Injuries and RehabTell us where it hurts! Do a quick search before asking about your shoulder injury to make sure your question hasn't already been answered (about 50 times), and read the sticky post first.
About 9 months ago I was involved in a very serious car accident. Among other things, I had some severe bruising and swelling on my upper thighs from blunt trauma to the area. Most of it went away after a couple months, but in one area (upper right though, just below the hip) there was a big "lump", which was painful to the touch. I went to physical therapy 2-3 times a week. The physical therapist said it was a hemotoma and he did massage and applied heat and ultrasound. Nothing helped. After about 4 months he started to suspect something else might be wrong. He thought the tissue might be calcifying. I had an x-ray done, but it did not show any signs of calcification. After that they did an MRI. I wish I had the MRI report in front of me, but it's buried somewhere beneath a stack of papers... but I do know that the report said that the test was consistent with the formation of scar tissue.
My rehabilitation doctor said that this was a surprise due to the type of injuries I had. He said that it should get less painful in a year or so, but that physically it was not likely that the scar tissue would get much smaller. My physical therapist said he thought it could get smaller, but wasn't sure. His suggestion was to just work the area out as much as possible to try to break down the tissue... or he said possibly try accupressure, but the rehabilitation doctor didn't agree with that. The physical therapist said that the injury reminded him of when hockey players get a stick to the upper thigh. He said that's the only times he's seen something similar. He also said the muscle is more susceptible to future injury because it's not able to expand and contract properly.
I was released from physical therapy 3 months ago and there hasn't been much change to the area. It's still painful to the touch and the area aches after I workout my legs.
I was just wondering if there's something else I could be doing right now while the injury is still in the healing stage.
Thanks.
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Sandra (aka Erika\'s Las Vegas friend)
I think Bill Hartman would have the best advice, but I know for heavily scarred plantar fascias on the bottom of the foot, they often use a non-invasive sound wave to break up the scar tissue and 'release' the PF. This extra-corporeal shock wave therapy is used with sedation and used instead of the traditonal surgical release.
The fascia is different from muscle tissue, so I'm not sure if this would work in your case, but since you mentioned possible calcification, which is present in most severe cases of plantar fascitiis, I'm throwing this up for Bill to see if this would be applicable in your case. Best of luck!
Actually, extracorporeal shockwave therapy (ESWT) is NOT used for "heavily scarred" plantar fasciitis. It's currently approved in the US for use in treatment resistant plantar fasciitis (which isn't the same thing). And ESWT doesn't always require sedation either--it depends on whether you're having the "high-energy" or "low-energy" one (both have similar effects, but differ in that high protocol requires only one session, but a low protocol requires up to 5).
Calcifcation also has very little to do with plantar fasciitis-related pain. There are many people who have plantar fasciitis who don't have bone spurs or calcifcation of the fascia; and many people who have bone spurs and/or calcifcation who don't suffer from plantar fasciitis pain.
That being said, ESWT is primarily a PAIN modality, not a "tissue destroying" one. The high-energy technology is the least well-understood of the two (only a handful of studies). It is NOT recommended for the break of excess tissue growth.
Additionally, in the US, this would be considered "off-label" use of ESWT, since it's only approved for plantar fasciitis (and since July 2003, for lateral epicondlyitis, but only the low energy, not the high energy). The cost of the therapy in the US is also incredibly exorbitant. I've heard it costs $1000 per session for the low-energy, and $3000 for the high energy (at least, since it requires the services of an anesthesiologist--it's a general anesthetic).
The only reason I know these things is because ESWT is the subject of my dissertation =). We've had a low-energy machine in the clinic for 3 years.
But for Sandra's question: Excess tissue formation can be caused by trauma--the question is whether this tissue is being formed around a scar in your muscle (ie. did you tear it?) or off of some other structure (like tendon, or bone). Does your MRI report say anything?
Hi Sandra,
I think Kaiser tossed this to me because of my backround in using Active Release Techniques (ART). This is a soft-tissue treatment technique which has been pretty darned effective (there are actually many techniques that are effective) on chronic injuries such as yours. Will it "break up" the scar tissue. That's debateable (see the debate we had in an earlier post). Will it change the lump? Maybe. I have used it everyday on someone for the last 3 years and I would say that about 70-80% of my patients improve in 1-3 treatments (I have no hard stats on that...it's a guess based on typical outcomes). I've worked on some patients muscles that originally felt like wood and a couple days later, the lesion was difficult to identify. So something changes, we just haven't been able to identify what exactly.
I've also used Augmented Soft-tissue Mobilization (ASTM...isn't it cool how we have all these acronyms in the medical fields). This is a tool-based therapy which has also been shown to dramatically improve soft-tissue lesions.
The scar tissue has pain receptors but a lower blood supply than "normal tissue" so it can be quite the source of chronic pain. These treatments may alter the tissue, improve blood flow and eventually reduce pain and restore movement to injured tissues.
General massage, ultrasound, moist heat may feel good temporarily, but usually a more aggressive form of therapy is more successful in improving symptoms long-term or permanently.
Keep in mind that neither of these treatments are a cake-walk and typically are described as "it hurts so good" (ART) and it feels like you're stabbing me with a knife (ASTM), but both have decent records of success.
You'll also need to continue to exercise the area (stretch and strengthen) as this contributes to the remodeling process.
ART info can be found at www.activereleasetechniques.co m and you most likely have a practitioner in your area. ASTM info can be found at www.graston-hall.com or by doing a search for ASTM or Graston Technique.
It seems that we are destined to butt heads over and over. [img]smile.gif[/img] Sorry, but in real-life clinical situations in the US, high energy ESWT IS used to treat heavily scarred (as well as treatment resistant) plantar fascitiis. For that matter, it is the heavy scarring that often makes a patient 'treatment resistant.' I know because I've suffered from PF for over 6 years and was supposed to have it done last summer (I deferred). My doctor is also (and first and foremost) my friend since HS and basketball buddy to boot and we've had many a discussion on this subject. The ESWT is a non-invasive measure to treat thickened PF bands at the calcaneous in order to release some of the pressure that the thickening causes, and subsequently relieve the pain of the PF. It is taking the place of surgical 'release', which is simply cutting part of the PF to relieve pressure at the heel.
If you notice, I said most people who have severe cases of PF ( and these would often be treatment resistant) also have calcification. I didn't say all, as you have implied and I didn't say that calcification neccesarily has anything to do with PF pain. However, many treatment resistant cases of PF have to do with excessive pronation, pressure and tearing of the PF band and subsequent thickening near the calcaneal insertion. For those with excessively thick bands at that point (for example, mine is 7 mm thick when normal is 1 mm thick), of course much of the regrowth is calcification. The calcification and subsequent heel spur don't have to be the cause of the pain (I have a heel spur but it isn't the cause of my discomfort), but severe cases most often show a concurrent thickening of this band due to chronic tearing and also significant calcification. Again, this information is coming from an actual practicing doctor with 15 years of clinical experience.
I'm not sure why you are saying that ESWT doesn't break up excessive scar tissue in severe PF cases....that is EXACTLY its function(non-invasive release) and not only is it approved for that in the US, a good number of insurance companies in the US cover it as well. Again, I know from my own first-hand experience that this is so.
Further to my last message, the breaking up of the excessive thickness of the PF band is one of the effects of the ESWT...the part that isn't understood is exactly WHY after the therapy that healing seems to take place better than before and patients don't fall as easily into the same pattern of tear, repair/scar, pain, esp as they seem to do after a normal release. Increased blood supply is suspected, but not yet proven. Anyway, here's an abstract on the size of the PF pre and post ESWT: http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=Abstract
Since you've done your research on tennis elbow, you're no doubt very familiar with the number of small German studies using ESWT for both tennis elbow and PF treatment? And this year's randomized placebo-controlled study in the American Journal of Sports Medicine? I've only seen abstracts on those. There is also a new larger sample size German study (I think from earlier this year, but it may have been last year) that pointed to lack of efficacy in treating chronic PF...I haven't seen any response to that yet.
Heh, but butting heads with you is so much fun, Kaiser! =)
I would challenge any physician or researcher to prove that the plantar fascia is actually scarred in any way in a person who is suffering from plantar fasciitis. First off, there's no clear definition of what "scar" actually is, in the tendon/plantar fascia world. Some argue that it's just the presence of type II collagen; others argue that it's the presence of hypoechoic areas during ultrasound examination (a finding that has been shown to have poor reliability by Khan's research group formerly in Australia and now in British Columbia).
The truth of the matter is that no one knows why some people are treatment resistant and others are not. We just finished a randomized control trial on plantar fasciitis last year (it's in press I think), and ours is the first trial to actually compare the three most used clinical therapies side-by-side. The literature is devoid of any studies that have shed any substantial light on the nature of tendon injury or plantar fasciitis injury (the plantar fascia is considered a separate entity, but can also be considered as an extension of the Achilles tendon, since the two structures are anatomically continuous). It's also questionnable as to whether thickening means anything at all. Surveys of athletes (with or without pain) have shown that thickening is present in many individuals who don't suffer from pain. The most promising research these days on the nature of tendon pain is coming out of Sweden, where Oberg and Alfredsson have discovered the existence of extraneous blood vessels which may be the cause of pain in some tendon-pain sufferers. When these blood vessels are locally sclerosed, they die, and the pain goes away. Our lab is currently trying to replicate their findings.
Secondly, there's no evidence to link PAIN in plantar fasciitis with "scarring" or even bony changes (i.e. heel spurs). The common misconception is that heel spurs cause heel pain. I mean, there's a sharp spur thingy pointing downward into the heel in your x-ray! It must cause pain! Our study involved over 100 people sampled from the Calgary area. Everyone had their feet x-ray-ed. And I can tell you with certainty that not everyone who has plantar fasciitis has a bone spur. I can also tell you that not everyone who has a bone spur has plantar fasciitis. AND, there's no way to tell if the chicken came before the egg--i.e. whether the bone spur was there first, or whether the bone spur was there as a result of the plantar fasciitis. So, despite the thousands upon thousands of physicians and podiatrists TELLING their patients, "You have a bone spur, which is causing your plantar fasciitis." I'm telling you that there's no evidence to suggest anything of the sort. Furthermore, if the bone spur _was_ causal, then the surgery for plantar fasciitis (which involves removing the spur for some surgeons) would theoretically be 100% effective at removing plantar fasciitis-related pain. But it's not even 50% effective. But, I think we already agree on this point.
And speaking of surgery and "scarring". The surgery for plantar fasciitis (which is the last resort for treatment) involves cutting open the foot, making several large gashes in the plantar fascia to encourage bleeding, and then closure of the bloody wound. That's it. Theoretically, this manoveur should cause more scarring than would be present in the plantar fascia before surgery. Yet,some people get relief from this procedure. So, scarring->plantar fascia? Probably not.
No offense to your friend, or to you, but whether your doctor has 15 years of clinical experience is moot in this case. ESWT was approved in the US in July 2003 for tennis elbow and in January-ish 2003 for plantar fasciitis. Studies up until about 1999 had been of insufficient quality to make any grandiose statements about efficacy. The reality is that we don't understand why or how ESWT works. We're not even sure which subsets of the populations suffering from tendon/plantar pain respond best to their therapy.
Anyone who tells you that ESWT is breaking up "scar tissue" (whatever the heck that term means) is talking out their ass.
While my primary area of expertise is research methods and statistics, my content area of expertise is tendon injury and shockwave therapy. The past 3 years of my life have been devoted to this field. You can't run a randomized control-trial (the results of which are being peer-reviewed as we speak for the American Journal of Sports Medicine too) without a full understanding of the existing literature. I've read and analysed every published study on ESWT since it was first used orthopaedically in 1993 (including the ones written in German--got them translated). Check out http://www.ncbi.nlm.nih.gov:80/entre...&dopt=Abstract
The first author is me. After summarizing every single study that had been published up to that point (and some abstracts too) in that paper, I feel that I am intimately familiar with the subject. I would challenge anyone to come up with evidence to show me that ESWT decreases "scar tissue". Not even the FDA randomized control trial published by Ogden demonstrates this effect.
P.S. Kaiser, if you want to have your plantar fasciitis zapped with ESWT, come up to Calgary. I guarantee you, it's at least 66% cheaper than doing it in the US. We charge $802.50 CDN for 3 sessions; not $1000 USD per session. Even with flight and hotel included, it's still substantially cheaper. And you get to be treated by the second most experienced tech in North America =P.
Originally posted by bryanc:
I would challenge any physician or researcher to prove that the plantar fascia is actually scarred in any way in a person who is suffering from plantar fasciitis. First off, there's no clear definition of what "scar" actually is, in the tendon/plantar fascia world. Some argue that it's just the presence of type II collagen; others argue that it's the presence of hypoechoic areas during ultrasound examination (a finding that has been shown to have poor reliability by Khan's research group formerly in Australia and now in British Columbia).
Bryan, you're arguing semantics here. Whether or not the thickening of the PF band is 'scarring' or 'tissue growth' is secondary to anyone here but researchers (i.e. you). What is being discussed by me is whether or not the thickening of the band is a common occurrence in many cases of chronic PF (it is); I'm not arguing that the two are mutually exclusive or always together.
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The truth of the matter is that no one knows why some people are treatment resistant and others are not.
Again, I agree with you - in recalcitrant cases of any medical kind, it's just guesses and iterations of protocols until something works for the individual. In other words, so what?
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It's also questionnable as to whether thickening means anything at all. Surveys of athletes (with or without pain) have shown that thickening is present in many individuals who don't suffer from pain. The most promising research these days on the nature of tendon pain is coming out of Sweden, where Oberg and Alfredsson have discovered the existence of extraneous blood vessels which may be the cause of pain in some tendon-pain sufferers. When these blood vessels are locally sclerosed, they die, and the pain goes away. Our lab is currently trying to replicate their findings.
I've adressed that above. Just because A is sometimes seen without C and vice versa, it doesn't mean that A couldn't be a contributor to B. They are obviously not mutually exclusive.
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Secondly, there's no evidence to link PAIN in plantar fasciitis with "scarring" or even bony changes (i.e. heel spurs). The common misconception is that heel spurs cause heel pain. I mean, there's a sharp spur thingy pointing downward into the heel in your x-ray! It must cause pain! Our study involved over 100 people sampled from the Calgary area. Everyone had their feet x-ray-ed. And I can tell you with certainty that not everyone who has plantar fasciitis has a bone spur. I can also tell you that not everyone who has a bone spur has plantar fasciitis. AND, there's no way to tell if the chicken came before the egg--i.e. whether the bone spur was there first, or whether the bone spur was there as a result of the plantar fasciitis. So, despite the thousands upon thousands of physicians and podiatrists TELLING their patients, "You have a bone spur, which is causing your plantar fasciitis." I'm telling you that there's no evidence to suggest anything of the sort. Furthermore, if the bone spur _was_ causal, then the surgery for plantar fasciitis (which involves removing the spur for some surgeons) would theoretically be 100% effective at removing plantar fasciitis-related pain. But it's not even 50% effective. But, I think we already agree on this point.
Yes, I'm not making any causal connection between heel spurs and chronic PF pain.
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And speaking of surgery and "scarring". The surgery for plantar fasciitis (which is the last resort for treatment) involves cutting open the foot, making several large gashes in the plantar fascia to encourage bleeding, and then closure of the bloody wound. That's it. Theoretically, this manoveur should cause more scarring than would be present in the plantar fascia before surgery. Yet,some people get relief from this procedure. So, scarring->plantar fascia? Probably not.
Again, you're playing semantics, perhaps with my misuse of the word 'scar' - since, by your argument above, no one knows whether thickening of the PF band can be classified as 'scar', 'hypertrophic tissue growth' or something else. The fact remains that PF release does work in many chronic cases...often if you combine a severe pronator with release and corrective orthotics, you can prevent the recurring episodes of pain, whereas one of the fixes may not work on its own.
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No offense to your friend, or to you, but whether your doctor has 15 years of clinical experience is moot in this case. ESWT was approved in the US in July 2003 for tennis elbow and in January-ish 2003 for plantar fasciitis. Studies up until about 1999 had been of insufficient quality to make any grandiose statements about efficacy. The reality is that we don't understand why or how ESWT works. We're not even sure which subsets of the populations suffering from tendon/plantar pain respond best to their therapy.
No offense taken. However, just because we don't know who will definitely respond well to a therapy, does that mean we shouldn't try it at a clinical level after weighing the benefits and risks? No, that's the job for researchers and their subjects, not physicians and their patients.
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Anyone who tells you that ESWT is breaking up "scar tissue" (whatever the heck that term means) is talking out their ass.
Well, you need to click on the abstract above. Call it what you will, 'scar tissue', 'thickening', whatever. You can see the study showed a significant decrease in the size of the PF band after ESWT. So if you want to say that my layman's statement that the ESWT breaks up the excessive thickening of the PF band, feel free. The procedure decreases the size of the bad, plain and simple. Doctors here have had great success with the treatment, despite the fact that your research hasn't yet confirmed it. Enough success, in fact, for many insurance companies to cover it. And, as we know, they don't willingly cover 'experimental' or 'unproven' therapies.
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While my primary area of expertise is research methods and statistics, my content area of expertise is tendon injury and shockwave therapy. The past 3 years of my life have been devoted to this field. You can't run a randomized control-trial (the results of which are being peer-reviewed as we speak for the American Journal of Sports Medicine too) without a full understanding of the existing literature. I've read and analysed every published study on ESWT since it was first used orthopaedically in 1993 (including the ones written in German--got them translated). Check out http://www.ncbi.nlm.nih.gov:80/entre...&dopt=Abstract
The first author is me. After summarizing every single study that had been published up to that point (and some abstracts too) in that paper, I feel that I am intimately familiar with the subject. I would challenge anyone to come up with evidence to show me that ESWT decreases "scar tissue". Not even the FDA randomized control trial published by Ogden demonstrates this effect.
As I've said, click on the absract link in my post above.
You can research all you want, but in the end all the patient wants is for the pain to go away. If it happens, whether it has been validated by research or not or it is a placebo or not, are they any less 'cured'?
The semantic of "scar tissue" and "pain" is incredibly relevant, when the topic that started this whole debate is you suggesting that Sandra look into ESWT as a means of removing painful scar tissue in her _thigh_, based on results of studies on plantar fasciitis, which you claim (by abstract), show that "scar tissue" is removed. Therefore, the only reason I posted was to correct your impression that ESWT decreases "scar tissue", because
a) if you subscribe to the theory that "scar tissue" in plantar fasciitis is not well defined, then it's not possible to equate thickening with "scar tissue" and thus, a study that shows decreases in tissue thickening can't make any statements about "scar tissue", and hence, recommending ESWT to someone who has "scar tissue" in their thigh is practically irresponsible advice.
b) if you subscribe to the theory that "scar tissue" just a semantic term for excess tissue or hypertrophic (excessively growing) tissue, or something "bad", then technically a tumor (benign or malignant) is the same as "scar tissue", and by the evidence presented in the abstract, we could start blasting tumours with this technology (which we don't).
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I've adressed that above. Just because A is sometimes seen without C and vice versa, it doesn't mean that A couldn't be a contributor to B. They are obviously not mutually exclusive.
Except in this case, A (thickening) is (more than sometimes) seen without B (plantar fasciitis), which means that if you're trying to make the statement B causes A, then you have to explain why people with B don't have A, and why more than some people have A but no B. C doesn't even enter into this.
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Well, you need to click on the abstract above. Call it what you will, 'scar tissue', 'thickening', whatever.
I did click on the abstract above, and I'm waiting for the paper to come out before making substantial comments (It's an early abstract index, which means the study in still in press). On a surface glance I can see three possible fatal flaws. 1) no control group. We don't know whether these people would have had pain relief and/or reduction of plantar fasia thickness without ESWT (and yes, spontaneous pain relief does happen after 6 months of unsuccessful therapy); 2) Use of the contralateral limb as a "control". It's becoming more and more evidence that this is an inappropriate control to use, due to the growing body of evidence to suggest that what happens in one limb, affects what happens in the other limb, affected or not. It also means that using statistics that have the assumption of independent observations is inappropriate and potentially biases the interpretation of the p-value; 3) Using the failure to reject the null hypothesis of a statistical test to make inferences about whether two populations are the same. It's not possible to make positive statements (especially if you have only 22 subjects) about the null hypothesis (i.e. that no difference exists between the two fascia) since a statistical test can only reject or fail to reject the null (as opposed to "accepting" the null--a seemingly semantic statement, but one that has large implications about interpretations of trials results). Just because you don't detect a difference in your sample, doesn't mean one isn't actually there in the population.
My experience with abstracts is that they're not sufficient to determine study quality and thus, insufficient to use to evaluate external and internal validity. However, your casual treatment of the terms "thickening" and "scar tissue" and "whatever" makes it clear that you perhaps don't make a distinction between them--which only adds to the perpetuation of myths and misconceptions in the field of musculoskeletal health and interventions.
The FDA approved the use of high-energy ESWT based on the FDA trial performed by Ogden et al, the results of which were published in 2002. His trial demonstrated that ESWT is effective at reducing pain in people diagnosed with intractable plantar fasciitis. His study made no statements about tissue changes, nor was approval by the FDA contigent on there being any tissue changes. Insurance companies cover many things that are unproven. Physiotherapy, massage therapy, chiropractic therapy, acupuncture. None of these treatments meet the FDA requirement of a randomized, placebo-controlled trial for evidence.
Yes, ESWT is promising therapy. I've been treating patients with plantar fasciitis (and tennis elbow, and patellar tendinopathy and rotator cuff tendinopathy) for 3 years (in my fourth now). I've personally treated people who have such bad plantar fasciitis that they need crutches--and yes, many of them get better. Never, ever have I claimed that ESWT will do anything but relieve pain--the evidence only supports pain. By what mechanisms, we don't know yet (though some preliminary, recent papers suggest that ESWT relieves pain by acting on the dorsal root ganglions, which may shed light on what causes tendon pain in the first place, and it might not be thickening).
Yes, one should weigh costs and benefits of a therapy, even if it is unproven, but a responsible clinician should be evaluating these therapies based on evidence as well (perhaps arguably as their primary reasoning if we, as a medical community, are going to truly subscribe to an evidence-based paradigm). Otherwise, we may as well be scanning our palms with electric stapler-looking machines and eating Lifepaks like there's no tomorrow.
And yes, if the effect is entirely placebo, the person is no less "cured", but responsible medicine is not based on the principle of "the ends justify the means", regardless of how desperately a patient wants to get better. Medicine is far from perfect. But it's not going to get any better if practitoners continue to subscribe to a "Well the patient got better, so what do I care if I'm using a valid intervention or not?" attitude. That just brings us closer to peddling snake oil, and preying on the vulnerability of the unknowing.
Frankly, whether this is your specialty or not, I think you just enjoy debating. [img]smile.gif[/img]
I never suggested to Sandra that she look into using ESWT. I threw out the fact that it is used for PF, and asked Bill (and by extension any other expert) to comment on whether you could use the same for that. I specifically said "but since you mentioned possible calcification, which is present in most severe cases of plantar fascitiis, I'm throwing this up for Bill to see if this would be applicable in your case."
Statement A: ESWT is used for chronic PF.
Statement B: there is often calcification existant in chronic cases of PF. As you said, no one knows what the relationship is between the thickening of the PF band and heels spurs.
Statement C: I put the idea out there for Bill to comment on.
So, where's the problem? My use of the word 'scar'?
So basically, your problem with my statement had to do with me calling the PF band thickening 'scar tissue' and then saying that the ESWT decreased that. However, I've given you what my doctor has said (ESWT being a non-invansive form of tension release on the PF band) and what abstract I have been able to find in the past that tends to support that. On a personal level, I could give a rat's ass whether or not reasarch studies support it...medical history is tending to, and your own research shows that. As a sufferer, that's what I care about.
Finally, I do think it is irresponsible of you to suggest possible flaws in research design from an abstract without reading what actual methodology was followed. I threw out the link for your or Russ' perusal (since I can't access the full study) and commentary, not for a review of my post or thoughts about the abstract. I can read the abstract. I have a graduate specialty in statistics. I can jump to my own conclusions with just the abstract about research design without any help.
Yes, I'm mildly irritated. Picking on a semantic error on my part could have been done in a much nicer manner. A simple "There is no research I know of that can conclusively show how ESWT works' would have illicited a much nicer exchange. There is a thing called 'bedside manner' and I realize it may be scarce in the ivory tower, but it does exist, even in cyberspace. You've made your point by nitpicking an error by a layman trying to help someone else. Just about everyone who is here who knows me from MH board knows it takes an awful lot to rile me up.
This is what the MRI says:
"The examination demonstrates a focal area of abnormal increased intensity on STIR sequences immediately below the markers indicating the
area of clinical concern, confined to the subcutaneous tissues. There does not appear to be abnormal signal intensity involving the underlying
muscle. This focus is consistent with fibrosis and/or scarring. The possibility of underlying calcification is difficult to exclude on MRI
and if clinically indicated a CT scan would be of benefit to evaluate subtle calcifications."
__________________
Sandra (aka Erika\'s Las Vegas friend)
I enjoy debating, that's true--and with you, it's such a treat =).
Sorry if I came across as confontational. I admit, I responded to your posts more emotionally than I normally would have responded to another topic; and it doesn't help that I recently (over the past 3 days) peer-reviewed yet another inadequate study on shockwave therapy. The literature is a mess; and the quality of trials is, for the most part, abyssmal. So, everytime ESWT comes up in conversation and people start making claims that aren't supported (just because a study concludes that something is true, doesn't mean it actually is true), it really touches a nerve--because I've had to wade through the crap for the 3.5 years I've been in this PhD program, keeping more-than-up-to-date with the literature.
The issue of "scar tissue" is also one near and dear. The closer discussions get to chronic musculoskeletal injury, the closer we get to what seems to be becoming my life's work. And the reality is that there are a lot of snake-oil pushers out there claiming that their product does "blah", and literally preying off of people who don't know any better. The term "scar tissue" gets thrown around like so much confettii as though, solving the "scar tissue" problem will be the ultimate answer to all of our prayers. And it's the casual use of this term that keeps the vicious cycle going. The number one question I get from my patients is, "Will this break down scar tissue?" (well, number one after, "Why is this treatment so expensive?") because someone (whether it's their doctor, their podiatrist, their friend or a web site) has told them that that's what ESWT does. It sets up false expectations ("My pain didn't go away and my doctor says it's because the ESWT didn't break up the scar"). It sets up misinformation ("I was told this would break up the scar, so why am I not better?). It substantially affects the degree to which they are informed to make a decision about their course of treatment ("I've been informed that my pain is caused my scar tissue and that ESWT breaks up scar tissue, so I'm deciding to have and pay for ESWT based on information that I don't know isn't true"). So, yes, in a way, it's because you used the word "scar".
I know you're giving me what your doctor told you, but it's misinformation to a degree, as well, to tell you that ESWT is some form of tension release too. I'm not saying that he's malicious or that he's stupid, but that perhaps he's also misinformed. If you knew that your heel pain was caused by excessive tension, then ESWT would not be the treatment for you; and as a treating technician, if I knew that, I would send you back to your physician. If you had some sort of compression compartment syndrome in your foot, ESWT would not address that either. If you knew with certainty that your foot pain was a result of some genetic abnormal collagen formation, ESWT would probably not be effective. Thickening of the plantar fascia may be a clinical characteristic, but it's more likely a symptom that is caused by the underlying pathology of plantar fasciitis--not the other way around--just as calcification is a symptom of tendinopathy, as opposed to being the cause of tendinopathy. It may be semantic to you as a consumer, but it's an integral part of the language for the people who are trying to figure out whether your insurance company is spending their dollars wisely.
And if it was irresponsible for me to comment on possible flaws of an study based on an abstract, then it would have been equally irresponsible for you to cite it as clear evidence that ESWT decreases plantar fascia thickness--especially if you can already recognize those design flaws from an abstract yourself.
Hey, I'm irritated too. I just had a "layperson" tell me that I don't understand the field of knowledge I've been studying and publishing in for the past 4 years based on what his doctor (who has less clinical experience with ESWT than me) told him. It's like someone saying, "I was told it was okay to do a t-test to test proportions. I get a p-value of less then 0.05 whether I do I t-test or a chi-square, what does it matter?" or "Standard error, standard deviation, same difference." I mean you may as well wave a chiropractic flag in front of Russ, or a t-rag one saying, "Surge is the ONE supplement" in front of TS or JP.
I'm not saying that you should defer to me in all things musculoskeletal, but that I hope you understand that I wouldn't debate on a point I didn't think was both relevant and important--and that I wouldn't debate on a point that I thought I didn't understand. You're not the only one trying to help people around here. I mean, that's why we're here, isn't it?
So, I'm sorry that I attacked you. I also felt attacked and responded more strongly than I intended it to be received--though I still maintain that there are very few studies (Hammer's not being among them) that have shed much light on the mechanisms by which ESWT seems to function (after all, its efficacy is still also somewhat in question too).
And seriously, if you're thinking of having that foot zapped with ESWT, come up here. I have no idea why it works, but it seems to work for most of the patients that return their follow-up questionnaires (we seem to get the extreme results back though--either they've done really well, or really badly). Either way, it's a helluva lot cheaper up here than it is down there. And no anesthetic required either (our machine is a low-energy one). I promise not to hurt you...too much. =)
Fibrosis is the synthesis of fibrous tissue. It actually is associated with the most accepted definition of "scar tissue" (i.e. tissue formed as a result of trauma, infection or disease, or healing, consisting mostly of fibrin fibres, and thus, distinguishable as being completely different than the native tissue). The most common example of this definition of "scar tissue" is when you cut your skin, and it bleeds and clots. The redness of the scar is caused by dead red blood cells that are enmeshed in the fibrin clot.
Some tissues when they're traumatized can start to overproduce tissue. Bone reacts in this way--if someone's shin is hit hard enough but not broken, a bone callus can form on the shin. It sounds as if the radiologist thinks that the formation is purely just under the skin--not some sort of "muscle callus". Russ would be best to interpret these readings, and perhaps to suggest possible remedies.
"The examination demonstrates a focal area of abnormal increased intensity on STIR sequences immediately below the markers indicating the
area of clinical concern, confined to the subcutaneous tissues. There does not appear to be abnormal signal intensity involving the underlying
muscle. This focus is consistent with fibrosis and/or scarring. The possibility of underlying calcification is difficult to exclude on MRI
and if clinically indicated a CT scan would be of benefit to evaluate subtle calcifications."
The abnormal signal that the radiologist is describing is a finding that one might see on MRI as a result of an inflammatory process. Presumably, you're having pain where they placed the markers for your MRI study, and the high signal that was seen in this area would confirm the inflammatory process.
Unfortunately, I don't think that I can make any useful treatment recommendations for you. You would be best served by discussing your treatment options with someone experienced in the management of this type of problem.
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