The -itis versus -osis debate!!
I’m sure that you will agree that our patients are our best advertisement. Word of mouth travels fast! But what happens when the doctor becomes the patient? Please read the testimonial below from one of your colleagues on the North Shore who was treated at WalkWell Rehabilitation.
“As a family practitioner I thought I knew a fair bit about musculoskeletal problems and their treatments. But after a few treatments I had learned a tremendous amount of new things about physical medicine and I have not felt better in years. I now recommend Chris to all my patients who need physical therapy for treatment of conditions of the lower extremities.” – PhillipBurrer,MD of Family Medicine Associates
-ITIS VS -OSIS…
WHAT YOU NEED TO KNOW!!
One of the most controversial topics in orthopedic medicine is the –ITIS versus -OSIS debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions. This is apparent through the use of NSAIDS, steroid injections, and modalities such as iontophoresis. As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating chronic pain. Evidence-based treatment is the MAIN FOCUS in my clinic. Can we prevent the reoccurrence of pain by ONLY treating the inflammation?? What does the research tell us?
Karim Khan, MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that animal studies conclusively demonstrate that, “within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”
Karim Khan, MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”
Harvey Lemont, DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237
states that, after analyzing tissue samples from 50 plantar fasciotomies, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”
Almekinders, Temple, et al in “Etiology, Diagnosis, & Treatment of tendonitis: an analysis of the literature”, Med Sci Sports Exer 1998;30(8):1183-1190 state that they “found little evidence that NSAIDS and corticosteroids were helpful in treating tendinopathy.”
Because no inflammatory cells have been demonstrated in biopsies from chronic tendinopathy, some authors have abandoned the tendonitis “myth” as well as the use of steroids. Recent studies, however, have begun to question this new opinion. Recent placebo controlled, randomized studies of ultrasound-guided peritendinous steroid injections have been shown to be very effective in reducing the pain and thickness of Achilles and patellar tendons in athletes with chronic tendinopathy.
Fredberg et al in “Ultrasonography as a tool for diagnosis, guidance of local steroid injection..”, Scand J Rheumatol 2004; 33: 94-101 state that steroid injections “significantly reduced the average diameter of the affected tendons” and “in several cases the thickening of the tendon regresses completely.”
Koenig, et al in “Preliminary results of colour Doppler-guided intratendinous glucocorticoid injections..”, Scand J Med Sci Sports 2004: 14: 100-106 found that “neovascularization disappears” after ultrasound-guided, intratendinous injections.
Injection technique appears to play a pivotal role in the effect of the steroid on pathologic tissue. Should the practitioner continue to inject “blindly” or use ultrasonography to guide the precise placement of steroid? The next unanswered question is how to maximize the therapeutic benefit AFTER injection. Fredberg also states that steroids “cannot repair degenerative changes” and attempted to explain “the high frequency of relapse” 6 mo after the first injection. He now recommends 3-6 months of rehabilitation after injection. At OrthoWell/WalkWell, the functional regeneration of tissue is our goal.