Plantar fasciitis A degenerative process (fasciosis) without inflammation

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Plantar fasciitisA degenerative process
(fasciosis) without inflammation

• Harvey Lemont,
• Krista M. Ammirati,
• and
• Nsima Usen
• Presented by Garrett Hays

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Contents

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

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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

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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

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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

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Figure 1Normal fascial enthesis exhibiting
metaplasia of bone to fibrocartilage to fascia
(HE, x40)
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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
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Figure 2Fibrocartilage interface between bone
and fascia (HE, x 40)
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Analysis of Figure 2
The same 10 represented in Fig 1 also showed
fibrocartiloginous fibers running parallel to
each other
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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)
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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)
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Figure 4Artifacts within fascia representing
areas of probable previous corticosteroid
deposits (HE, x40)
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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
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Figures 5 6Low-power view of calcaneal marrow
demonstrating vascular engorgement (HE, x20)
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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
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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

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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

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Result of MisdiagnosisFasciitis 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