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Question for Dr.Z about the Atypicals

Posted by Robert J on 5/11/04 at 14:17 (150408)


I'm curious what treatments you offer patients who come to you with atypical PF. Just to be clear about the definition of 'atypical,' I'm talking about those who have no first-step pain and whose pain extends through the arch rather than being limited to the insertion area.

I ask because, in the past, I know you have commented that ESWT and surgery rarely produce good results with atypical cases. That being the case, what does produce good results with these people, if anything?

I'm also curious whether you believe atypical PF is just another version of the standard PF injury or whether you believe it's something else altogether. I believe you once commented that atypical PF might be an early version of TTS.

I ask these questions for a couple reasons. First, of course, because I have atypical PF and I'm looking for answers. Also, I've noticed on these message boards that atypical cases seem to have patterns of their own and, if anything, they are more difficult to treat than standard PF (if that's possible). If the atypical group is dealing with a fundamentally different injury that requires a different approach, that would be very helpful to know. Thanks.

Re: Question for Dr.Z about the Atypicals

Dr. Z on 5/12/04 at 02:24 (150450)

You need to rule out any neuropathetic diseases, TTS, local nerve entrapments and any systemic diseases. If the plantar fascia is inflamed, confirmed by ultrasound and or mri I would address this condition with the classic treatment. Some other treatment are RFL. Cryotherapy chemical neurolysis ie alchol injections, if you can determine that it is a nerve pain.
This is a very tough condition to help I will admit.

Re: Question for Dr.Z about the Atypicals

HilaryG on 5/12/04 at 07:39 (150452)

Robert- I have had Atypical PF for a long time and nothing helped until I tried ART- Active Release Techniques. It is performed by a chiropractor. You can do a search on this message board and also you can look at the websites activerelease.com and drabelson.com for more info. Dr. Z and Dr.Ed are not very positive about this technique and I can't really blame them because I guess there is really no scientific research to back it up; nut it really has helped m. And I am really a cynic. I am just a person who was desperate and didn't know what else to try. Luckily my health insurance covers chiropractic visits. Hopefully yours does too. Hilary

Re: Question for Dr.Z about the Atypicals

Tricia H on 5/12/04 at 09:18 (150455)


I too have atypical PF. No first step heel pain, only a weakness & ache in the arch, so much so in the beginning that I had to be in a camiwalker for 3 months. I had ESWT 6 weeks ago, which unfortunately seems to have made it worse, so be careful before you are 'talked into' that treatment. Taping helps a lot, as do orthotics & wearing the arch braces they sell in running magazines.

good luck - I've had this for over 9 months & it is ruining my life.


Re: Question for Dr.Z about the Atypicals

Robert J on 5/12/04 at 13:02 (150469)

To Hillary and Tricia --

Thanks for the responses. As you can tell from Dr.Z's response, he suspects that atypical PF may have a neurological basis. I'm curious whether either of you have had any of the tests that he suggests, and, if so, what were the results? I have not had these tests. I'd also like to know if either you sense, from your experience, that your condition is neurological as opposed to a degeneration/inflammation condition.

Hillary, are you mostly recovered now? And if so, how long did it take ART to get you there?

Finally -- sorry for all the questions -- I'm curious if both of you also have high arches. I have noticed that several of the atypical people on the message boards have said they have high arches, and so do I. Maybe there's a link there.

Thanks much. Like Tricia, this injury is ruining my life and I would love to find some answers.

Re: Question for Dr.Z about the Atypicals

HilaryG on 5/12/04 at 13:54 (150471)

No, Quite the opposite, I have extremely flat feet. I never had the nerve tests. My ortho was certain that this is PF and NOT TTS. As far as the ART treatments --- it took about 6 treatments before I started feeling better. At first I felt worse. ART is not an easy treatment to undergo, but it is so worth it. PF was ruining my life. I thought I was going to have to get a scooter or at least a cane. Now I am walking like a semi-normal person. I cannot take long walks but at least I can stand on line at the supermarket and walk around the mall without wanting to cry. I used to lie in bed crying in pain. I feel like I'm babbling. If you want to email me it's (email removed)

Re: Question for Dr.Z about the Atypicals

Vern S. on 5/12/04 at 14:48 (150472)

There appears to be a number of us in this boat. My first Pod sent me to have a nerve response test done since I had no morning pain, nor improvement from other attempts. Neurologist said the responses were normal for my age of 50.
Second Pod said just stretch more.
After two years of pain, I saw a 3rd Pod last week He said I did not respond to his Neuroma or TTS checks, so to check out peripheral neuropathy with my GP, and that the nerve test fron 2 years ago should be updated. He also gave me 9 Celebrexs to see if the problem was inflammation that the pills would help with. No such luck. The GP said first he wants to review blood work, and then off to the neurologist.
I don't know if it feels more like nerves or degeneration, but I would guess degeneration since it gets worse during the day.
And, FYI, I have high arches.
Hope some one else in this boat has some answers to share.

Re: Question for Dr.Z about the Atypicals

Tricia H on 5/12/04 at 15:11 (150473)


I had an MRI done, and the doctor said it was clear I had ruptured my plantar. I don't even know what the other diagnosis referred to is - it was never mentioned to me. I can say that slowly it was getting better (this was a running injury - the old overtraining syndrome). I had the ESWT & it is much more sore now. Have you tried taping? It really does help a lot.

I have normal to high arches. I've read that makes our feet inflexible & rigid. It also forces the fascia to stretch more with each step (you can tell I've done a lot of research on this).

My question to Hillary - what makes the ART hard to do? Is it painful? Is it similar to a very deep foot massage?

Re: Question for Dr.Z about the Atypicals

HilaryG on 5/12/04 at 15:25 (150474)

Tricia- Yes, ART is somewhat painful. But not as painful as PF. It is not the same as deep massage. Please look at the websites activerelease.com and drabelson.com for more info. I am not an expert, just a very satisfied patient. All I can say is that nothing else worked for me and ART gave me back my life. Other than ART the only thing I do for my Atypical PF is wear Birkenstocks and ocassionally New balance sneakers with orthotics that were made by a pedorthist. (I have a closet full of orthotics that I cannot wear). I also do a little stretching of the calf muscles. Please look at the websites. The Dr. Abelson website in particular gives a lot of information about ART. I highly recommend it. Hilary

Re: Question for Dr.Z about the Atypicals

Tricia H on 5/12/04 at 16:01 (150478)

thank you Hilary - I will definitely look into this. Given NOTHING else has really helped cure this, it is worth a try.

Re: Question for Dr.Z about the Atypicals

lauriel on 5/12/04 at 17:29 (150480)

I am glad I found this. I do have TTS ans surgery for in 12/02. I also have PF, but my symptoms are not like the heel pain and cant wlak when you first get up. I have it in both of my feet, very localized pain in different areas very hard to pinpoint since the are of intense pain is about the size of a pencil eraser, maybe even smaller. And then I have all over pain in my arches, I have flat feet I have new orthodics, but they are making it worse so I think they need more adjustment. I do a lot of stretching, ice forzen ih a water bottel. I am going tp checkout the ART sites


Re: Question for Dr.Z about the Atypicals

Robert J on 5/12/04 at 19:40 (150489)

I will also check out the ART people here in Los Angeles. There's gotta be some practitioners around here.

From your general responses, it sounds like there's little evidence that atypical PF has a neurological basis. Frankly, my PF has never felt neurological although that probably doesn't mean much. It feels like a searing soft tissue injury that simply refuses to heal. When I first get out of bed in the morning, the first steps feel fine. By the 50th step, a narrow line of searing pain extends along the inside of my arch from the metatarsals to the heel. As the day goes along, the pain rises according to the number of steps I take.

In my case, I've had periods of 6-7 months where I was gaining strength and carefully -- very carefully -- increasing walking time. But true healing never took place and a small miscalculation would send me back to the starting point. It's been maddening.

To answer Tricia's question, yes, I use tape constantly. It helps but doesn't heal. Three pairs of custom orthotics sit in my closet because they didn't help and actually seemed to hurt. Three pods and an orthpaedist have trotted out the usual conservative treatments to no avail. I stretch religiously, non-weight bearing of course, use heat,DMSO, and do strengthening exercises twice daily, and swim a local pool. And I'm conscious of every step I take. This routine allows me to walk enough to go to a store but no more than that.

What truly drives me crazy is that no one -- and I mean no one -- even knows what's wrong with the atypicals. And, unlike classic PF, there's no accumulated experience of success on these message boards about atypical cases, no basis for passing along advice. Partly that's because we are a subset of a subset and our numbers are correspondingly small. So I have a suggestion: if any of the atypical people out there DO have success, even partial success, let the rest of us know.

And I will check out the ART people.

Re: Question for Dr.Z about the Atypicals

Dorothy on 5/12/04 at 21:33 (150493)

Foot Trainers? Infrared? Massage with and/or without infrared? Compression socks intermittently or protracted? Contrast foot baths?
The Aaron Mattes stretching program? the Michael Young stretching program?
Strength training program? Circulation increasing activities (non weight-bearing)? Supplements for circulation, nerves, anti-ox., etc.? A different taping method? (There are a plethora of 'styles' apparently)

Re: Question for Dr.Z about the Atypicals

Kathy G on 5/13/04 at 12:35 (150516)


I have atypical PF but my doctors would tell you that just about everything about me is atypical. :D

I don't mean to make light of it as it is not a laughing matter. My symptoms are exactly the same as yours. First step of the day is no big deal. Last step of the day can be a nightmare. I actually had to give up two jobs over the last five years because of my PF and now I don't work. Up until approximately sixteen months ago, I was quite limited in my activity but lately I have seen an improvement in my feet. I still don't have normal feet and there are still bad days but there seem to be more good days when I am able to do more. I have become more atuned to my feet and seem to know when to stop. And if I overdo it, it takes my feet much less time to rebound. I still can't do what I used to do but I accept that and I'm happy for anything that I couldn't do a year and a half ago.

I wear orthotics which I swear by. They are custom-made by my Pod and are made by Foot-Maxx. John h also wears them. Most of the Pods who post to these Boards don't like them but I've had great luck with them. For several months, I iced and rested a great deal. It was most frustrating but I think it really helped me. I didn't find taping helped me but I'm sure you've read the Heel Pain Book and seen that it does help many people. I do Julie's Yoga Stretches every morning and frequently during the day, if I'm sitting, I find myself unconsciously doing them. I have a tilt board that my husband made me and I use that whenever I get a twinge of pain in my calf muscle, which was a big problem for me.

But the only thing that I've done differently in the last sixteen months is that I started taking MSM, 1000 mg. twice a day. I haven't got a clue if it's responsible for my improvement but I have no intention of going off of it to see if my symptoms get worse. I throw it to you for what it's worth. Unfortunately, in that it's a natural supplement, there have been no controlled longterm studies on it. On the other hand, I've read nothing that says it leads to any longterm ill effects and it's been widely available for quite some time.

I'm not a doctor but just thought I'd share with you. Oh, and my Pod doesn't think I show any signs of TTS or nerve entrapment and it's going on ten years now so I think something would have shown up by now if it were nerve related.

Hope I've helped but I've probably just muddied the waters even more!

Re: Question for Dr.Z about the Atypicals

Robert J on 5/13/04 at 12:54 (150518)

Dorothy and Kathy --

Thanks for your posts. As a regular reader of these boards, I have already tried most of your suggestions, including MSM. Some have helped -- though MSM wasn't one of them. One thing that perplexes me is my intolerance of the custom orthotics, which now sit in my closet. I may try another approach with orthotics, using one of the off-to-shelf products that are linked to the site. If I have any success, I'll let you know.

Re: Question for Dr.Z about the Atypicals

Dorothy on 5/13/04 at 16:28 (150524)

Not meaning to press the point or beat a dead horse or anything, but I mentioned a long string of possibles (I think Kathy must have mentioned MSM) and some, maybe all, of the possibles that I mentioned would require more than a cursory effort. Hardly anything recommended on this site is a short-term/instant panacea. I listed the Foot Trainers; are you saying that you have used them? All of the other recommendations as well?? The established stretching/strengthening programs?? All of this for a reasonable, protracted-enough, period of time?? Quality exploration of the role of your circulation system?? Quality exploration of your nervous system?? Of your psychological/emotional coping mechanisms?? Of your mood??
Please understand, what you do is entirely 100% percent YOUR business and none, 0-% of my business - but I admit to being puzzled when posters say they have 'tried everything' and 'nothing works' and ask for advice and suggestions, etc. If that is the actual truth with you, that you have 'tried everything' as you said and nothing works, then so be it.
If you haven't 'tried everything' but you are simply saying that you have no interest in trying other modalities suggested to you, then I wish you would just say that. It is very difficult for me to resist responding to people who seem somewhat desperate and out of ideas for what to do/try next so I hope that such desperate expressions would only be used when that is exactly the way it is. In any case, I wish you well and that you find what you seek. These problems are certainly among life's challenges.

Re: Question for Dr.Z about the Atypicals

dr ben pearl on 5/14/04 at 04:49 (150560)

Dr Z
Have you tried sclerosing of baxters nerve?
I have concerns about the anatomy in this area an have not offered it as an alternative for my patients.

Re: Question for Dr.Z about the Atypicals

Jill H. on 5/14/04 at 12:48 (150586)

I have high arches. I have been to two POD and two Ortho. Surg. I have tried almost everything and are wondering about ESWT. My foot was feeling somewhat better, so much that I walked at a faster pace than I have been about 4 blocks. 24 hours later I was back to major pain. It seems hard for me to know when I am crossing the line. I used to be an avid walker, had done nothing these last 8 weeks. Even the bike and swimming hurt. I'm not sure to just wait it out or go with the procedure (that is in insurace will cover)

Re: Question for Dr.Z about the Atypicals

Dr. Z on 5/14/04 at 14:20 (150592)

On a few patients. I am also investigating cryotherapy . It does work. Dr. Fallet from Detroit and Dr. Tresott from Jacksonville, Florida are doing alot of work with this treatment. I am going to study with Dr. Tresot in June.