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Plantar fasciitis A degenerative process (fasciosis) without inflammation

Plantar fasciitis A degenerative process (fasciosis) without inflammation. Harvey Lemont, Krista M. Ammirati, and Nsima Usen Presented by: Garrett Hays. Contents. Plantar Fascia Overview Diagnosis Inflammation Analysis (Presence or Absence) Corresponding Data with Analysis

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Plantar fasciitis A degenerative process (fasciosis) without inflammation

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  1. Plantar fasciitisA degenerative process (fasciosis) without inflammation Harvey Lemont, Krista M. Ammirati, and Nsima Usen Presented by: Garrett Hays

  2. Contents • Plantar Fascia Overview • Diagnosis • Inflammation Analysis (Presence or Absence) • Corresponding Data with Analysis • Fasciitis or Fasciosis? • Conclusion

  3. Plantar Fascia: Overview • The plantar fascia ligament extends from Calcaneus to metatarso-phalangeal joints • Function is arch support • Composition of plantar fascia is bundle of white fibers • Common Definition of plantar fasciitis: a painful heel with inflammation of the plantar fascia at its origin

  4. Diagnosis • Plantar Fasciitis: Painful heel with inflammation • No evidence of inflammation, only suggested • Inflammation may be a misdiagnosis of heel pain • Much data supports a fasciosis look at heel pain

  5. Inflammation analysis More data support degeneration over inflammation: • Specimens show thickening and fibrosis at origin on medial tubercle • Other specimens show strictly degeneration • Biopsy specimens point to collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and matrix calcification • No cellular proof of inflammation

  6. Figure 1:Normal fascial enthesis exhibiting metaplasia of bone to fibrocartilage to fascia (H&E, x40)

  7. Analysis of Figure 1 Of 50 heel spur samples analyzed at the Laboratory of Podiatric Pathology at Temple University, 10 showed normal plantar fascial enthesis with a regular transition of bone to fibrocartilage to fascia as seen in Fig. 1

  8. Figure 2:Fibrocartilage interface between bone and fascia (H&E, x 40)

  9. Analysis of Figure 2 The same 10 represented in Fig 1 also showed fibrocartiloginous fibers running parallel to each other

  10. Figure 3: A: Zones of dark staining representing mucopolysaccharide (curved arrows), with degeneration of collagen (straight arrow) B: Close up view of degenerated collagen (fascia) (alcian blue [pH 2.5], x40)

  11. Analysis of Figure 3 16 samples show fiber fragmentation with myxoid degeneration characterized by basophilic zones of mucopolysaccaride stained positive with alcian blue (pH 2.5)

  12. Figure 4:Artifacts within fascia representing areas of probable previous corticosteroid deposits (H&E, x40)

  13. Analysis of Figure 4 In 2 of the previously mentioned 16 samples, fascial artifacts and fragmentation in association with crystalline material noted in the area before processing was suggestive of previous corticosteroid injections

  14. Figures 5 & 6:Low-power view of calcaneal marrow demonstrating vascular engorgement (H&E, x20)

  15. Analysis of Figures 5 & 6 Between 12 and 16 samples also demonstrated vascularization of the attached bone marrow. Low-power cross-sections of bone removed from the attachment site demonstrated multiple dilated vessels

  16. Analysis conclusion • Dilated vessels in the bone marrow not a result of inflammation • Hyperemia may be the cause of bone contusion in patients with heel spurs • All samples out of the 50 show no signs of inflammation histologically • Evidence points more to degeneration of the fascia than inflammation of the region

  17. Corticosteroid Injections • Corticosteroid injection is a common form of non-invasive treatment for plantar fasciitis • Out of 765 patients diagnosed with plantar fasciitis, 51 had plantar fascial rupture. 86% of these ruptures were associated with corticosteroid injections • 5 out of 6 athletes in another study with repeated injections reported fascial rupture • 1/3 of 37 patients in another study treated for plantar fasciitis with injections were later diagnosed with fascial rupture

  18. Result of Misdiagnosis:Fasciitis or Fasciosis? • Lack of inflammatory evidence may be proof of misdiagnosis • Patients mistreated for inflammation may have serious side effects • The most notable side effect is the rupture of the plantar fascia, as well as the mild to moderate pain associated with the rupture • A more correct form of terminology for Fasciitis would be fasciosis

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