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Anachronistic categorisations

Following on the theme of KI3, let’s take a look at one of the favourite rationales given for using it: the zang-fu concept that ‘Kidney governs Bone’. 

Viewed from this perspective, PHP is seen as pain in the bone (“calcanodynia”) or pain caused by bony growths (calcaneal spurs).  Within this frame of reference, some authors reported on the presence or absence of spurs on X-ray and some even went so far as to use the disappearance of spurs from X-rays as an outcome measure.  With this diagnosis, in zang-fu theory, it follows logically to address Kidney dysfunction. 

“Calcanodynia is mostly due to bone disease resulting from Kidney Deficiency … .” 1

However, there seems to be consensus these days that bony pathology is NOT the cause of heel pain 2.  Many sufferers have no spurs and, conversely, many people with spurs on X-ray have no pain.  Instead, the problem is explained in terms of soft tissues: pathology in the fascia, or trigger points in the muscles.  In this case, perhaps we should invoke the TEAM notion that ‘Liver governs Sinews’ and expect Liver dysfunction rather than Kidney.  Some practitioners are already aware of this, e.g. ‘Duncan’ in the BAcC forum, said: “people I have treated have more often had a liver pattern3.

The thing is you only find patterns if you perform syndrome differentiation.  Many of the papers we found did not do so.  Instead, they used a Categorical approach (as defined in my book), which magnifies the problem of using possibly erroneous nosology. 

Usually, in RCTs and in case series studies, the problem of heel pain is slotted into the category of ‘kidney deficiency’ and treatment protocol is predefined on that basis.  This is done before subjects are recruited into the study.  Then the criteria for inclusion are based on an abstract set of characteristics, such as the defining features of PF.  The pattern differentiation of each individual is never done, so we cannot know whether they had ‘kidney deficiency’ at all.  If they did not, clearly their treatment would be suboptimal and the research invalid. 

Maybe there is a subset of PHP sufferers who DO have ‘Kidney deficiency’, and others who have Liver patterns, or mixed patterns, or something else, such as traumatic stagnation.  We’ll never know, until researchers pay attention to the realities in front of them, rather than abstract categories.

Of course, there are issues around the reliability and reproducibility of TEAM diagnoses4.  This in itself deserves further study and I suggest that PHP offers an ideal focus for such studies.  It seems to me that this condition is inherently less complex than (e.g.) dysmenorrhoea, which may make it simpler to explore.

The problem of outdated categorising terminology also affects biomedical approaches to PHP.  The terms ‘fasciitis’ still prevails, presumably due to normative pressure and institutional inertia, in spite of general understanding that degeneration, not inflammation, is the relevant pathology (except perhaps in some acute cases).  Indeed there may be no local pathology at all (as indicated by relevant scans) if the PHP is related to the presence of MTPs further up the leg.

Yet there are many practitioners still recommending the use of ice, or NSAIDs, or injected corticosteroids, as strategies to counteract inflammation.  How are these interventions justified in the absence of inflammation?  What harm might they be doing?  Some (even the guy who originally promoted it, Gabe Mirkin 5) argue that the use of cold (‘icing’) is likely to be harmful 6-8.  Yet, a glance at social media shows that PF sufferers are still being advised to do it.

From a TEAM perspective, the patient with PHP is more likely to have a ‘cold’ condition (Cold Bi, or Yang deficiency) particularly after the acute phase.  In this case coldness would be expected to make the pain worse, and warming treatment (moxibustion) may be indicated.  This also makes physiological sense – the application of warmth will enhance local blood flow, which in turn will aid tissue healing. 

So which approach is right?  I contend that we do not know yet and I would not expect that one approach fits all.  We need to conduct patient-centred research to find out. 

References

  1. Nie H. Puncturing Zhanggen in treating 106 cases of calcanodynia. International Journal of Clinical Acupuncture 1993; 4: 201-202.
  2. Kadakia AR. Plantar Fasciitis and Bone Spurs, https://orthoinfo.aaos.org/en/diseases–conditions/plantar-fasciitis-and-bone-spurs/ (2010).
  3. Laura R and others. Plantar Fasciaitis [sic] – any experience!, http://www.acupuncture.org.uk/forum/viewtopic.php?f=23&t=642&hilit=plantar [login required] (2007) .
  4. Schnyer RN, McKnight P, Conboy LA, et al. Can Reliability of the Chinese Medicine Diagnostic Process Be Improved? Results of a Prospective Randomized Controlled Trial. J Altern Complement Med 2019; 25: 1103-1108. DOI: 10.1089/acm.2019.0260.
  5. Mirkin G. Why Ice Delays Recovery, https://www.drmirkin.com/fitness/why-ice-delays-recovery.html (2015).
  6. Dubois B and Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med 2020; 54: 72-73. DOI: 10.1136/bjsports-2019-101253.
  7. Mannix L. Putting ice on injuries could be doing more damage than good, https://www.theage.com.au/national/putting-ice-on-injuries-could-be-doing-more-damage-than-good-20191011-p52zw0.html (2019).
  8. Wood Z. To Ice Or Not To Ice An Injury?, https://www.physio-network.com/blog/ice-for-acute-injury/ (2021).
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