This topic contains 4 replies, has 2 voices, and was last updated by Christopher Stepien October 7, 2017 at 8:00 am.
October 6, 2017 at 11:42 am #3160
I have a patient with mildly degenerated plantar fascia, achilles tendon, and tibialis posterior tendons.
We’ve gotten about 20% improvement over 12 visits (3.5″ DF to 5″, clean PK test, clean tests except QLF of 60%) as she must be on her feet all day for work and she’s not even allowed to wear a boot or have crutches.
Due to the frustration of slow progress, she went to see an old podiatrist who wants to inject cortisone around the plantar fascia tendon (not into). I told her several times how research strongly supports cortisone further degenerating this tissue.
I’ve never heard this argument before.
I almost discharged her for this doctor to deal with her because she’s unable to deload her foot. I adamantly told her “I do not support cortisone. But a boot and ‘stretching’, there’s probably minimal harm there.”
Does cortisone around the PF help any differently than into the tissue? Is there less harm for this?October 6, 2017 at 1:22 pm #3199
Carl Nottoli, DCParticipant
Draw the Sx/Dysfxn chart. She has cumulative dysfunction that exceeds the symptom threshold. If she gets an injection and it actually does decrease her pain and increase her symptom threshold, but does not decrease her load, how well do you think this will go? So the question of whether or not cortisone will degrade tissue is irrelevant because her load will degrade the tissue further while she has less pain.
However, bonus for her is that both will happen. The cortisone will impact the health of the tissue and her increased load to already damaged tissue will also continue to degrade the tissue.October 6, 2017 at 2:06 pm #3200
John Appleman, DC
Was there a lockout test performed? How is her strength? Does she need an orthotic to help decrease load on those tendons?
Maybe I’m wrong here but I think I would advance her to strength and implement an orthotic, (assuming you haven’t done this already?)October 7, 2017 at 7:48 am #3201
Eric Lambert, DCParticipant
Yes, absolutely cortisone is bad in the PF, especially if it’s loaded with adhesion and the physician doesn’t discuss unloading the area like we do.
I just had this discussion with a patient yesterday. He came to me via a medical doctor referral because everyone has told him he needs surgery. for his foot.
He is a manager/cook of a restaurant and has to stand on concrete a lot of his day. He has had “plantar fascitis” for the past 4 months. His podiatrist put a cortisone injection in 3 months ago and the three days later after the cortisone injection he tore something (sorry haven’t seen the MRI yet) in his medial posterior foot. He states it happened after he working all weekend walking up and down a hill, so tons of load in dorsi-flexed position.
DF measured 3 inches, couldn’t lift his toes at all, loaded with adhesion in his foot and calf areas. No one told has him to slow down and decrease his load. He told me no one had actually tested it or palpated it at all like me either.
So it left me very thankful that I know ID and the testing that lead me to be able to help him more than his other providers.
I understand the frustration Chris, but at the end of the day, we are the only ones actually doing this for our patients. Cortisone makes money and the insurance companies will pay for it, even if it’s not necessary.
Keep up the good work Chris and thanks Carl for all your educational help. I’ve used the SX/Dysfxn chart more since being at your office, it works.October 7, 2017 at 8:00 am #3202
Thank you all.
Carl – good perpective on the Sx/Dysfxn chart.
Carl and John – Yes, I’ve already addressed lockout, posterior chain weakness, and orthotic support.
Practically speaking, this post from me is coming from a place of beating the “You need to deload” drum and this person being unable to do it based on her work environment and income needed to live. I’ve told her “You have no other choice but to keep getting treated because this is NOT as bad as it will get.”
Eric – thank you. That’s helpful to read.
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