Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

MRIs & PF (DPMs' & Radiologist's Opinions)

Posted by Scott Mc on 6/14/05 at 13:25 (176767)

The debate continues.

DPMs continue to be split on the value of expensive MRIs.

The radiologist told me that MRIs could: 1) Show if 'flexor tendons' are affected, 2) show if the tissue is 'fibrotic' or 'inflammed', and 3) if the PF is 'active' or 'inactive'. He was not clear on identifying tissue tears.

What does the above mean?!? How likely are 'flexor tendons' to be involved? What its symptoms? What does it mean for PF to be 'active', 'inactive', 'inflammed' or 'fibrotic'? Would these discoveries affect treatment or just be a waste of $2,750 (both feet)? (Can't these descriptors discovered by symptomology?!?)

Re: Question? MRIs & PF (DPMs' & Radiologist's Opinions)

Ralph on 6/14/05 at 13:38 (176769)

I was on a plane last year and the older women next to me had some type of nerve problem throught out her legs and it was starting in her arms. She said in order to figure out what was causing her pain they did a nerve biopsy which she described as very painful. She was not put out for the procedure. Just talking about it seemed to make her uncomfortable. She was waiting for results.

I'd never heard of such a thing, but now I'm wondering if they can biopsy a nerve to find out what is wrong can they biopsy the tissue of the Plantar Fascia and would it tell them anything more than what an MRI would tell them?

Re: Question? MRIs & PF (DPMs' & Radiologist's Opinions)

Scott Mc on 6/14/05 at 16:36 (176774)

Nerve biopsies are usually useless. Neurologists just like to test things. They have no effective treatments for neuropathies.

I doubt if the plantar fascia is ever biopsied.

Re: Question? MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. Z on 6/14/05 at 17:47 (176778)

The only biospy is when you do surgery. When I did foot surgery I send the tissue out to the lab and in all cases degenerative was indicated and the diagnosis of fasciosis was confirmed. This is what I called a soft tissue mal- union meanng that the tissue was poor quality

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr Ben Pearl on 6/14/05 at 18:04 (176780)

usually symptoms guide treatment not visual studies with p.f.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Scott Mc on 6/14/05 at 18:37 (176781)

So, are both the docs recommending against an MRI in my case of PF?

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Ed Davis, DPM on 6/14/05 at 22:50 (176799)

Scott:
Sonography can often tell you the same thing for 1/10 th price. Unfortunately, not all podiatrists are well trained in diagnostic ultrasound (sonography). An MRI also creates another opinion, that of the radiologist thus decreasing the practitioner's liability. If it is a risky case, I would rather get a reading from a radiologist rather than be liable for $500,000. Tort reform = more sonography and less MRI's.
Ed

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Scott Mc on 6/15/05 at 10:27 (176822)

Turned out that I had sonagraphy done before the failed ESWT. The ESWT tech determined that fascia (both feet) were 5.6 and 5.7 mm. That is all the tech reported. I'm not sure if my case is 'risky' -- probably only if surgery and the DPM who recommended the MRI does not do surgeries.

Why did DPM recommend an MRI? I suspect out of desperation. Perhaps he is thinking that the PF is a misdiagnosis, (higly unlikely, given symptoms, his initial agreement, & the PF diagnoses by 3 previous DPMs). What are the chances that the 'flexor tendons' have been affected? What are the symptoms of this? I believe that the other descriptors ('active' vs. 'fibrotic', etc) found thru an MRI would be merely useless terms.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Ed Davis, DPM on 6/15/05 at 11:09 (176828)

Sorry Scott but I am taking a leave of absence from the site so contact me at my email: (email removed)
Ed

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. David S. Wander on 6/15/05 at 14:56 (176868)

MRI's are certainly not useless and can often determine whether there is a tear or partial tear of the plantar fascia and whether there is bone marrow edema indicative of a stress fracture of the calcaneus. I recently had a patient that had a small soft tissue tumor that was detected via MRI that was not detected on plain films and not palpable. This may have been detected on ultrasound. My only concern with ultrasound in the podiatric office is that many practitioners are using this in the office without the proper training. Ultrasound has a relatively large learning curve to truly distinguish structures since there is basically black, gray and white shades. Radiologists often spend years in fellowship training learning to read ultrasound studies and some doctors are purchasing units for their offices and taking weekend courses to learn how to interpret these studies. My concern is that some pathology may be missed, though some simple pathology will certainly be picked up. This is just my opinion, and I think that ultrasound is an excellent modality, but hope that those that are utilizing it in the office feel confident that they can diagnose all pathology, not just the simple cases.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Ralph on 6/15/05 at 15:35 (176876)

Thanks Dr. Wander for giving credit to Radiologist who are often times not given credit for the work they do. I think they work behind the scenes so to speak and because of this their training and their fine work is sometimes forgotten by both doctors and patients.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Scott Mc on 6/15/05 at 18:07 (176894)

I have the same symptoms in both feet. Would this change the number & types of potential complications? Thus, would it change the value of the MRI?

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. Z on 6/15/05 at 18:14 (176897)

Dr. Wander,
The training is sure out there for ultrasound diagnosis. Both are good diagnostic tools but when it comes to plantar fascia's it is my opinion as well as leading ultrasound experts that ultrasound will give you more information. The most important part when learning ultrasound is to know anatomy and that ultrasound is dynamic and not static. I have yet to find a radiologist except from Jefferson Ultrasound Clinic in Philadelphia that knows any thing about MS ultrasound
You must spend the time and energy when learning ultrasound just like any other procedure or tool

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. Z on 6/15/05 at 18:16 (176898)

Ralph,
There are no fellowship in MS ultrasound that I am aware. Most radiologist are against ultrasound because of the loss of money that MRI's bring in. Ultrsound $250 MRI $2000

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Ralph on 6/15/05 at 19:11 (176901)

Dr. Z,
Be assured that paying a bit of gratitude on this site to the field of Radiology, Radiologists, and their contributation to the entire field of medicine will take away very little lime light from the contributations made on this site by any resident heelspurs Podiatrist. Homage will always fall at their feet first and foremost.

Dr. Wander appeared to point out the value of Radiologist in the over diagnosis process. I took the liberty of extending my opinion to include all fields of medicine when I agreed with him.

Knowing only one good ultra sound Radiologist probably means you just haven't visited every major medical center in the world yet. If you really looked I bet you'd find a few.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. Z on 6/15/05 at 20:35 (176906)

Ralph,
I agreed that radiologists have made many many contributions. MS ultrasound just isn't at the top of the list of modalities that they want to embrace. Sad but true. I listen to lectures by the radiologists that are the leaders in MS ultrasound and I am expressing an opinion based on their views and resistance . Change is difficult in all fields and MS ultrasound is something that most radiologist haven't taken the lead in MS ultrasound
This has nothing to do with lime light just the facts of MS ultrasound life
I talk to patients all over the country it is next to impossible to get an MS ultrasound ordered locally except if you can find a podiatrist who has one in his office. Just the facts.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Ralph on 6/16/05 at 07:41 (176923)

Dr. Zuckerman,
If I was looking for a place to get an MS ultrasound ordered I'd be calling and talking to Radiologist at large medical centers all over the country not patients.

It seems to me if MS ultrasound is that much better and should become the test of choice doctors are the ones that have to make it that way. After all Radiologist don't order specific tests for patients their doctors do.

Could it boil down to using what is less trouble and located closer to the doctors office than searching out what is really better? Either way the patient get a test done.

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Scott Mc on 6/16/05 at 13:34 (176951)

I will again ask the question posed earlier in this thread:

'I have same symptoms in both feet. Would this condition/symptom(s) change the likely number and the likely types of potential complications that could be spotted via the MRI? Thus, would the value of the MRI be reduced?'

Re: MRIs & PF (DPMs' & Radiologist's Opinions)

Dr. David S. Wander on 6/17/05 at 07:36 (176992)

Dr. Z,

I agree with you, Dr. Nazarian at Jefferson is well versed in MS ultrasound and this is a very new field. However, many radiologists do have fellowships in ultrasound and know the basic fundamentals of the principals of ultrasound and have been reading different types of ultrasounds for years. The transition and learning curve for them to begin reading MS ultrasound should be less than for someone who just purchased a machine and put it in his/her office. This is a very new field, and as I'm sure you'll agree many doctors are purchasing these units because it is a new billable service. These are the doctors that are going to get burnt when they miss a diagnosis. You and I know that the few bad apples are the ones that give guys like you and me a bad reputation. I agree that ultrasound gives a wealth of useful information, in 'real time' without the expense of MRI. But I'm sure that you'll agree that unfortunately, since it is now available for the office, it will be abused and overutilized.