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Dear Colleagues: One of my pet peeves in medicine is pseudo-diagnosis - labelling a condition with a name suggesting knowledge that does not exist. "Arthritis of the spine" comes to mind, used for non-specific backache associated with disc degeneration on x-ray. This is a standard "out" for physicians who don't have a clue as to what is causing the patient's backache, but feel they have to tell the patient something. The suffix -itis is similarly misused. Attaching "itis" to the name of a painful organ or structure implies that inflammation is present even when calor, rubor, or tumor is not. All we have is dolor - but not enough to justify the "itis" suffix. I have already written about pseudo-diagnosis of this kind in the case of trochanteric "bursitis" (Vol. 7, No. 2) now more properly called "greater trochanteric pain syndrome". A similar situation occurs with "plantar fasciitis", that common condition of pain in the posterior sole of the foot - dolor, but no calor, rubor or tumor - at least at a macroscopic level. However I was surprised to find on a PubMed search considerable literature on the subject. And yes, there is objective evidence of something going on in the fascia but it is not inflammation. Histological studies have shown that the condition is a degenerative process, which means that steroid injections and/or anti-inflammatory medication are not indicated. Ultrasound and MRI demonstrate a thickening of the fascia confirming what is a relatively simple clinical diagnosis: pain on taking the first few steps in the morning, and after prolonged standing; tenderness at the plantar-medial aspect of the heel; and pain on passive dorsiflexion of the ankle and toes. Plantar fasciitis is most common in middle age, in the obese, in runners and those spending much of their time on their feet. Almost twice as many women are affected as men. In one study, 45% of patients had pain persisting at 15 years from onset. And up to 50% have bilateral symptoms. The pathophysiology is felt to be one of repetitive strain and micro-tears. Most treatment has been directed at the plantar fascia itself, with corticosteroid injections, plasma rich platelet injections, extra-corporeal shock wave therapy, prosthetics and orthotics, taping and other conservative measures showing minimal benefits. Osteopathic manipulative treatment of the foot may provide short-term relief, but no evidence exists of a lasting effect. However I could find nothing about the use of more general osteopathic treatment (at least in PubMed and "Foundations for Osteopathic Medicine"). And plantar fasciitis is not mentioned in the Dosch or Barop neural therapy textbooks. It is a little known fact that pain can be referred to the underside of the heel from the sacrotuberous ligament. Hackett demonstrated this in his studies of pelvic ring ligament referral patterns*. Because referred pain is often also tender, this scenario can easily be misdiagnosed as "plantar fasciitis". Correction of pelvic ring imbalance with manipulative treatment, or perhaps prolotherapy, can relieve this type of heel pain. In my practice, heel pain from the sacrotuberous ligament is not rare. Recently however, I came across a case of plantar fasciitis that fit none of the above categories. A relatively healthy 64 year old man presented with a variety of complaints including psoriasis for 15 years, gastrointestinal reflux for 40 years, a myocardial infarction two years previously and left plantar fasciitis of about two years duration. Past trauma included a fractured right forearm requiring orthopaedic surgery in his teens, a right inguinal hernia repair at age 59 and several root-canalled teeth I obtained a complete history and examined the man thoroughly, but decided to concentrate on a few physical findings that potentially related to the plantar fasciitis. His left hamstrings were tighter than his right, the left pube was a few millimetres inferior to the right (while supine) and the left sacroiliac joint was looser than the right - while prone, gentle cephalad pressure on the left side met less resistance than the same maneuver on the right. (I call this an "innominate upslide" - similar to an "innominate upslip" except that the ischial tuberosities are level and the sacroiliac joints are motion-tested. See "The Innominate Upslide sign...") Autonomic response testing indicated an interference field in the medial half of the hernia scar. This was treated using the Tenscam device (an alternative treatment would have been infiltration with dilute procaine) and the pelvic ring assymmetry returned immediately to normal. Four weeks later the man reported that his plantar fasciitis was 60% better; at two months it was almost normal. I suspect that in this case the heel pain was referred from the sacrotuberous ligament that had been under strain from the pelvic ring imbalance. This mechanical imbalance was in turn a result of an interference field in the inguinal hernia scar. The "take-home" lessons here are: beware of the suffix "-itis". Not all pain and tenderness is due to inflammation. And even if inflammation is present, we should not stop there. Let us find out the cause and treat it. It could be due to an interference field!
--------------------------------------------------------------------------------------------------- NAANT NEWS (North American Academy of Neural Therapy) The executive has been holding biweekly telephone conferences and will be meeting with the Founders on the weekend of June 9th in Chicago for a day-long discussion of neural therapy training. Tentatively the plan is to develop workshops and defer our first "conference" until a little later. The website is under construction and should be launched within the next month or so. It is not yet ready to receive membership applications but readers are encouraged to sign-up to a mailing list at https://www.naant.org. We now have 25 founding members and have recently received a generous "start-up" gift of $1000 from the Austrian Neural Therapy Society. We look forward to co-operating with the Austrian Society in the years to come.
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Neural therapy workshops: The Best of Pure Neural Therapy: an exclusive training in NY Organized by Dr. Michael Gurevich. Register early to receive discount.
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Join this list and become a Founding Member of the North American Academy of Neural Therapy. 1. Michael Gurevich 11. Karl A. Anderson 21. Theodore Jordan 2. Christopher Turner 12. Perry A. Perretz 22. Phil Mollica 3. Jeff Harris 13. Linda Tao 23. Julio Paez 4. Robert Kidd 14. Leann Astawan 24. Andrew Oswari 5. Isaak Yosef 15. Ara Elmajin 6. Jeffrey Morrison 16. Kyu Chung 7. Pedro Toweh 17. Igor Ostrovsky 8. Robert Banner 18. Richard Nahas 9. Bernadette Kohn 19. Ilana Gurevich 10. Gerald Harris 20. Kumar Biswas Send your cheque of $1000 to Dr. Michael I. Gurevich, Treasurer of NAANT, 97 Glen Cove Avenue, Glen Head, NY 11545, USA.
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