Plantar fasciitis A degenerative process (fasciosis) without inflammation

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Plantar fasciitisA degenerative process
(fasciosis) without inflammation
2003.  J. Am. Podiatric Med. Assoc. 93234-237.

• 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

Buchbinder. New England Journal of Medicine. 350
(21) 2159, Figure 1.
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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 (middle portion of bone at
  attachment site)
• Other specimens show strictly degeneration
• Biopsy specimens point to
• collagen necrosis cells burst, harming
  neighboring cells
• angiofibroblastic hyperplasia abnormal increase
  in fiber degeneration and decrease in blood flow
• chondroid metaplasia ossification of cartilage
  to bone
• matrix calcification calcification of matrix
  solution between cells
• No cellular proof of inflammation

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Figure 1Normal fascial enthesis exhibiting
metaplasia of bone to fibrocartilage to fascia
(HE, x40)

• Out Of 50 heel spur samples analyzed, 10 showed
  normal transition of bone to fibrocartilage to
  fascia.
• The dark cells are bone cells
• The white, parallel cells are the plantar fascia

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Figure 2Fibrocartilage interface between bone
and fascia (HE, x 40)

• The same 10 represented in Fig 1 also showed
  fibrocartiloginous fibers running parallel to
  each other

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Figure 3

• 16 samples show fiber fragmentation
• Samples also show myxoid degeneration
• These are characterized by basophilic zones of
  mucopolysaccaride

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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Figure 4Artifacts within fascia representing
areas of probable previous corticosteroid
deposits (HE, x40)

• 2 of the previously mentioned 16 samples showed
  fragmentation
• Fragmentation is associated with crystalline
  material
• suggests previous corticosteroid injections

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Figures 5 6Low-power view of calcaneal marrow
demonstrating vascular engorgement (HE, x20)
Between 12 and 16 samples demonstrated
vascularization of attached bone marrow. bone
removed from attachment site demonstrated
multiple dilated vessels
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Analysis conclusion

• Dilated vessels in bone marrow not a result of
  inflammation
• Hyperemia may cause bone contusion in patients
  with heel spurs
• out of 50 samples, All show no inflammation
• Evidence points more to degeneration of the
  fascia than inflammation

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Corticosteroid Injections

• is a common form of non-invasive treatment
• of 765 patients diagnosed, 51 had rupture. 86
  were associated with corticosteroid injections
• 5 out of 6 athletes with repeated injections
  reported fascial rupture
• 1/3 of 37 patients treated 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
• most notable side effect is rupture, as well as
  pain associated
• more correct terminology for Fasciitis would be
  fasciosis

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