30
January
2008
Plantar fasciitis causes pain on the bottom of the foot. (The plantar side of the foot is the sole.) Usually it occurs in one foot though 30% of the time it will affect both feet. Approximately 1 million visits to the doctor are due to plantar fasciitis. It occurs mostly in 40-60 year olds, and younger folks who have it tend to be runners.
Plantar aponeurosis is the deep layer of the plantar fascia. Fascia is fibrous tissue like you see coating a chicken breast – it is a pearly white tissue. The fibers run from the heel to each of the toes to provide support - in particular when walking. When the toes are extended and pushing off during walking, the plantar fascia elevates the arch of the foot as well as doing other functions for support. It does attach to the heel (calcaneous bone) so it is associated with heel spurs. But like the chicken and the egg, we don’t know which comes first. In plantar fasciitis, the fibrous tissue become inflamed and can even degenerated.
Risk Factors: well, as with most things, the cause is unknown. Risk factors include: obesity, flat feet, trauma/stress from jumping or standing too much, poor ankle dorsiflexion, and as mentioned above heel spurs. For runners, poor running shoes might be a reason, either flat feet or a really high arched foot, shortened Achilles Tendon (making it hard for ankle dorsiflexion – you dorsiflex when you flip your foot towards your nose…you plantar flex when you step on the gas peddle). Overtraining and running on hard cement might cause plantar fasciitis.
Dancers beware too. Ballet dancers (who always say it destroys their feet) and aerobic class folks are more at risk because of the stress upon the Achilles tendon. Interestingly tight hamstrings can decrease knee extension which can lead to plantar fasciitis.
Associated diseases include osteomalacia, fibromyalgia, reactive arthritis, and fluoride treatment (such as in treating osteoporosis).
Diagnosis: it is pretty easy to diagnose plantar fasciitis on physical exam because there is tenderness in the arch of the foot to the heel. It especially hurts when stretching out the fascia by extending the toes. Xrays usually aren’t needed but it can show if there is a heel spur, which might be a separate issue. I have never seen it but some reports say that an X-ray & ultrasound can see increased plantar fascia thickening and fat pad abnormalities. MRI is rarely required.
Bad cases: rupture of the plantar fascia can occur and hurt severely. Nerve damage can occur kind of like in carpal tunnel syndrome. The posterior tibial nerve can become entrapped leading to numbness of the sole and heel pain.
Treatment: ARCH SUPPORT in the shoes is most recommended. Resting padded foot splints – not proven to work but some use them. Don’t go barefoot or in slippers because there isn’t arch support so many people with plantar fasciitis complain of pain when getting out of bed and stepping barefoot onto the floor. Good padded shoes to reduce the stress from standing all day on hard floors. Avoid running, jumping, and other impacting things. Lose weight to reduce the stress on the foot. Rest, ice, taping, and even NSAIDS might be considered. Stretching out the plantar fascia with bands can be useful, curling the toes, and doing range of motion at the ankle.
Steroid injections hurt terribly, and so are done in extreme cases. Steroid can be delivered by iontophoresis which is painless. Shock wave therapy has mixed results. If everything fails, about 2-5% of people end up having surgery. But for most people, plantar fasciitis goes away 80% of the time within one year.
drjohnhong 
Uncategorized, Bones & Muscles, Pain 
Comments (0) » |
30
January
2008
Vytorin has been in the news since January 14, 2008 due to the announcement of the ENHANCE trial. Vytorin is a combo pill of simvastatin (Brand name was Zocor) and Zetia. Simvastatin was shown in the Heart Protection to reduce cardiovascular deaths. However, Zetia has not been proven to reduce heart attack, strokes, or cardiovascular deaths. But Zetia has been shown to lower LDL – bad cholesterol that is associated with cardiovascular disease.
Back in 2001 a medical journal (Lancet) published the ASAP trial. It looked at a rare population of people with Heterozygous Familial Hypercholesterolemia, a genetic disorder seen in 0.2% of people with high cholesterol. The ENHANCE trial looked at the same group of folks. In the ASAP trial Zocor and Lipitor were compared to see reduction in carotid intima media artery thickness (IMT). IMT is measured simply by ultrasound. It is a clinical predictor of coronary artery disease. I never understood this study because the dose of Lipitor was 80mg (the highest dose) but Zocor was 40mg (though 80mg is the highest dose). So in the end of ASAP, Lipitor reduced IMT (which is good) but Zocor showed an increase in IMT (bad).
The ENHANCE trial basically did the same study as the ASAP but compared simvastatin (AKA Zocor) vs. Vytorin. This time though, the ENHANCE used 80mg of Zocor instead of 40mg in ASAP. Also the Vytorin group got the standard 10mg of Zetia and 80mg of Zocor.
The 720 folks with Heterozygous Familial Hypercholesterolemia had really high LDL levels, way higher than most people have. I would say in my practice, a person with an LDL 200 or more is pretty unusual. In the ENHANCE trial the average LDL at the start of the study was 319 in the group whom received Vytorin and 318 in the simvastatin group. Pretty darn high—ouch!
The IMT baseline means were 0.68mm (Vytorin group) and 0.69mm (simvastatin group). After 2 years of the trial, there was an increase of 0.0111mm in Vytorin group and 0.0058 in simvastatin group. If I did my math right, that means the end mean IMTs were 0.6911 in Vytorin and 0.6958 in simvastatin. Statistically it was not significant meaning they were basically the same from what we can tell. What is normal carotid IMT? It depends on your age, sex, and risk factors. Also I don’t know if they did this study in kids or not. Sigh.
So what does the IMT increase mean? The inner layer of the artery can become plump from cholesterol buildup. For adults, there is a moderate graded positive association between the carotid IMT and CAD (coronary artery disease). A meta-analysis of 8 studies showed: 15% increased risk of heart attack and 18% increased risk of stroke for every 0.10mm increase in carotid IMT.
Now I don’t have the real paper article. Because of the MEDIA not waiting for physicians to be able to critically appraise the study, I am forced to make my assessment from the literature in the papers, including Merck/Schering-Plough, CNN, AHA, and ACC. It doesn’t look like Vytorin is a dangerous drug compared to a plain statin like simvastatin alone and we have always known a very small increased risk of liver toxicity (2.8% Vytorin vs. 2.2% simvastatin) and muscle breakdown (2.2% Vytorin and 1.1% simvastatin). The problem is…how does this relate to reducing real heart attack and strokes in people who don’t have a genetic high cholesterol disorder as in the ENHANCE study? I don’t know. There isn’t a research trial to show this. I will say it is not great news the IMT didn’t improve but got worse with both simvastatin and Vytorin. But then again in the ASAP simvastatin had worsening IMT but the Heart Protection Study shows the benefits of simvastatin. This to me means more research needs to be done, but at this point it won’t make me take anyone off Vytorin and Zetia or stop it in my patients
drjohnhong Uncategorized, medicines Comments (0) » |
Email it
