Combating The Dogma On Plantar Fasciopathy With The Gift Of Truth

You know that feeling you get when, after countless hours of the endless drudgery of searching, you finally find that perfect thing and all of the frustration and tiredness suddenly melt away, almost like they never happened?

The world fades away and, like a little kid at Christmas, the energy and excitement of the new toy I was clutching at my side stole all of my focus. Mesmerized by the power of this thing, I suddenly found I had stumbled down a small, dark alley. Trepidation tickled at the back of my spine but with the glow of those magnificent retail stores behind me and what I had just “scored,” I was feeling pretty big. The long shadow I cast in front of me added to that feeling as it stretched out endlessly, created by the retail neon holiday glow.

Enthralled by my own shadow and my self-satisfaction, I almost ran into the gentleman. His nimble dodge saved me from becoming a holiday tragedy. “Hey, fella,” he said with a baritone voice and tone of incredulity. Quickly, the bigness I was basking in disappeared and the moving shadow became stationary.

“I’m sorry, sir. I was so engrossed in my recent holiday shopping experience that I was tripping on the endogenous opioids of a shopping high. I didn’t see you,” I politely responded.

“Happens every year, my good man,” he softened. I struggled to see his face but the beacon of illumination from the two stores behind us muted it. “Folks get caught up in the feeling as their nucleus accumbens lights up with shopping anticipation and the endorphins of purchasing swim around every glial cell in their hard little noggins.”

“Nucleus accumbens,” I repeated back to him. “You must be a neuroscientist, sir?” I questioned him with all ready brimming admiration.

“Sort of. What’s in the bag you’re clutching so hard?” he asked.

Now a pair of mental gladiators started a battle inside my head. Should I talk to this guy (he’s kind of scary)? Maybe he knows me? Who is he? “Nucleus accumbens!” For God’s sake, who knows about that tiny little shopping center of the brain? I just have to find out who this dude really is. He obviously knows stuff. With my chest swelling with pride from the treasure I just obtained, I answered his question. “I have a gift box of truth in here.”

“Truth about what?” he volleyed back.

“The plantar fascia,” I whispered like this was a much more sacred tissue than the nucleus accumbens (and it really is if it prevents the shopper from shopping.)

“Really, my man. For yourself or a gift?” he inquired.

Now I was feeling guilty. I knew this gift was really more for me than the friends that I was going to share it with. “For both,” I reluctantly admitted.

“Tell me about the truth," he responded.

"I am telling you the truth," I said.

"No, no, no. I mean about the box of truth you have," he said with a slight patronizing tone in his voice.

"Oh, yeah. Well, let’s see. There is a lot in this box," I stammered. “I’ll give you a couple of my truths if you give me some of yours. Are you ready?”

The Truth About The Origin Of Heel Pain

“Ok, number 1. While the human plantar fascia is very similar to tendon, it has a distinct histology of its own. There has been much dogma relating tensile force to histological breakdown of the fascia but recent findings have redefined how we should look at what occurs during the degenerative process of the fasciopathy.1

“Number 2. It has been proffered for decades that the biomechanical force which causes the breakdown or degeneration of the fascia is tensile force.1 However, there is abundant research that contradicts this closely held belief and it is more likely that the degeneration of the plantar fascia is due to shearing and vertical compression type forces rather than tensile ones.”2

I continued on with my numbered soliloquy. “Number 3. It is likely that foot type has nothing to do with plantar fasciopathy.”3

“Whoa! Hold on a minute, my reckless heretic!” he scolded me in his original baritone. “You can’t start rocking the boat like this unless you are prepared for some backlash.” I wanted to tell him that to get into the store where I just “bought” this gift box of truth, you had to thrive on backlash and, in fact, relish it.

But I didn’t tell him. “Maybe you can’t handle it?” I provoked. I continued with the soliloquy.

“Number 4. The presence of an inferior calcaneal exostosis does not cause pain but there is a high correlation with its presence and that of plantar fasciopathy, and calcaneal spurs are a response to vertical compression, not longitudinal traction at the calcaneal enthesis.”4

By now, I could hear my new but yet to be introduced acquaintance sighing with interest and noticed a glint in what I could make out of his eyes that were still mostly shrouded by the alley’s darkness. “Just stop a minute. How much did that cost?”

“Nothing but a paradigm shift, sir,” I replied with only a touch of smugness. “It’s free if you have the right attitude and a willingness to open the shackles of your mental bias.”

“So if there is no relation to foot type and the degeneration of the plantar fascia is not related to axial tension, is there really any role for a custom orthotic device?”

“Wow, cowboy, you are really trying to bust the bubbles now. I’m sure there are many studies showing the efficacy of orthotic devices for the treatment of plantar fasciopathy, are there not?”

“Not really when you look at it closely. Most are anecdotal and level 5 at best.” (For the record, I do use custom orthotic devices but for the purpose of spurring, again no pun intended, controversy, I have to ripple the water.) “If you do a PubMed search from 1988 through 2012, there are only 13 publications when using the search words ‘custom orthotic devices’ and ‘plantar fasciitis.’”

By now, I noticed that I had turned around and was following the stranger back toward the beacons of retail light. My shadow was gone and I was following him, trying to keep the conversation going. “You have nothing more to say?” I said to him.

He stopped and turned around. “I’m going to this store to see for myself.”

Evidently, I had intellectually piqued his curiosity. However, I wanted to fire his nucleus accumbens up even more. “I’ll walk back with you and tell you something else I found out about steroids and the plantar fascia.” His pace slowed. He nodded for me to continue.

“You may be better off injecting Botox rather than a glucocorticoid,” I told him. “Plantar fasciitis should be stricken from our vocabulary as we know that plantar fasciopathy is not inflammatory but degenerative.”

“But steroids are the gold standard,” he blustered back.

“Yeah and how is the long-term efficacy?” I challenged. “Look, the reason steroids ‘work’ is that they may be mediating nociceptive chemicals in the degenerative plantar fascia. However, steroids can lead to further degeneration of tendon so we may be making these patients worse in the long term.”4

“What is the name of the store?” he begged. I pointed in front of us.

“There it is, right next to the Apple Store.”

He stared for a moment and smiled with implicit understanding. In big, bold, flashing neon, the name of the store (iamgoD) was irradiating us both.

“What’s your name, sir?” I finally thought to ask.

“You don’t know me?” he shot back. “My name is Jack Doktor.”

While extending my hand to shake his, I said, “You don’t know jack, Doktor.”

References

1. Wearing SC, Smeathers JE, Urry SR, Hennig EM, Hills AP. The pathomechanics of plantar fasciitis. Sports Medicine. 2006; 36(7):585-611.
2. Li J, Muehleman C. Anatomic relationship of heel spur to surrounding soft tissues: greater variability than previously reported. Clin Anat. 2007; 20(8):950-955.
3. Menz HB, Zammit GV, Landorf KB, Munteanu SE. Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J Foot Ankle Res. 2008, 1(1):7.
4. Torricelli P, Fini M, Giavaresi G, Carpi A, Nicolini A, Giardino R. Effects of systemic glucocorticoid administration on tenocytes. Biomed Pharmacother. 2006; 60(8):380-385.



Marrtin Pressmansays: March 6, 2014 at 7:38 am

I loved this piece of prose. It is funny and of course indicative of how evidence-based medicine does not play a role in our day-to-day lives as physicians and surgeons caring for, in this instance, painful heels. We, of course, choose only the literature that we already believe in to make our points. Papers from 6-8 years ago may be profound and "the truth," but each has its own flaws. Are there tenocytes in fascia? Have you seen a fibroma of a tendon? Is tendon the same histology as fascia? Hardly!

Heretics come in all shapes and sizes, and make us rethink our built-in and difficult to change notions of "The Truth." For that, I am grateful to them.

When we published a paper which looked at 100 fascial specimens collected over twelve years and found 51 % were fasciosis, 25% were proximal plantar fibroma and 25% were indeed fasciitis ( white cell infiltrate), these heretical findings were received to the sound of crickets. We will just have to wait and see if there is a single theory that explains all this. My guess is there are multiple truths to confront about this and Dr. Barrett continues to challenge us to find them.

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