Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
PURPOSE: To compare the effectiveness of sonographically guided and palpation-guided steroid injection for the treatment of proximal plantar fasciitis.
PATIENTS AND METHODS: Twenty-five consecutive patients with unilateral proximal plantar fasciitis were recruited and randomly divided into a sonographically guided group (n = 12) and palpation-guided group (n = 13). Proximal plantar fascia was assessed with a 5- to 12-MHz linear-array transducer. Pain intensity was quantified using a "tenderness threshold" (TT) and a visual analog scale (VAS). Injection of 7 mg (1 ml) of betamethasone and 0.5 ml of 1% lidocaine into the inflamed proximal plantar fascia was performed under the guidance of sonography or palpation. Patients were evaluated clinically and sonographically before injection and at 2 weeks, 2 months, and 1 year after injection. VAS- and TT-measured pain intensity, thickness, and echogenicity of the proximal plantar fascia, as well as the recurrence of heel pain, were assessed.
RESULTS: Both VAS- and TT-measured levels of pain improved significantly after steroid injection in both groups (p < 0.001). Also, the thickness decreased significantly after injection (p < 0.01 in the palpation-guided group; p < 0.001 in the sonographically guided group). The number of patients with hypoechogenicity at the proximal plantar fascia decreased after steroid injection in both groups (p < 0.01 for both groups). The recurrence rate of plantar fasciitis in patients of the palpation-guided group (6/13) was significantly higher than that of the sonographically guided group (1/12) (p < 0.05).
CONCLUSIONS: Steroid injection can be an effective way to treat plantar fasciitis, and injection under sonographic guidance is associated with lower recurrence of heel pain.
Would be interesting to know if they injected plantarly or medially into the heel. I believe that plantar injections are much more effective at resolving pain than medial injections. Did the article say how the injections were given?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Given the recent evidence showing the lack of "inflammation" with plantar fascia pain (forget the reference - recent histology study in JAPMA). What is it that steroid injections do in this condition?
I am no expert in the area of histology and pharmacology, but some of the Sports Doctors suggest that it could be acting on substance P, very similar to that of what happens in achilles/patella tendinopathy. A significant break in the pain cycle with the possible ability to be able to load the fascia up more heavily. Not sure on the last comment.
Pl Fasciitis/Fasciopathy is the same underlying process of excessive up regulation of cellular activity in response to overloading that we see in achilles tendinopathy. Similar to hypergran tissue in the absence of IGT, useless tissue that is very painful and very vascular.
Steroid down regulates cellular activity, reduces ground substance (which is the hydrophilic aspect of the fasciopathy), reduces vascular growth of small capillaries into the tissue that are associated with pain fibres, and of course the needle itself would most likely stimulate a more appropriate healing response by traumatising the area which would lead to fibroblastic activity and remodelling.
It would appear from my simple analysis that it is a highly appropriate treatment when used correctly. Combine injection with orthotic support (of any type) and/or strapping and improvement in biomechanics through stretching/strengthening where appropriate.
Pl Fasciitis/Fasciopathy is the same underlying process of excessive up regulation of cellular activity in response to overloading that we see in achilles tendinopathy. Similar to hypergran tissue in the absence of IGT, useless tissue that is very painful and very vascular.
Steroid down regulates cellular activity, reduces ground substance (which is the hydrophilic aspect of the fasciopathy), reduces vascular growth of small capillaries into the tissue that are associated with pain fibres, and of course the needle itself would most likely stimulate a more appropriate healing response by traumatising the area which would lead to fibroblastic activity and remodelling.
Matt
In this and other recent threads, there has been reference to plantar fasciitis being a fasciosis without inflammation, but rather a degeneratiion of the fascial tissue (incl. the JAPMA histology study). This is very interesting and plausible, but I am confused as to the difference between "excessive cellular activity described above in relation to plantar fasciitis/fasciosis, and a generalised "inflammatory response". Is it not one and the same?
If there is no inflammation of the fascial tissue in plantar fasciosis, and it is simply a degenerative condition, what accounts for the often classic clinical presentation of localised tissue swelling, first-step pain, redness and pooling of fluids at the site?
The degenerative tissue has higher levels of ground substance which as I mentioned is hydrophilic. Hence it acts as a sponge when you take pressure off it (weightbearing). Thus pain in morning.
The generalised swelling is more likely due to abnormal ankle range in people with nasty cases. This has been documented before in that they have reduced heel contact and reduced ROM use during gait cycle. Hence pumping action is reduced in venous/lymph system plus there is abnormal use of muscles which also aid in normal pumping action.
I am not completely convinced there is a total absence of inflammation but I agree with past papers that it is not a significant effect.
Pl Fasciitis/Fasciopathy is the same underlying process of excessive up regulation of cellular activity in response to overloading that we see in achilles tendinopathy. Similar to hypergran tissue in the absence of IGT, useless tissue that is very painful and very vascular.
Steroid down regulates cellular activity, reduces ground substance (which is the hydrophilic aspect of the fasciopathy), reduces vascular growth of small capillaries into the tissue that are associated with pain fibres, and of course the needle itself would most likely stimulate a more appropriate healing response by traumatising the area which would lead to fibroblastic activity and remodelling.
It would appear from my simple analysis that it is a highly appropriate treatment when used correctly. Combine injection with orthotic support (of any type) and/or strapping and improvement in biomechanics through stretching/strengthening where appropriate.
.....and......The degenerative tissue has higher levels of ground substance which as I mentioned is hydrophilic. Hence it acts as a sponge when you take pressure off it (weightbearing). Thus pain in morning.
The generalised swelling is more likely due to abnormal ankle range in people with nasty cases. This has been documented before in that they have reduced heel contact and reduced ROM use during gait cycle. Hence pumping action is reduced in venous/lymph system plus there is abnormal use of muscles which also aid in normal pumping action.
I am not completely convinced there is a total absence of inflammation but I agree with past papers that it is not a significant effect.
Matt
Matt:
I have read your comments about plantar fasciitis not being inflammatory in nature. I have also read the paper by Lemont et al on their study regarding fasciitis being a "fasciosis" and not inflammatory. However, my clinical experience in treating thousands of these patients seems to point to the fact that this painful condition responds to ice and NSAIDS, both anti-inflammatories. In addition, these patients also respond, sometimes to the point of the pain being cured, to cortisone injections, also anti-inflammatory. Therefore, I don't agree with you that plantar fasciitis doesn't involve some form of inflammation surounding the damaged plantar fascial tissue, since if there isn't inflammation, why is the condition responding to anti-inflammatory measures and why is it painful in the first place??!!
Until you, or Lemont et al, or anyone else can explain with a scientifically coherent manner why plantar fasciitis responds well to anti-inflammatory measures and can explain what the pain in plantar fasciitis is caused by, then I will remain sceptical that plantar fasciitis does not have some form of an inflammatory component.
By the way, not all researchers agree with the results of the study by Lemont et al:
Quote:
Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur. A report on 38 cases.
Acta Orthop Belg. 2003; 69(3):267-74 (ISSN: 0001-6462)Jarde O; Diebold P; Havet E; Boulu G; Vernois J
Service d'Orthopédie-Traumatologie, Hôpital Nord-Amiens, France. jarde.olivier@chu-amiens.fr
The authors studied 38 cases of degenerative lesions of the plantar fascia which were treated surgically between 1989 and 1999. MRI showed chronic fasciitis in eight cases and an old rupture of the plantar fascia in 30 cases. Surgical treatment, which was performed in all cases after failure of conservative treatment of several months duration, combined excision of the fascia with resection of the heel spur. Histological examination found inflammation in all cases (fasciitis or rupture), calcification of the aponeurosis in four cases, cartilaginous metaplasia in four and fibromatosis in four. Patients were assessed a minimum of one year and a maximum of seven years after operation. The postoperative results were assessed using three criteria: resolution of pain, results on the static foot and patients' functional activity. Overall there were 24 very good and good results, nine fair and five poor. MRI performed at the time of follow-up revealed good healing of the plantar fascia in 16 cases, defects in two cases, inflammation in seven cases and defects associated with inflammation in 13 cases. Surgical treatment may be considered in cases where conservative treatment of talalgia has failed. Symptoms originating from degenerative damage to the plantar fascia, such as rupture or fasciitis, may benefit from fasciectomy. Short-term results show resolution of pain in 75% of cases, and a slight sagging of the plantar arch. Pre-operative MRI study is useful to determine the exact location of the lesions.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
The same could be said of achilles tendinopathy. For many years it has been treated with NSAID's, etc and continues to be treated so until this day. Yet some unquestionable shift has occurred in its treatment through recent histological studies and understanding.
Evidence for an effect is weak for NSAID's and from the studies I have read no better than placebo. Analgesic action could explain its effect.
Cortisone clearly has an effect on ground substance which could more easily explain its effect on the treatment of fasciopathy. Why else would the effect be sustained? How has reducing inflammation ever cured musculoskeletal problems if the underlying problem is not cured? In fact the effect of cortisone seems to be ideal on paper for the treatment in all fasciopathy and tendinopathy when used appropriately (not to say that it should be).
The same could be said of achilles tendinopathy. For many years it has been treated with NSAID's, etc and continues to be treated so until this day. Yet some unquestionable shift has occurred in its treatment through recent histological studies and understanding.
Evidence for an effect is weak for NSAID's and from the studies I have read no better than placebo. Analgesic action could explain its effect.
Cortisone clearly has an effect on ground substance which could more easily explain its effect on the treatment of fasciopathy. Why else would the effect be sustained? How has reducing inflammation ever cured musculoskeletal problems if the underlying problem is not cured? In fact the effect of cortisone seems to be ideal on paper for the treatment in all fasciopathy and tendinopathy when used appropriately (not to say that it should be).
Matt
If you are correct, then how do you explain the results of the study from Jarde et al that I posted: " Histological examination found inflammation in all cases (fasciitis or rupture)".
In addition, I have to admit that I have not stayed up on my histology since learning it over 20 years ago in podiatry school. Has the definition of inflammation changed over the past 20 years?? When I was taught about the inflammatory response, when a ligament or tendon was damaged, an inflammatory response was mounted which caused pain, thus ice, NSAIDS and cortisone are used to dampen the inflammatory response and decrease the pain. Are you saying now that this is not true? What then causes the pain when someone has a small tear in the plantar fascia if it is not the inflammatory response that is mounted by the body to repair it?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Good to get a bit of interest in this debate. I think what you have said is a fair point. However, I was looking more at the precise point of the role of inflammation. If inflammation caused the problem, then stopping inflammation would cure the problem. Inflammation is obviously secondary to something else therefore is not the underlying problem in plantar fasciitis. Controlling inflammation may help cure the problem but it is not the pathological process that leads to the fasciitis. This would be the same for all musculoskeletal injuries.
Therefore the "cure" would aim to treat the underlying cause. This may be any one of biomechanics, stretching, strengthening, etc.
My belief is that by dealing with these points I do not have to resort to NSAID's and its own associated list of problems, or the hassles of icing. I especially don't need to use these now that I believe it is a more degenerative process than inflammatory.
On the point of the articles I think it is interesting that there is so much disagreement. You would think histology and biochemistry would not be such an inexact science. It appears they are still trying to work out what exactly causes the pain in achilles tendinopathy also and that has been studied to death.
Good to get a bit of interest in this debate. I think what you have said is a fair point. However, I was looking more at the precise point of the role of inflammation. If inflammation caused the problem, then stopping inflammation would cure the problem. Inflammation is obviously secondary to something else therefore is not the underlying problem in plantar fasciitis. Controlling inflammation may help cure the problem but it is not the pathological process that leads to the fasciitis. This would be the same for all musculoskeletal injuries.
Therefore the "cure" would aim to treat the underlying cause. This may be any one of biomechanics, stretching, strengthening, etc.
My belief is that by dealing with these points I do not have to resort to NSAID's and its own associated list of problems, or the hassles of icing. I especially don't need to use these now that I believe it is a more degenerative process than inflammatory.
On the point of the articles I think it is interesting that there is so much disagreement. You would think histology and biochemistry would not be such an inexact science. It appears they are still trying to work out what exactly causes the pain in achilles tendinopathy also and that has been studied to death.
Matt
When you read the article by Lemont et al, they make it very clear in both the title and the body of their paper that they believe that inflammation is not a part of what we call plantar fasciitis (Lemont H, Ammirati KM, Usen N: Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation. JAPMA, 93: 234-237, 2003). I think that this is, at best, misleading. The title on their article reminds me a little of one of Rich Blake's articles on running limb varus (Tristant S, Blake RL: The myth of running limb varus. JAPMA, 6:325-327, 1991). I don't think authors should be allowed to have titles like these in scientific medical journals since these titles certainly do tend to make the authors out to be much more confident of their opinions than they really should be.
I think that you will find most podiatrists believe that inflammation is not the primary etiology of plantar fasciitis since they feel, like I do, that inflammation is the result of the chronic mechanical stresses and tissue injury (fasciosis) that occur within the substance of the central component of the plantar aponeurosis during weightbearing activities. To say that plantar fasciitis does not involve inflammation by doing a histological study like Lemont et al is probably like looking at healing metatarsal fractures under the microscope and seeing no inflammation within the bone, but ignoring the swelling in the soft tissues adjacent to the bone (here's the title of the article: Healing Bone Fractures: A Reparative Process Without Inflammation). .
Certainly, there is an inflammatory component to plantar fasciitis but it may not actually be within the collagen fibers of the fascia, but in the tissues surrounding the fascia. When I inject a patient that has severe plantar fascial tenderness with cortisone, they have a whole lot of pain compared to those patients that have little plantar fascial tenderness. Is this pain from a "fasciosis" or more from a "fasciitis"? I believe that the increased pain is caused more from the latter than the former.
Good discussion. Makes me want to dust off my histology textbook again....
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
When you read the article by Lemont et al, they make it very clear in both the title and the body of their paper that they believe that inflammation is not a part of what we call plantar fasciitis (Lemont H, Ammirati KM, Usen N: Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation. JAPMA, 93: 234-237, 2003). I think that this is, at best, misleading. The title on their article reminds me a little of one of Rich Blake's articles on running limb varus (Tristant S, Blake RL: The myth of running limb varus. JAPMA, 6:325-327, 1991). I don't think authors should be allowed to have titles like these in scientific medical journals since these titles certainly do tend to make the authors out to be much more confident of their opinions than they really should be.
I think that you will find most podiatrists believe that inflammation is not the primary etiology of plantar fasciitis since they feel, like I do, that inflammation is the result of the chronic mechanical stresses and tissue injury (fasciosis) that occur within the substance of the central component of the plantar aponeurosis during weightbearing activities. To say that plantar fasciitis does not involve inflammation by doing a histological study like Lemont et al is probably like looking at healing metatarsal fractures under the microscope and seeing no inflammation within the bone, but ignoring the swelling in the soft tissues adjacent to the bone (here's the title of the article: Healing Bone Fractures: A Reparative Process Without Inflammation). .
Certainly, there is an inflammatory component to plantar fasciitis but it may not actually be within the collagen fibers of the fascia, but in the tissues surrounding the fascia. When I inject a patient that has severe plantar fascial tenderness with cortisone, they have a whole lot of pain compared to those patients that have little plantar fascial tenderness. Is this pain from a "fasciosis" or more from a "fasciitis"? I believe that the increased pain is caused more from the latter than the former.
Good discussion. Makes me want to dust off my histology textbook again....
Dr. Kirby (Kevin)--
Thank you to both yourself and Dr. Matt Dilnot for tackling a topic that also puzzles and divides many podiatrists I know. It was interesting to hear your thoughts. I continue to administer steroid injections with some frequency while also informing my patients of the need for prevention of recurrence based on underlying causes.
I couldn't agree more with your thought regarding articles such as that from JAPMA on plantar fasciosis. Declaring inflammation irrelevant to plantar fasciitis or that which we PERCEIVE as fasciitis? Tantamount to facilitating dogma, I feel, until we have a better understanding of the cellular pathology. This type of blanket statement adds to that part of the foundation of podiatric research which is less than evidence-based, from which we, as a profession, are fortunately moving away.
Thank you to both yourself and Dr. Matt Dilnot for tackling a topic that also puzzles and divides many podiatrists I know. It was interesting to hear your thoughts. I continue to administer steroid injections with some frequency while also informing my patients of the need for prevention of recurrence based on underlying causes.
I couldn't agree more with your thought regarding articles such as that from JAPMA on plantar fasciosis. Declaring inflammation irrelevant to plantar fasciitis or that which we PERCEIVE as fasciitis? Tantamount to facilitating dogma, I feel, until we have a better understanding of the cellular pathology. This type of blanket statement adds to that part of the foundation of podiatric research which is less than evidence-based, from which we, as a profession, are fortunately moving away.
Tanya M. Barton, DPM
Minocqua, WI
Tanya:
Good to see you taking the initiative to comment on this topic, Tanya.
To say that inflammation is not a part of plantar fasciitis, or what we now call plantar fasciitis, is misleading. However, to think that plantar fasciitis is only inflammatory in nature without having any component of cellular damage to the central component of the plantar aponeurosis is also wrong.
I believe that part of the problem with histological studies, especially if the researchers are not careful at how they set up their study (or their goal is to prove a "pet point" of theirs), is that they often only look at the structure that is offered up as a specimen and not at the local or systemic effects of the pathologic process as a whole. Can't see the forest for the trees??? If the trees being sampled are healthy, but 60% of the trees of the forest are infected with a pathogen, would it be correct to conclude from the experimental sample that the forest is healthy?
Research literature must be read with a careful eye. If it doesn't make sense, the objective physician should raise a question as to its validity and accuracy. Keep a slight skepticism about you because you can't believe everything you read, even in the best scientific journals.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Having only read the JAPMA study regarding plantar fasciosis and not able to access the article that Kevin K talks about, my view is very narrow. In this study they gave no figures on what they determined as "chronic". Was this 6 months, 2 years. Is there a component of fasciitis in the early stages and then as time goes by there becomes more of a degenerate change within the aponeurosis as more of the cellular changes that Matt Dilnot explains occur. Is there a grading that we should be giving our patients? Could this be possibly defined by the different types of symptoms? With this should we then be able to more accurately follow their progress with treatments, and be better able to give evidence at which stage of the pathology which treatment should work better.
Maybe we need to follow in the work of Alfredson et al and the work they are doing with tendons and aim to investigate the plantar aponeurosis in a similar manner. They seem to be going to great lengths to gain more knowledge about how best to understand what is happening inside the tendon.
I agree with Kevin's "wood and trees" analogy. I'd go further and say that there is a lot more anatomy located in and around the classic site for "plantar fasciitis pain" than just the plantar fascia. I'm not convinced the plantar fascia is always the source of pain/ inflammation, but it gets labelled as plantar fasciitis because the symptoms seem to fit. If you only think about the plantar fascia, you only see one pathology...
__________________ Science is the antidote to the poison of enthusiasm and superstition
Lateral plantar nerve injury following steroid injection for plantar fasciitis.
Br J Sports Med. 2005 Dec;39(12):e41;
A 41 year old man presented with pain and numbness affecting the lateral aspect of his foot after a steroid injection for plantar fasciitis. Examination confirmed numbness and motor impairment of the lateral plantar nerve. The findings were confirmed by electromyographic studies. The anatomy of the lateral plantar nerve and correct technique for injection to treat plantar fasciitis are discussed.
You have to be pretty ignorant of foot anatomy to hit the lateral plantar nerve when injecting the plantar calcaneus for plantar fasciitis. Ignorance of foot anatomy is way too prevalent within the podiatry profession. Ignorance of foot anatomy is the norm in non-podiatric health professionals. Bagging the lateral plantar nerve is inexcusable in plantar fascial injections since no one should be poking a needle around inside the foot unless they know exactly where all the major neurological structures are located.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Bone Scintigraphy Predicts Outcome of Steroid Injection for Plantar Fasciitis. J Nucl Med. 2006 Oct;47(10):1577-1580
Frater C, Vu D, Van der Wall H, Perera C, Halasz P, Emmett L, Fogelman I
Quote:
Plantar fasciitis is a common cause of foot pain and may be disabling. Although localized injection is painful, anesthetics or corticosteroids can relieve symptoms well. Bone scintigraphy can confirm the diagnosis. We hypothesized that blood-pool abnormalities could provide prognostic information on the response to such injections.
METHODS: We devised scintigraphic criteria that graded the blood-pool abnormalities as being localized to the plantar enthesis, being localized to half the length of the aponeurosis, or involving the whole aponeurosis. We evaluated 24 patients with an established diagnosis of plantar fasciitis, 8 of whom had bilateral disease, leading to a total of 32 feet injected.
RESULTS: After injection, pain was relieved either completely or nearly completely in 20 feet. The other 12 feet had short-term or no improvement, with persistent pain and loss of function at 4-5 wk after injection. Of the 20 feet responding to injection, 14 had focal hyperemia on blood-pool images and 6 had minimal extension into the proximal third of the plantar soft tissues. No patient with diffuse hyperemia in the plantar fascia had a response (5/12 feet). On the delayed images of the 20 responders, mild inferior calcaneal uptake was seen in 8 feet, moderate uptake in 6, and severe uptake in 6. These groups did not significantly differ (P > 0.05). The blood-pool studies had good reproducibility, with a kappa-value of 0.64.
CONCLUSION: Critical evaluation of plantar blood-pool images provides prognostic information on the response to localized injection into the enthesis. Reporting such studies is simple and reproducible.
Re: Plantar fasciitis treated with local steroid injection
Much of the disagreement on this topic stems from different definitions of the term "inflammation". An editorial and thorough review on this topic were recently published in the British Journal of Sports Medicine:
Re: Plantar fasciitis treated with local steroid injection
Just An Odd Note I Do Not Beleive That A Study Of Such Small Numbers Should Have Us Jumping Threw Hoops. I Have Been Injectinging Across From The Medial Side For Some Time Now And Seem To Get Good Results. But If You Explain How Injecting Plantar Is Better In Less Then Ten Studies Would Love To Here It.
Re: Plantar fasciitis treated with local steroid injection
Bizarre post above! . I'm not at all sure about injectinging!
Simon wrote
Quote:
I'd go further and say that there is a lot more anatomy located in and around the classic site for "plantar fasciitis pain" than just the plantar fascia. I'm not convinced the plantar fascia is always the source of pain/ inflammation, but it gets labelled as plantar fasciitis because the symptoms seem to fit. If you only think about the plantar fascia, you only see one pathology...
This is a subject close to my heart. I can't help feeling the PF is often the "fall guy" for the more subtle master criminals of planter foot pain. Its back to the "if you have a hammer everything looks like a nail" problem. I have had pain reffered to me as pf on areas ranging from the medial aspect of the navicular to the area just inferior to the lateral malleolus. GPs and some physios are the worst culprits but the "sideshow" podiatrist brigade are also frequent offenders. You then have to spend ages trying to convince your patient that they do NOT have planter fascitis. Not an easy task as people love to be told they have a problem with a cool sounding name and Planter Fascitis is as neat and serious sounding as it is vague unhelpful.
"You're heels hurt cos you have a laminate floor and don't wear slippers when standing still ironing for hours on end"
just does'nt trip off the tongue the same way and they will fight to the death to avoid a diagnosis of
"forefoot pain due to 3 inch heels for 4 hours worth of shopping".
Re: Plantar fasciitis treated with local steroid injection
What is everyones experience of neural involvement with plantar fascia like symptoms? I tend to test neural tissue in any presenting heel pain (by slump and/or SLR) - is this something most practitioners do?
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by Robertisaacs
"You're heels hurt cos you have a laminate floor and don't wear slippers when standing still ironing for hours on end"
just does'nt trip off the tongue the same way and they will fight to the death to avoid a diagnosis of
"forefoot pain due to 3 inch heels for 4 hours worth of shopping".
Couldn't agree more! Trying to explain to patients they have something different (whether diagnosed by physio, GP, other foot health professional, Podiatrist or even their best friends' mothers' aunt!!!) is a daily nightmare. The next biggest problem I find is trying to get across that as their foot barely fits in the shoe how the heck is an insole going to get in there as well!!, let alone be of any use.
Probably the most bizzare referral I recieved from a GP was for "a painful plantar faciitis, with an unusual bump on the lateral side of the calcaneum"
Turns out to be a very large Haglunds deformity, and the pain was an Achilles tendonitis/osis, later confirmed by ultrasound.
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by Ian
What is everyones experience of neural involvement with plantar fascia like symptoms? I tend to test neural tissue in any presenting heel pain (by slump and/or SLR) - is this something most practitioners do?
Dear Ian
Why would anyone perform a straight leg raise? It tells you nothing.
AS back pain is very prevelant in the community, almost anything that moves the back will cause pain.
If you do the maths and use likelihood ratio (this remove prevelance) the ratio reduces to about 0.48 to -.54 depending on whose study you follow.
A Likelihood ratio of tossing a coin is one, ie. heads or tails. Thus if the ratio is less than one, you are worse off for having performed the test. You are better off asking you receptionist for to answer the question do you think there is a back problem in this patient.
A good likelihood of 4 plus means there are good chances that you have power in your test or data.
The highest I have read for musculoskeletal testing is about 3.4 and the ood 4.0. Basically extremely poor on any test you care to name.
There are studies on plantar fasciitis regarding causes picking on obesity. Those who have a BMI of greater than 30 the likelihood is ovewr 9.0 and those who have a BMI >35 the likelihood Is 14.
I have yet to see better result on likelihood anywhere in the literature.
Conclusion, do not perform a SLR, you are wasting your time in more ways than one.
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by Ian
What is everyones experience of neural involvement with plantar fascia like symptoms? I tend to test neural tissue in any presenting heel pain (by slump and/or SLR) - is this something most practitioners do?
I know of the slump test but admit I don't use it (for no particular reason). I would also be interested in others experiences, including yours Ian.
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by HJM41
Just An Odd Note I Do Not Beleive That A Study Of Such Small Numbers Should Have Us Jumping Threw Hoops. I Have Been Injectinging Across From The Medial Side For Some Time Now And Seem To Get Good Results. But If You Explain How Injecting Plantar Is Better In Less Then Ten Studies Would Love To Here It.
iH hjm41,
yOU hAVE aN oDD wAY oF tYPING wHICH iS tOTALLY fOREIGN tO mE, aND gOES aGAINST aLL tHE cONVENTIONS tHAT i hAVE lEARNED.
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by musmed
Dear Ian
Why would anyone perform a straight leg raise? It tells you nothing.
AS back pain is very prevelant in the community, almost anything that moves the back will cause pain.
If you do the maths and use likelihood ratio (this remove prevelance) the ratio reduces to about 0.48 to -.54 depending on whose study you follow.
A Likelihood ratio of tossing a coin is one, ie. heads or tails. Thus if the ratio is less than one, you are worse off for having performed the test. You are better off asking you receptionist for to answer the question do you think there is a back problem in this patient.
A good likelihood of 4 plus means there are good chances that you have power in your test or data.
The highest I have read for musculoskeletal testing is about 3.4 and the ood 4.0. Basically extremely poor on any test you care to name.
There are studies on plantar fasciitis regarding causes picking on obesity. Those who have a BMI of greater than 30 the likelihood is ovewr 9.0 and those who have a BMI >35 the likelihood Is 14.
I have yet to see better result on likelihood anywhere in the literature.
Conclusion, do not perform a SLR, you are wasting your time in more ways than one.
I disagree. I use neural tension testing both diagnostically and for treatment. If I have a patient with heel pain and symptoms atypical of plantar fasciitis (no first step pain, night pain, neuritic sensations, etc). I will slump test them. It is more than performing a simple SLR. I have the patients sit of the end of the table. I will extend the knee, DF the ankle, with the hip at 90. I will then have them curve the T and L spine into flexion and monitor symptoms. I will then have them flex the C spine (chin to chest) while in this position- if heel pain/symptoms result, then I am dealing with a neural issue and not typical plantar fasciitis. Treatment is then directed toward the nerves. This test really impresses the patient as they increase/decrease the pain with movements of the head only.
Of note- I do not perform this test in patients with garden variety PF signs/symptoms.
Re: Plantar fasciitis treated with local steroid injection
Quote:
Originally Posted by Scorpio622
I will slump test them. It is more than performing a simple SLR. I have the patients sit of the end of the table. I will extend the knee, DF the ankle, with the hip at 90. I will then have them curve the T and L spine into flexion and monitor symptoms. I will then have them flex the C spine (chin to chest) while in this position- if heel pain/symptoms result, then I am dealing with a neural issue and not typical plantar fasciitis. Treatment is then directed toward the nerves.
Nick,
let's say you do this slump test, the one which 'is more than performing a simple SLR', and bam, it lights them up like a christmas tree. What information is gathered, where is the problem based from the information gained with test, and what do you do with your treatment 'directed towards the nerves'?
Quote:
Originally Posted by Scorpio622
This test really impresses the patient as they increase/decrease the pain with movements of the head only.
So the problem with their foot is in their head?
Nick, maybe you have hit on something much greater than you ever knew possible.
DaFlip
Plantar fasciitis treated with local steroid injection
.
Linear Mode
