besides night splints, streching, and a $360.00 pair of orthotics. This is great if you have no life! I have children and a husband and myself to take care of. I have a vacation home at the beach. And since we bought it, I have never been able to stroll on the beach! My time there is resting up for the work week that is ahead. My company that I work for is between letting me go, to keeping me, to letting me go. They are not sure what to do with me.

I had 3 injections in my heal from my PCP. Then I made an apt with ortho. My ortho said that is what caused the repture. Now, I am starting to have pain in my right foot. What am I to do? I wear my support shoes. I am on light duty at work. Which will not going to last much longer.

My question is how does someone deal with it? I get take-out almost every night for supper. Just tonight my son said, 'Mom, I am tired of Subway, Bojangles and all our take outs. I want some real food. Like you use to cook that was so good. Like the poor cooking you use to do.' I just started crying! That broke my heart. I told him that after Christmas I was probably going to quit my job and stay home. Then he said, 'Wait! I don't want to be poor! I just like to eat the foods we use to when we could not afford to eat out!' Now, that will get to a momma's heart. Straight through it.

I have read some of the post where alot of people have gotten disability due to PF. But, I live in SC and everyone here is applying for disability! I know, I see all their medical records. I feel that I would just fall through the cracks. And NO, my doctor has never mentioned disability to me. He said that it would get better because I would learn to stay off my feet, not do anything that may cause me pain and that after one has pain for so long, they just get use to it. Well, yes I have got use to it. But that does not stop me from crying when I am alone. I have learned to just try to keep going.
Do any of you Dr.'s have a miracle for me? Or for my sons stomach? Thanks for letting me blow off my steam. I originally wanted to see if there was something that I could be doing, that I wasn't already.

Thank You!
Monica

Re: Complete tear of PF

BrianJ on 11/20/03 at 22:24 (138184)

Monica --

I've had PF in both feet for 5 years now, so I can sympathize. While there is no magic bullet that works for all of us, there are some treatments and some adjustments that might help. First, try taping your feet to reduce your pain level. It takes some trial and error, but can yield a surprising amount of pain relief. Second, try deep water running or water aerobics in order to stay active without irritating your feet. Activity both increases your circulation (good for healing), and decreases the tendency to get depressed. Third, put a stool in the kitchen so you can sit on it while you're preparing meals or washing dishes. Sounds simple, but it has really helped me. Fourth, as strange as it sounds, try to see some of this as a morbidly fun intellectual challenge. There are answers out there that will help each of us. Are we smart enough and determined enough to find them?

Good luck, and please let us know how you are doing.

Re: Complete tear of PF

Dorothy on 11/20/03 at 23:22 (138189)

Oh, Monica ~ Your note really got to me. This PF is just such a bummer and I am so sorry that anyone has it. I am going to comment only on the meal issues and give you my opinion for what that is worth. I would suggest that you SIT in your kitchen and you give directions to your son for making a meal. You will rest; he will learn and you will have a homecooked meal and the two of you will share an important experience. Plus, he will know that he is needed and is helping in a genuine way and that is very important for young people. He may learn a skill that he will enjoy all his life; he may even find a career in it as many do. In any case, he will learn a skill that he will need to have in life - how to feed himself in a healthful, self-produced way - and how to help someone in need (you!). You have my best wishes -

Re: Complete tear of PF

Julie on 11/21/03 at 02:27 (138197)

Monica

Brilliant posts from Brian and Dorothy. I agree with all they've said. One thing in your post stuck out for me - 'I have a husband and children and myself to take care of'. It sounds from that, and from other things in your post, that you are trying to do all that you always did, while struggling with a disability. And maybe you need to rethink that, and let your family take care of you. This is very much in line with Dorothy's suggestion to get your son involved in the nurturing process of preparing food for the family - that is a wonderful idea. I don't know your family situation, but maybe your husband could take on some of the responsibility too?

Brian mentioned taping. There is a very helpful section on taping in part 2 of the heel pain book. Taping has helped many of us, and it would certainly be worth trying. Briefly, it works by providing the support for the arch of your foot that the injured fascia can no longer give. Thus it 'rests' the fascia and contributes to healing, as well as relieving pain. I found it enormously helpful. Read up on it and if you want to try it come back and ask questions. I will probably be able to help you with it, but before I start rabbiting on about it, you should first decide if you want to do it!

Finally, it would be worth investigating disability, just in case you do have to leave work because of your PF (and that should be YOUR decision, not your employers'). I know that because of your job you are more aware of the problems than most people, but equally, because of your job, you have a skewed impression of the difficulties. It can't hurt to try.

I wish you all the best.

Re: Complete tear of PF

Dr. David S. Wander on 11/21/03 at 08:07 (138214)

Monica, I'm sorry to hear about your frustrations. However, there may be a light at the end of the tunnel. First, it appears that you've had a quality MRI report since it was very descriptive. Your orthopedic surgeon may be correct regarding the possibility of the 3 injections by your family doctor causing the actual rupture of the plantar fascia.

As you know, surgery/release of the plantar fascia is often a last resort option for patients that have chronic recalcitrant heel pain. Many times there are significant complications from the surgery, with nerve injury being one of the common complications. You've had your fascia 'released' without the side effects of surgery.

Many patients on this site have had chronic heel pain that has failed conservative care, but have not had ESWT or surgery (though many have). My point is that you were having heel pain and your family doctor gave you 3 injections that may have caused a tear of the fascia. The MRI has confirmed that tear of the fascia. Essentially, you've just undergone a non surgical release of your plantar fascia! In my 18 years of experience, patients that have been in this situation usually end up doing quite well.

It is imperative that the foot be immobilized in a rigid cast or removable walking cast to allow healing to occur. I would NOT recommend a night splint at this point or weightbearing. The area must heal and you must gradually resume weightbearing to tolerance. Additionally, physical therapy will play an important role in your recovery. Remember, you no longer have plantar fasciitis, you now have a tear of the fascia and it must be treated properly to allow the area to heal. If you have any specific questions don't hesitate to email me at (email removed).

Re: Complete tear of PF

Julie on 11/21/03 at 09:12 (138219)

Dr Wander

It's good that you responded so fully to Monica - I was hoping you would! I tried the email address you gave to thank you for doing so, but was taken to Scott's product page with the message 'File not found'. Perhaps you could have a look at it, in case Monica has some questions, and correct it if its wrong?

Re: Complete tear of PF

Aly R. on 11/21/03 at 10:14 (138224)

I just read this now Dorothy - I think that was a really great idea!! :)

Re: Complete tear of PF

Dr. David S. Wander on 11/21/03 at 12:24 (138245)

Julie, the email address (email removed) is correct. Make sure you don't use any periods, etc. If you try that address and it still doesn't work, let me know on this forum. I have no idea why it would link you to Scott's product page. Try emailing me directly from your internet carrier.

Re: Complete tear of PF

Julie on 11/21/03 at 14:40 (138259)

Dr Wander

I've just sent you an email. This time the link worked - I can't imagine why it took me elsewhere before, but it's all right now.

Re: Complete tear of PF

Monica K on 11/21/03 at 14:59 (138261)

Thank you everyone. I just got home from work and I am about to leave for the weekend. I have so much to say and/or ask. But it will have to wait till Monday. Thank you all again. I thank God I found this site! You all are wonderful!
Monica

Re: Complete tear of PF

Dr. David S. Wander on 11/21/03 at 15:16 (138263)

I wrote to Scott and he 'fixed' the problem. If you click on the email address it should now work correctly.

Re: Complete tear of PF

Julie on 11/21/03 at 15:51 (138271)

Dr Wander, I've read here on previous occasions that the rupture of the fascia has an effect similar to its surgical release. Perhaps you would explain something I have been wondering about. What, exactly, is healing? Does the ruptured fascia reconnect itself to the calcaneus? Or, if it has torn elsewhere than at its insertion point, is the 'healing' the growing together of the torn tissues?

If I'm asking the wrong questions, please correct me. What I'd like to know is - what does healing, in such a case, consist of?

Thanks for your time.

Re: Complete tear of PF

Dorothy on 11/21/03 at 15:58 (138274)

Yes! Brilliant question! Thank you for asking what I have been wondering, too, but it hadn't yet formed into a coherent question. I am eager to read the discussion of this most pertinent question.

Re: Complete tear of PF

Pauline on 11/21/03 at 16:10 (138281)

Great question Julie. We sure talk about healing enough, but I don't ever think anyone actually ask your question.

Re: Complete tear of PF

Dr. David S. Wander on 11/22/03 at 07:53 (138332)

Julie, that's an excellent question. Healing of the plantar fascia is basically the same if it was surgically released or if it was traumatically injured, with a few exceptions. With a traumatic rupture, the ends of the fascia are often not 'clean' as it would be with a surgical release. Additionally, with a traumatic rupture, there is usually a very limited area/number of fibers that are torn. It is rare to have a complete rupture, though it does occur. Additionally, a surgical release has the other potential complications of damage to other tissues such as nerves, blood vessels, surrounding muscle, etc., due to the invasive nature of the surgery. This can happen with 'open' procedures, MIS procedures or endoscopic procedures. Each of these procedures has it's pro's and con's, but all have potential complications with possible injury to surrounding structures.

Surgical release used to involve cutting the entire fascia, but modifications have recommended release of only the medial portion to avoid complications laterally such as calcaneal-cuboid syndrome, lateral column dysfunction, etc.

To get back to the original question, the answer is really that wound healing is wound healing no matter how the fascia was cut, torn, or released. The area may 'reattach' via scar tissue depending on the size of the gap between end fibers, or if there is a gap. The fibers of the fascia will heal by forming scar tissue no matter how the fascia was torn or released. Once again, with a traumatic tear there is usually less scar tissue since there was no blade inserted to traumatize other tissues that will have to heal.

Healing is judged by symptoms. After the initial injury is treated with a cast, etc., healing will be judged by your discomfort level and your ability to function. After the acute phase, support of the fascia, gentle stretching and physical therapy are imperative to limit the amount of scar tissue and to maintain mobility.

I hope this explanation provides some insight.

Re: Complete tear of PF

Dr. David S. Wander on 11/22/03 at 07:57 (138333)

This is an addendum to my previous post. Monica's case is unique since the report does state that there is a complete rupture, with retraction of the distal and proximal ends. Depending on the gap, once again this will heal with scar tissue. Since there was a complete tear, Monica may end up with symptoms similar to patients that have had a complete surgical release of the fascia, with lateral column discomfort. This should be addressed BEFORE it happens, with proper support of the entire foot to prevent these problems. Some of the problems can be predicted, therefore may be prevented.

Re: Complete tear of PF

Dr. Z on 11/22/03 at 08:26 (138335)

There is an article on this site that talks about pf rupture secondary to local steriod injections. Very interesting reading. Go to the journal article section on heelspurs.com

Re: Complete tear of PF

Julie on 11/22/03 at 09:12 (138345)

Yes indeed it does, Dr Wander, and thank you very much for both posts. I'm quite clear about it now. I'm sure Monica, when she returns, will find your explanations helpful - and I hope she can persuade her own doctor to see the point and immobilise her instead of telling her again to 'deal with it'.

Thanks again.

Re: Complete tear of PF

Pauline on 11/22/03 at 15:40 (138381)

Dr. Wander,
From your discription, it sounds like a 'natural' rupture is almost better for the patient than having surgery because no other tissue is being traumatized by a doctors blade.

How do you know with a natural rupture that the surrounding nerves, blood vessels and tissue was not traumatized by the event?

Re: Complete tear of PF

Dr. David S. Wander on 11/23/03 at 08:25 (138447)

Pauline,

Unless there was 'major' trauma from some extraordinary injury/accident, the chance of injury to the blood vessels, nerves or surrounding tissue is minimal. Assuming there was no single major trauma to the area, the plantar fascia can rupture from overuse, chronic interstitial tears, multiple injections, etc., and would rarely result in any other significant injury to the nerves or blood vessels. In Monica's case it appears that multiple injections may have significantly contributed to or caused her complete rupture. Although a nerve or blood vessel can be 'hit' by an injection, it would be very unusual to have any major injury from an injection with a small gauge needle (though it's always possible).

Re: Complete tear of PF

Pauline on 11/23/03 at 12:42 (138468)

Dr. Wander,
Outside of using orthotics how can a person with a total P.F. rupture avoid LCS?

Left with no support following the rupture aren't they doomed to LCS unless they provide some support back to the foot?

Re: Complete tear of PF

Julie on 11/23/03 at 13:36 (138472)

Pauline, I'm sure Dr Wander will reply, but judging by what he said to Monica and afterwards to me, isn't the answer the immobilisation he recommended?

Re: Complete tear of PF

Dr. Z on 11/23/03 at 13:44 (138473)

Pauline,
That is a good question. Yes a patient can always have compensatory weight shift depending on the degree of pf rupture and or surgical pf release. There is a very good article in our APMA journal this month confirming this specific mechanical problem with pf release. There is an article in the journal section from this heelspurs.com board that talks about the problems associated with steriod induced pf rupture and the one year permanent compensatory problems associated with pf rupture.
Casting, rest, non-weighting and alot of physical therapy are the main stay treatment for this problem. Biomechanical orthosis are another source to help prevent any compensatory weight shifting that can occur

Re: Complete tear of PF

Pauline on 11/23/03 at 19:17 (138496)

Julie,
I wanted to look at the picture from when the cast comes off. Exactly what happens then? I think Dr. Z pretty well answered it orthotics.

Re: Complete tear of PF

Monica K on 11/23/03 at 19:29 (138498)

Hey! I am home. And boy did I have some catching up to do. My MRI was conducted on 5-6-03. And since then, I have seen 2 foot and ankle spec. and they have not mentioned immobilization of the foot. Actually, the 2nd ortho (keep in mind I have seen 4 doctors, 2 ortho and 2 foot spec.) that I saw put me in a walking cast after he saw my MRI results. Then he referred me to a foot and ankle spec (Dr#3). I saw Dr#3 2 weeks later and he told me not to wear the boot any longer. He wanted me to get out of it as soon as possible. He treated me without any medical records from my last 2 doctors. Well, that did not go over well with me. He(#3)is the one who put me in a night splint and wanted me to be fitted for molded inserts. I was not happy when I left his office that day and never went back. How can you treat what you don't know? Then I made an apt with Dr.#4. He has not changed what Dr.#3 did. Now, my right foot is giving me problems and he (#4) ordered a nerve study on that foot which I told him was a waste of time. He as not happy with my attitude. He said I should let him decide what was best for me. I wanted an MRI of that foot. I hate to be one that says I told you so, but, I did. There is no nerve damage in my right foot.
I am a firm believer that my job caused the tear in my foot. And I kept working and working until it was a complete tear. I work with 3 doctors every day. I complained all the time and they did not pay me any attention. If you are not begging for pain medication they really don't think your in pain. I am allergic to codine and if I took anything strong enough for pain, it had codine in it. So the only thing I have ever taken for pain is Advil 800mg.
Dr. Wander, you said in a post that I may end up with symptoms similar to patients that have had a complete release, what are these symptoms exactly? I do wear my inserts every day or I wear Dansko professional clogs which feel better. My legs and feet do not hurt nearly as bad with my Danskos on. Is this not a good thing? I love my Dansko.
As far as healing time, I have not had any to speak of. I have continued to work. But, Dr#4 put me on light duty. His defination for light duty was, no walking or standing for greater than 3 hours per day and no walking further than 100ft. And my employer got the full 3 hours out of me!
There was a post that I read that mentioned some procedure like a LCU?? I am not sure what that is. I will find the post and ask again.
Thanks!

Re: Complete tear of PF

Monica K on 11/23/03 at 19:33 (138499)

LCS - what is this?