Plantar fascitis ProJR

Summary: This ProJR is a user driven project on patients with plantar fascitis sharing their diagnostic and therapeutic uncertainty and eventual journey on dyadic messages or global CBBLEs that after processing through CRH is slated to develop into an insightful UDLCO for people grappling similar problems.

Keyword Glossary:: http://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1

CC licence: https://commons.m.wikimedia.org/wiki/File:PF-PainAreas.jpg

Conversational Transcripts from various patient advocates from 2012 to 2025:

Date: Sat, Feb 18, 2012 at 1:51 PM
Subject: Re: Suggestions after going through your medical reports

I had a look at your attached reports, which were mostly normal and your history that you wrote in text was definitely very insightful as i could manage to localize, interpret and formulate a plan for your current problem as in my description below (do let me know if i have missed anything):

Problem of Joint pains affecting the spine, hand and knees.

My interpretations: 1) Pain in the heel suggests 'Plantar fascitis' which can be seen in 'Seronegative spondylo-arthropathy' which may be one possible explanation for your joint pains. Knee degeneration can occur in any chronic joint affection.

2) 'Seronegative spondylo-arthropathy' is a self limiting disease and recovers on its own. The other possible diagnosis for your condition is 'Osteoarthritis.'

My suggested Plan: I may require a few more X rays to diagnose it properly. Especially an X ray of the sacro-iliac joints B/L as well as X ray hands B/L ap view. However even a physical examination would be very useful.

Would it be possible for you to meet some of my students in ... College' who can either meet you in ... or ... (and then they can let me know a few more findings they may detect on examining you clinically)?

Do let me know. If you agree to my students seeing you and if i can share your medical reports with them we can hopefully find the current best solution to your problem soon. regards, 

On Fri, Feb 17, 2012 at 3:25 PM,  65M wrote:

I thank you very much for your kind hearing of my problems yesterday.
I am really grateful to , who was also our student at .
It was so nice to talk to you.
 As I told you I am suffering from joint pain for a long time. Pain is
not beyond tolerable. However, I can not walk properly now a days. I
can not grip things properly.
Doctor said that my X-ray of knee says there is degeneration. I had
once stiff neck, in 1995 I had to take collar.  I had vertigo problem,
but after a treatment of ear in 2008 I do not have vertigo.
In the past I could not walk after getting up in the morning because
of pain at the bottom of the heel. After changing shoe and number of
different medicine including Homeo and Aurvedic I do not have that
problem, but do not know which medicine cured me.

I am sending the reports of some test I had undergone last year. If
required I can come to your place and discuss the matters.
I look forward to your kind suggestions.
Best regards,

From the patient advocate of a 70F 

14 Oct 2012, at 12:06, 

>> This is real time ongoing experience my mother wishes to share with the medical community and public for any benefit or insight it may provide.
>>
>> She is an elderly active mobile lady and a music teacher by profession who undergoes regular blood checks every couple of years.
>>
>> For last one month she has mild pain in her one heel which comes when she starts walking after getting of the bed anytime of the day and gets relieved after she continues walking or rests herself. If she exercises her foot and ankle before getting off the bed the pain does not comes at all on walking.
>>
>> She has a background of poor compliance with allopathic medications in view of non specific side effects including gastritis and gets stressed even if told to take paracetamol 4 times a day as she feels that is higher than needed dosage, but ok to take same if explained the reasons in a gentle educative manner.
>>
>> On my insistence she saw a qualified orthopaedic surgeon as I wanted to know the diagnosis while sitting thousands of miles, overseas, away from her.
>>
>> The doctor who saw her today diagnosed Plantar Fasciitis and has given a prescription to start a paracetamol+NSAID oral combination, tab methyl prednisolone 4mg, a PPI, anti oxidant tablets. So a total of 5 types of salts. Also suggested some blood tests. I spoke to the doctor and he agreed that the symptoms and disease pattern is of mild nature at this point of time.
>>
>> I realised, that no history was taken about her apprehensions regarding the allopathic medications and obviously and probably correctly she wants my opinion what all she should be starting and why?
>>
>> There was no suggestion for physiotherapy at this stage either, considered the main stay of therapy otherwise for this usually self limiting condition otherwise, as i understand.
>>
>> Given my limited knowledge in Orthopaedic but not so of internal medicine I have concluded the following:
>>
>> 1. Given her mild symptoms the medications being given i felt, are more than needed out of which anti-oxidant has no role to play in this condition. Steroids being prescribed at this stage for mild symptoms are questionable and on top orally and in a very small dose will produce what benefit I fail to understand. However, a good chance of gastritis along with NSAIDs due to direct affect on gut epithelium is probably a sure shot side affect leading to high likelihood of poor patient compliance in future.
>>
>> 2. I have forwarded  my mother a credible link for patient knowledge highly commended and also awarded by BMA in 2012, which shall help her to understand the clinical condition in lay man's language and to help comply with right medications and exercises via physiotherapy and sharing with you all in case you may be interested.
>>
>> 3. I am also wary of starting NSAIDs in healthy elderly patients due to case reports of renal damage they can cause  and hence avoid giving same in my regular practice unless really needed and that too only for few days if really needed.
>>
>> Basis of background medical knowledge, ongoing communication skills knowledge to help me understand illness perspective of patients and knowledge from credible website linked pasted below led me to discuss the matter with orthopaedics colleague to help me suggest my mother the following for her MILD plantar fasciitis:
>>
>> 1. Paracetamol 1 tab 6 hrly

>> 2. Physiotherapy exercises as in link and also under guidance of local physiotherapist. Appy ibuprofen gel locally if pain worsens while physiotherapy as may happen at that point.

>> 3. Cold compression with frozen pea bag

>> 4. Exercises of foot n ankle every time before getting to start walking every time.

>> 5. Footwear suggestions and heel pad as in the link
>>
>> I wonder how many of me agree and how many disagree with the line of management tailored for her at this stage and thought of sharing the ongoing experience as a learning tool from various perspectives after my mother gave me the consent to share this with august medical fraternity on these forums.
>>
>> She coined the term that there is a sin (cine) in Medicine and also laughed when I asked if there is Crocin at home saying that there is a Sin (cin) in Crocin as well which i was persuading her to start off with and hence the subject of this mail.
>>
>> I look forward to all comments and criticisms to help me learn more and wonder if we are ready to take over the sins of medicine as this patient who happens to be my mother has expressly wished and consented gracefully this Sunday morning?
>>
>> I will look forward to keeping the forum aware how she responds to treatment designed for her including compliance to same.

The useful link is http://www.patient.co.uk/health/Plantar-Fasciitis.htm

Date: Tue, 16 Oct 2012, 11:34

One more therapy I have realised is contrast fomentation which many colleagues wrote back and the best one is putting feet in warm water for 4 min and then cold water 1 min and again warm then cold - total 4 times in each - time duration 20 min - each night - strangely missing in EBM

Of course exercises to stretch TA as in uk patient website in my 1st mail

Though i will try my best regarding patient centred queries as will help me learn more I will not promise success every time as lots depends on dynamics and incidences going around me, however I will try my best 

On 16 Oct, 2012, at 4:05 AM, cm> wrote:
This will definitely help one of my current patients who had visited us all the way from 1500 Kms and we couldn't do much except provide an insole for his shoes that didn't seem to work once he reached home.

Can i send you some of our patient centered queries from rural India so that you can provide us such excellent EBM answers that can help our patients?

best,

On Mon, Oct 15, 2012 at 9:56 PM, patient advocate 70F > wrote:

Dear All,

Many thanks to all who mailed with various non-invasive measures rightly needed to treat plantar fascitis in a sensible manner.

I wish to share 2 snippets from latest article on this subject published this week in BMJ.

I hope our orthopaedic colleagues will also reflect on indiscriminate use of steroids and anti-oxidants in their practice which is nowhere mentioned in evidence based literature and be safe to their patients and design therapy for individual patients rather than trying the formula of same size fitting all.

Thanks again,

 
Summary points (So : BMJ 13 Oct 2012)

• Plantar fasciitis is a condition which generally resolves over time with minimally-invasive management
• There is no one treatment with the highest level of evidence, but several with moderate levels of evidence, including stretching, orthotics, shock wave therapy, and injections
• The secondary cost of prolonged immobility can be severe (and can also worsen plantar fasciitis), so it is worth treating plantar fasciitis actively rather than with neglect
• Choice of treatments should be tailored to the individual patient’s circumstances and likelihood of response

Summary of individual selection for various treatments (So : BMJ 13 Oct 2012)

Management	Who it might help	Who might not benefit	Relative cost
Orthotics	Those with a longitudinal arch that is flattening in middle age	Those who don’t get any relief from low-dye taping	Low for tape and prefabricated orthotics, moderate for custom made orthotics
Night splints	Those with morning pain who are good sleepers	Those who struggle to sleep	Low
Extracorporeal shock wave treatment	Those with a heel spur on x ray	Those who don’t quickly respond to initial treatment	Moderate
Cortisone injection	Those who have had success with NSAIDs or cortisone injections elsewhere	Those with diabetes; those with thin fat pads or who have had previous injections	Low-moderate
Ultrasound guided cortisone injection	Those who need diagnostic confirmation	Those with poor pain tolerance (as slower technique under ultrasound)	Moderate
Rocker sole shoes	Those with pain on walking	Those who stand or run a lot or have coexisting knee or hip pathology	Low-moderate
Platelet-rich plasma injections	Athletes	Those with poor venous access (such as obese patients)	Moderate
Botox injections	Possibly those with cavus feet	Athletes or those who walk heavily at work (as side effects of muscle paralysis are poorly studied)	Moderate-high
Immobilisation	Those who refuse to reduce loading	Any overweight patient	Low (but high secondary cost)
Surgery	Those with longstanding pain who have been unable to unload the heel	Those who have not exhausted conservative treatment	High

NSAID=non-steroidal anti-inflammatory drug

From patient advocate of another patient from another location 65F 

6/9/15- 8/9/15 bartoman poristhiti -  betha nei tabe khichuni majhe majhei hochhe.Sorirer dan side ektu obosh obosh lagche.Thigh er nich thekei khuchuni suru hoy.Tab Ultracet plain newar por theke buk dharfor o matha khanik khaner jonno ghure jachhe. Ultracet 1/ 2  dine dui bar o Paracetemol 500 mg dine 4 bar dewa hoyeche.

Date: Sun, Sep 6, 2015 at 11:04 AM
Subject: Re: 66yrs.F swelling in right leg

Hain half tablet. 

On Sun, Sep 6, 2015 at 10:58 AM, patient advocate 65F wrote:

Ultracet Semi pawa na gele ultracet plain ki dewa jete pare !

On Sep 6, 2015 9:58 AM, "cm wrote:

Shune mone hocche plantar fascitis 

Local daktarer jonye suggestion. 

Kichu diner jonye mild pain killer nite paren.

Tablet Ultracet Semi dine char bar ebong Tablet Paracetamol 500 mg dine char bar.

On Sat, Sep 5, 2015 at 9:28 PM, patient advocate 65F wrote:

Exactly  goto 7 din theke sudhu payer patay betha chilo.Kichuni shuru hoyeche goto kal theke.Bichana theke namar somoy , hatte gele  khichuni shuru hochhe , 1-2 minute thake, darate gelei problem hochhe.Mone hochhe pore gie paa venge jabe.

On Sep 5, 2015 9:20 PM, "cm wrote:  Kotokkhone thake?

On Sat, Sep 5, 2015 at 9:08 PM, patient advocate 65F wrote:

Goto 7 din theke dan payer thigh theke payer pata porjonto prochondo khichuni.Majhe majhe mone hochhe paa obosh hoye asche.Khichunir somoy betha hochhe.Paye support dite osubidha hochhe.                              Please need your help !                 

41F from another location 

Date: Tue, 30 Jun 2015, 09:31
Subject: Re: New Patient Name - Zingiber Montanum( Koenig ) Age - 41 y Sex - F

Local daktarer saathe poramorsher jonye:

Gastritis/Gastric ulcer ebong kidney failure beshi din khele. 

On Tue, Jun 30, 2015 at 9:22 AM, patient advocate 41F wrote:

Dakthar  babu   Ai   Osud  guli    Khala   ke   Osubedha  Dakha  Dethay  paray

Aktuk  Janaben.

2015-06-29 21:01 GMT+05:30 cm wrote>:

Unar pathano payer chobi ta dekhlam. 

Unar daktarer saathe poramorsher por Tablet Ultracet semi dine 4 bar ebong Cap Indocap SR 75 mg raate ek bar ek saptaho nite paren.

regards, 

2015-06-28 17:50 GMT+05:30 cm wrote

>:

Dekhlaam. 

Local daktarer jonye suggestion:

Plantar fascitis howar sombhabona ache. Dorkar hole ekhane aro details a dekha jete pare. Ae chara ekta payer image (jekhane byatha hocche) whatsapp kore dite paren. 

On Sun, Jun 28, 2015 at 5:45 PM, patient advocate 41F wrote:

Dakthar  Babu      Patient  Tar   Payar   Gorale   Fula  Gachay  Hatacola  korthay

Ba   Aknagaray    bosay thakthay    para na Ai  Deka    Aonk  Chhekethsa  koray  chay   kenthu  kono    Upokar  hochay   Na  Tai  Sob  Repot  Gule   Dakha  Akta 

Replay   Deban   WhatsApp  A  Pateayche  Aktuk  Dakben

52M from another location:

Date: Sun, 21 Jun 2015, 11:39
Subject: Re: Old Patient Name - Terminalia Billereca ( Gaertn ) Roxb Age - 52 y Sex -M

Unar sampoorno record ta upload korun.

On Sun, Jun 21, 2015 at 11:35 AM, 

Patient advocate 52M wrote:

Dakthar babu Ai  Guli  tek  Ame  bujthay  parche Na Patient  Akhan  ke  korbay

Janaban Indocap 25 mg  Kala  Akden  Kom  Thaka   Ke  Korlay  AKTUK  Aram pabay

Seta  Aktuk  Janaben.

On Sun, Jun 21, 2015 at 9:31 AM, cm> wrote:

Unar record ta aekhono website a uploaded hoyni (amar Feb 9, 2015 er email ta niche dekhun). Sampoorno history samet upload korte parle bhalo hoto. Uni ki recently paralysis rugi tike niye aeshechilen tini? Unar ki payer X ray o amra koriyechilaam ebong Dr ... keo dekhate bolechilaam (jodi unei hoye thaken)?

Aekhonkar bortoman crisis er jonye local daktarer er saathe poramorshser por uni Cap Indomethacin 75 mg at bedtime 3 days khete paren (ebong Indocap 25 mg dine du bar sakal theke khete paren 3 days er jonye) kintu unar samporrno record ta dorkar. Aekhono poryonto shab shune rogtar naam mone hocche 'Plantar fascitis.' best, 


Date: Mon, Feb 9, 2015 at 10:34 PM
Subject: Re: Old Patient Name - Terminalia Billereca Age - 51 Sex - M

Local Daktarer jonye suggestion:

Complete history ebong discharge summary ta dekha dorkar. Upload kore dile bhalo hoi.

Cap Indopcap SR 75 mg at bedtime for two days.

On Mon, Feb 9, 2015 at 9:57 PM, 

Patient advocate 52M wrote:

Dakther Babu  Amar Bondhu  Aponar Kachay  Geaychlo   Or  Payar

Goraler Nechay  Kub  Batha  Hochay  Bortho Manay    Nechay  Ar

Osud  Guli  Kachay  Kenthu  Kono Kag  Hochay Na Ke  Osud  Kabay

Aktuk  Janalay  Kub  Valo Hoay.

1) Matesnal  Psy --

2) Finuncicel Crinin        

Ai Guli  Kachay.

On Sun, Jun 21, 2015 at 8:18 AM,

Patient advocate 52M wrote:

Dakthar  Babu   Nomoskar  Naben  Ai  patient   ta    2  times    Aponaka  Dakheaycha    payar  Gorale   thay   kub  batha    Akta  Capsul  deaycelan

Sata  khala   24  hours    Aram  thakay     Abar   batha hoay   2 den jaboth

akdom    Hatthay   parcha na  ke  korbay   aktuk   janalay   valo hoay, Akta

Replay  deban.

58M April 2025

[20/04, 14:52] 58M Patient Advocate Left Heel Pain 6 Months: Sir

I have a problem in my health

[20/04, 14:53] 58M Patient Advocate Left Heel Pain 6 Months: Left leg heel pains

When i went to orthopedic doctor he did x-ray said spur

And prescribed pain killer and soft shoe 

But thats not giving relief

I feel its linked to some major body disorder

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: How to connect 

Which body or organ disorder is giving this pain

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: In left leg heel

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: Throbbing pain

[20/04, 14:55]cm: It's more likely to be plantar fascitis which is a subset of spondyloarthropathy

[20/04, 14:55] 58M Patient Advocate Left Heel Pain 6 Months: Ok sir

[20/04, 14:56] 58M Patient Advocate Left Heel Pain 6 Months: My CBC report recent

[20/04, 14:57]cm: Please describe your patient's sequence of events that led to the current problems.

Please begin the sequence of events from the time your patient had absolutely no problems at all. 

Please describe your patient's hourly  routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

What are the patient's current requirements from us like if we had to give him a single medicine which problem would they prefer it to address?

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[20/04, 14:59] 58M Patient Advocate Left Heel Pain 6 Months: Left heel pain persistent from last six months

[20/04, 15:02]cm: Take your time to slowly answer the other questions like:

Please describe your patient's hourly  routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here

[20/04, 15:02] 58M Patient Advocate Left Heel Pain 6 Months: For 2 weeks i am having left leg heel pain mostly in night time

Throbbing and shooting pain last for half an hour to one hour

[20/04, 15:04]cm: Don't share any reports. I'm assuming they are alll normal

[20/04, 15:05]cm: Tell us how it was 6 months back

[20/04, 15:06]cm: What time exactly? Yesterday at what time? What was the patient doing at that time?

[20/04, 15:06]cm: Please don't share any patient identifiers in social media even on pm

[20/04, 15:09]cm: Please describe your patient's hourly  routine over 24 hours when he was perfectly alright and didn't have the following complaints:

1. Left leg heel pain

2. No sound sleep of 6-7 hours

3. Mild continuous headache 

4. Burning sensation in urethra. Burning micturition sometimes

Next please describe what happened to his hourly 24 hour routine once the above complaints took hold on his life

Please mention specifically which part of the patient's hourly routine was disrupted by which complaint at what time 

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[20/04, 15:11] 58M Patient Advocate Left Heel Pain 6 Months: Ok sir

Will do

[24/05, 17:08]cm: We need a better history with regular informational continuity.

Have asked my team members if they can connect with you synchronously to explain how our solution works

After a conversational gap from May to August 2025

[17/08, 10:38]cm: How's the heel pain?

[17/08, 10:59] 58M Patient Advocate Left Heel Pain 6 Months: Sir 

As I was traveling abroad 

I had to take steroid injection and go

[17/08, 10:59] 58M Patient Advocate Left Heel Pain 6 Months: So now it's no pain

[17/08, 11:00] 58M Patient Advocate Left Heel Pain 6 Months: But 

Not sure what's the prognosis

[17/08, 12:03]cm: Let's hope it won't recur.

@⁨Meta AI⁩ what's the epidemiological evidence for recurrence of plantar fascitis after local steroid injections? Please support your statements with single best RCTs in a PICO format taking care not to use any percentages

[17/08, 12:03] Meta AI: *PICO Format Analysis*

- *Population (P):* Adults diagnosed with plantar fasciitis, particularly those who have not responded to conservative treatments like stretching, orthotics, or physical therapy.

- *Intervention (I):* Local corticosteroid injections administered into the plantar fascia.

- *Comparison (C):* Placebo, other injections (e.g., platelet-rich plasma [PRP]), or non-invasive treatments like physical therapy or custom orthotics.

- *Outcome (O):* Recurrence of plantar fasciitis symptoms after a period of symptomatic relief.

*Key Evidence from RCTs:*

One high-quality randomized controlled trial compared *local corticosteroid injections* to *placebo injections* and *platelet-rich plasma (PRP)* for plantar fasciitis.

- *Findings:* Corticosteroids provided significant short-term pain relief and functional improvement (typically a few weeks to months). However, recurrence of symptoms was commonly observed in the long-term follow-up, particularly when the underlying biomechanical or inflammatory causes were not addressed. PRP, while slower to show benefits, demonstrated longer-lasting symptom control and lower recurrence rates compared to corticosteroids.¹ ²

Another RCT evaluated corticosteroid injections versus physical therapy (e.g., stretching and strengthening).

- *Findings:* While corticosteroids offered a faster reduction in pain, patients receiving physical therapy had better long-term outcomes with lower recurrence rates. This highlights that while corticosteroids may address inflammation temporarily, they do not resolve the root cause of plantar fasciitis.³ ⁴

*Conclusion:*

The epidemiological evidence suggests that corticosteroid injections are effective for short-term symptom relief but are associated with a higher likelihood of recurrence when used as a standalone treatment. Combining injections with physical therapy or addressing biomechanical factors may reduce recurrence rates. Would you like me to elaborate on alternative treatments or dive deeper into PRP evidence?

[17/08, 14:30] 58M Patient Advocate Left Heel Pain 6 Months: Yes sir

I hope so

[17/08, 14:31] 58M Patient Advocate Left Heel Pain 6 Months: The contrast is

I need to walk a lots for my health 

And if plantar fasciitis pain is there I can't do that

[17/08, 14:40]cm: @⁨Meta AI⁩ Can walking become a solution for plantar fascitis pain?

[17/08, 14:40] Meta AI: Walking can sometimes help alleviate plantar fasciitis pain, but its effectiveness depends on how it’s approached and the severity of the condition.

*Potential Benefits of Walking:*

- *Improved circulation:* Gentle walking can increase blood flow to the plantar fascia, aiding in healing and reducing stiffness.

- *Stretching effect:* Walking can help stretch the fascia and Achilles tendon, promoting flexibility and reducing tension on the heel.

*Risks or Limitations:*

- *Excessive pressure:* If walking is done without proper footwear or while the fascia is inflamed, it can worsen the pain and delay healing.

- *Biomechanics:* Poor walking posture or gait can exacerbate the condition, especially if the underlying cause is related to foot alignment or overuse.

Supportive footwear, orthotics, or walking on softer surfaces can make walking a more viable solution. Are you considering specific walking routines or seeking advice on footwear?

[17/08, 14:41]cm: @⁨Meta AI⁩ please provide specific walking routines and advice on footwear for Plantar fascitis

[17/08, 14:41] Meta AI: Certainly! Walking routines and footwear advice can be tailored to alleviate plantar fasciitis pain while promoting healing. Below are specific recommendations:

Walking Routines for Plantar Fasciitis Relief

1. *Start Slowly*

    - Begin with short walks (5–10 minutes) on even, soft surfaces (e.g., grass or a track). Avoid hard surfaces like concrete or asphalt, which can increase impact stress on the heel.

    - Gradually increase the duration and intensity as pain improves.

2. *Warm-Up Before Walking*

    - Perform gentle stretches to loosen the plantar fascia and Achilles tendon before walking. Examples include:

        - *Towel Stretch:* Sit with your legs extended and loop a towel around your foot. Gently pull the towel to stretch the foot and calf.

        - *Wall Stretch:* Stand facing a wall, place your hands on it, and stretch your calves by leaning forward while keeping your heels on the ground.

3. *Focus on Proper Walking Technique*

    - Maintain a neutral gait: Avoid overstriding or rolling inward/outward excessively.

    - Keep your steps short and controlled to reduce strain on the fascia.

    - Land softly on your heel and roll through to your toes.

4. *Incorporate Rest Periods*

    - If pain starts to increase during walking, stop and rest. Gradual progression is key to avoiding aggravation of the fascia.

    - Alternate walking days with non-weight-bearing exercises like swimming or cycling to reduce stress on the heel.

5. *Use Walking Intervals*

    - For beginners, alternate walking with rest periods (e.g., walk for 5 minutes, rest for 2 minutes). Over time, increase walking intervals as pain decreases.

---

Footwear Advice for Plantar Fasciitis

Wearing the right footwear is crucial for reducing strain on the plantar fascia and promoting healing.

1. *Key Features to Look For in Footwear:*

    - *Arch Support:* Choose shoes with adequate built-in arch support to reduce stress on the plantar fascia.

    - *Cushioned Heel:* A well-cushioned heel helps absorb shock and minimizes pressure on the heel bone.

    - *Firm Midsole:* A firm yet flexible midsole offers stability and prevents overpronation (excessive inward rolling of the foot).

    - *Deep Heel Cup:* Shoes with a deep heel cup provide better support and alignment for the heel.

2. *Recommended Types of Footwear:*

    - *Walking Shoes:* Look for walking shoes designed for plantar fasciitis, such as those from brands like Brooks, New Balance, or ASICS.

    - *Running Shoes:* Many running shoes provide excellent arch support and cushioning, which can be beneficial for walking routines.

    - *Orthopedic Sandals:* For casual use, consider sandals with arch support (e.g., Birkenstock or Vionic).

3. *Avoid These Types of Shoes:*

    - Flat shoes (e.g., flip-flops or ballet flats): Lack arch support and cushioning.

    - High heels: Increase strain on the fascia and Achilles tendon.

    - Worn-out shoes: Shoes with worn soles or inadequate support can exacerbate symptoms.

4. *Consider Orthotics:*

    - Custom or over-the-counter orthotics can be inserted into your shoes to provide additional arch support and heel cushioning. Brands like Superfeet, PowerStep, or Dr. Scholl’s plantar fasciitis insoles are popular choices.

---

Additional Tips for Walking with Plantar Fasciitis

- *Stretch After Walking:* Stretch your calves and plantar fascia after each walking session to prevent tightness.

- *Apply Ice:* If pain increases after walking, apply ice to the heel for 15–20 minutes to reduce inflammation.

- *Night Splints:* Consider using night splints to keep the fascia stretched overnight, which can reduce morning pain and improve walking comfort.

- *Monitor Pain Levels:* If walking causes sharp or worsening pain, consult a healthcare provider for evaluation and guidance.

---

By combining proper walking routines with supportive footwear, plantar fasciitis pain can be managed effectively. Would you like detailed instructions on specific stretches or exercises to complement your walking routine?

From 35F August 2025:

[17/08, 09:50] Patient Advocate 35F Plantar Fascitis: I am in trouble, please help me

[17/08, 09:56] Patient Advocate 35F Plantar Fascitis: Sent voice msg 👆🏻

[17/08, 09:58]cm: Please text if possible

[17/08, 10:11] Patient Advocate 35F Plantar Fascitis: Ok

[17/08, 10:16] Patient Advocate 35F Plantar Fascitis: আমার বাম পায়ের গোড়ালি তে হঠাৎ করে কয়েকদিন আগে থেকে খুব ব্যথা হচ্ছিল, গোড়ালির একটু উপরের দিকে এবং নিচ অব্দিও ব্যাথাটা হচ্ছিল এবং হাঁটতে খুব অসুবিধা হচ্ছিল। আমি একটা পেইনকিলার ওষুধের দোকানে জিজ্ঞেস করে পাঁচ দিন দুবেলা খাই। এবং তাতে যেহেতু আমি একটা ট্রিপে গেছিলাম ব্যথা কিছুটা বেড়েছিল এবং পরবর্তীকালে কমে। 

আজ সকাল থেকে আবার পা ফেলতে পারছি না এত যন্ত্রণা করছে বা পায়ের নিচের দিকে ভীষণ বেশি ব্যথা হচ্ছে। বিশেষ করে বাঁ দিকটা।

 আমি সাধারণত এখানে ঢাকা জুতো পড়ে চলাফেরা করি কারণ বেশ উঁচু-নিচু পাথরের উপর দিয়ে আমাকে হাঁটাচলা করতে হয়, কিন্তু বর্ষার জন্য শেষ কয়েকদিন আমি কিটো পড়ে হাঁটছিলাম তো হতে পারে যে আমার পা কোনভাবে এদিক ওদিক পড়েছে বা মোচকে ছে যেটা আমার খেয়াল নেই।

[17/08, 10:20]cm: Looks like plantar fascitis. 

@⁨Meta AI⁩ what would be the best management for plantar fascitis affecting the left heel of the foot for a few days.

No past history of similar pain

[17/08, 10:20] Meta AI: Plantar fasciitis is often managed conservatively, especially in the early stages. Here are some common approaches:

1. *Rest and Activity Modification*: Avoid activities that aggravate the pain, like prolonged standing or running.

2. *Stretching and Strengthening*: Perform gentle stretches for the calf muscles and plantar fascia. Toe stretches, calf stretches, and rolling a ball under the arch can be helpful.

3. *Ice Therapy*: Apply ice to the affected area for 15-20 minutes, several times a day, to reduce inflammation.

4. *Footwear*: Use supportive shoes with good arch support and cushioning. Avoid walking barefoot or wearing unsupportive footwear like flip-flops.

5. *Orthotics*: Consider over-the-counter arch supports or heel cups to reduce strain on the plantar fascia.

6. *Pain Relief*: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, can help with pain and inflammation if needed.

If the pain persists or worsens after trying these measures for a couple of weeks, consulting a healthcare provider might be necessary. They could recommend physical therapy, night splints, or other interventions.

Have you noticed if the pain is worst in the morning or after long periods of inactivity?

[17/08, 10:21] Patient Advocate 35F Plantar Fascitis: যেদিন প্রথম ব্যথা হয়েছিল সেদিনকে বাড়িতে ফিরে অফিস থেকে আমি অনেকক্ষণ বরফ জলে পা ডুবিয়ে রেখেছিলাম তাতে সাময়িক ব্যথা কমেছিল পরে আবার ব্যথা হয়।

[17/08, 10:23]cm: Prothom kabe hoi.

Aer aageo kokhono hoyechilo?

Komore kono byatha aer aage?

[17/08, 10:23] Patient Advocate 35F Plantar Fascitis: এখন হাঁটাচলা খুবই কম হচ্ছে কারণ অফিসের কাজের সেরকম দায়িত্ব অনেক কম, বেশিরভাগ সময়টা চেয়ারে বসেই সময় কাটছে। সেটা কি কোন কারণ হতে পারে?

[17/08, 10:24] Patient Advocate 35F Plantar Fascitis: দু সপ্তাহ আগে প্রথম হয়। অফিসের বাসটা এখন চেঞ্জ হয়েছে তাতে বসার সিট টা খুব অদ্ভুত মানে পা টা মাটি অব্দি পৌছয় না। পাটাকে একটু বেঁকে বসতে হয় তো সেটার জন্য মাঝেমধ্যে কোমর এবং পায়ে একটু স্ট্রেস হয়

[17/08, 10:25]cm: Hain

[17/08, 10:28] Patient Advocate 35F Plantar Fascitis: এর আগে কখনো এই ধরনের ব্যথা হয়নি। এই প্রথম হলো দু সপ্তাহ আগে

[17/08, 10:28] Patient Advocate 35F Plantar Fascitis: কিভাবে কমবে ব্যথা?

[17/08, 10:42] Patient Advocate 35F Plantar Fascitis: কি ওষুধ খাবো? Pain killer ছাড়া অন্য কোনো উপায় এ কমতে কত সময় লাগবে?

[17/08, 12:08] Rakesh Biswas: Sharing a similar patient who had to eventually get injected inside his heel 👇

58M April 2025

[20/04, 14:52] 58M Patient Advocate Left Heel Pain 6 Months: Sir

I have a problem in my health

[20/04, 14:53] 58M Patient Advocate Left Heel Pain 6 Months: Left leg heel pains

When i went to orthopedic doctor he did x-ray said spur

And prescribed pain killer and soft shoe 

But thats not giving relief

I feel its linked to some major body disorder

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: How to connect 

Which body or organ disorder is giving this pain

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: In left leg heel

[20/04, 14:54] 58M Patient Advocate Left Heel Pain 6 Months: Throbbing pain

[20/04, 14:55]cm: It's more likely to be plantar fascitis which is a subset of spondyloarthropathy

[20/04, 14:55] 58M Patient Advocate Left Heel Pain 6 Months: Ok sir

[20/04, 14:56] 58M Patient Advocate Left Heel Pain 6 Months: My CBC report recent

[20/04, 14:57]cm: Please describe your patient's sequence of events that led to the current problems.

Please begin the sequence of events from the time your patient had absolutely no problems at all. 

Please describe your patient's hourly  routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

What are the patient's current requirements from us like if we had to give him a single medicine which problem would they prefer it to address?

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[20/04, 14:59] 58M Patient Advocate Left Heel Pain 6 Months: Left heel pain persistent from last six months

[20/04, 15:02]cm: Take your time to slowly answer the other questions like:

Please describe your patient's hourly  routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here

[20/04, 15:02] 58M Patient Advocate Left Heel Pain 6 Months: For 2 weeks i am having left leg heel pain mostly in night time

Throbbing and shooting pain last for half an hour to one hour

[20/04, 15:04]cm: Don't share any reports. I'm assuming they are alll normal

[20/04, 15:05]cm: Tell us how it was 6 months back

[20/04, 15:06]cm: What time exactly? Yesterday at what time? What was the patient doing at that time?

[20/04, 15:06]cm: Please don't share any patient identifiers in social media even on pm

[20/04, 15:09]cm: Please describe your patient's hourly  routine over 24 hours when he was perfectly alright and didn't have the following complaints:

1. Left leg heel pain

2. No sound sleep of 6-7 hours

3. Mild continuous headache 

4. Burning sensation in urethra. Burning micturition sometimes

Next please describe what happened to his hourly 24 hour routine once the above complaints took hold on his life

Please mention specifically which part of the patient's hourly routine was disrupted by which complaint at what time 

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[20/04, 15:11] 58M Patient Advocate Left Heel Pain 6 Months: Ok sir

Will do

[24/05, 17:08]cm: We need a better history with regular informational continuity.

Have asked my team members if they can connect with you synchronously to explain how our solution works

After a conversational gap from May to August 2025

[17/08, 10:38]cm: How's the heel pain?

[17/08, 10:59] 58M Patient Advocate Left Heel Pain 6 Months: Sir 

As I was traveling abroad 

I had to take steroid injection and go

[17/08, 10:59] 58M Patient Advocate Left Heel Pain 6 Months: So now it's no pain

[17/08, 11:00] 58M Patient Advocate Left Heel Pain 6 Months: But 

Not sure what's the prognosis

[17/08, 12:03]cm: Let's hope it won't recur.

@⁨Meta AI⁩ what's the epidemiological evidence for recurrence of plantar fascitis after local steroid injections? Please support your statements with single best RCTs in a PICO format taking care not to use any percentages

[17/08, 12:03] Meta AI: *PICO Format Analysis*

- *Population (P):* Adults diagnosed with plantar fasciitis, particularly those who have not responded to conservative treatments like stretching, orthotics, or physical therapy.

- *Intervention (I):* Local corticosteroid injections administered into the plantar fascia.

- *Comparison (C):* Placebo, other injections (e.g., platelet-rich plasma [PRP]), or non-invasive treatments like physical therapy or custom orthotics.

- *Outcome (O):* Recurrence of plantar fasciitis symptoms after a period of symptomatic relief.

*Key Evidence from RCTs:*

One high-quality randomized controlled trial compared *local corticosteroid injections* to *placebo injections* and *platelet-rich plasma (PRP)* for plantar fasciitis.

- *Findings:* Corticosteroids provided significant short-term pain relief and functional improvement (typically a few weeks to months). However, recurrence of symptoms was commonly observed in the long-term follow-up, particularly when the underlying biomechanical or inflammatory causes were not addressed. PRP, while slower to show benefits, demonstrated longer-lasting symptom control and lower recurrence rates compared to corticosteroids.¹ ²

Another RCT evaluated corticosteroid injections versus physical therapy (e.g., stretching and strengthening).

- *Findings:* While corticosteroids offered a faster reduction in pain, patients receiving physical therapy had better long-term outcomes with lower recurrence rates. This highlights that while corticosteroids may address inflammation temporarily, they do not resolve the root cause of plantar fasciitis.³ ⁴

*Conclusion:*

The epidemiological evidence suggests that corticosteroid injections are effective for short-term symptom relief but are associated with a higher likelihood of recurrence when used as a standalone treatment. Combining injections with physical therapy or addressing biomechanical factors may reduce recurrence rates. Would you like me to elaborate on alternative treatments or dive deeper into PRP evidence?

[17/08, 12:08] Patient Advocate 35F Plantar Fascitis: Omg 🙏🏻

[17/08, 12:09] Patient Advocate 35F Plantar Fascitis: I am not willing for any injection if not emergency

[17/08, 12:10] cm : Ice ee choluk tabe

[17/08, 12:10] Patient Advocate 35F Plantar Fascitis: আচ্ছা 😊

UDLCO CRH: Reducing multidimensional real world data to feed our two dimensional academic flat lands began with cave paintings driven asynchronous communication?

Summary:  We explore the concept of dimensionality reduction, linking it to the evolution of human intelligence from ancient cave art to modern Artificial Intelligence (AI). The central argument posits that asynchronous intelligence, exemplified by early humans converting multi-dimensional reality into two-dimensional cave paintings for communication, is a primordial form of AI. This process, it argues, is a fundamental aspect of learning and knowledge creation, allowing for the simplification and storage of complex information. Furthermore, the discussion extends to the philosophical implications of this reduction, considering the trade-offs between simplifying reality for understanding and the potential loss of nuance, drawing parallels with concepts like abstraction, "Flatland," and the ethical considerations of bias in data reduction. Ultimately, the sources suggest that dimensionality reduction is a necessary yet inherently incomplete approach to comprehending the world.

Past reflections earlier archived here: https://medicinedepartment.blogspot.com/2025/04/first-draft-of-narketpally-syndrome-and.html?m=1

AI means asynchronous intelligence that thrives in a two dimensional academic flat land:Let's explore further in a thought experiment about what would education and research mean to cave men. It could mean another tool to solve their day to day issues such as trying to asynchronously communicate through a sketch on their cave walls where they had been hunting and where they would be leaving for the next hunt so that the next batch of hunting cave men who would be arriving at that cave a few days later could track their whereabouts? As cavemen evolved into us, the problems embedded in the whole ecosystem changed while human ability to learn through collective cognition didn't but became more refined. (Ref 31 https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1)

Rhetoric: Even now as humans continue to flow through time along with others who share the same space time globally, they and their uncertainties are like particles suspended in river water, which has a way of flowing around any object in it's path, a unique characteristic of the river that allows all other smaller particles in it to continue to flow unhindered albeit with a high degree of uncertainty of what future brings.

Human animals invented AI beginning with asynchronous intelligence through their ability to use cave painting tech to convert multidimensional real life data into two dimensional data in an xy axis cave wall that later evolved to paper and electronic media so that they could eventually manage their lives better as artistic modelling was easier in a two dimensional virtual plane than a multi dimensional real plane!


We have come all the way from primordial AI (aka asynchronous intelligence) to modern AI that models primordial AI to produce some currently interesting results particularly if the data capture is asynchronously hyperlocal.

Most learning is a process of objectively structuring subjective complex multidimensional real life data (blooms level 3-5) into a two dimensional space (blooms level 1 aka knowledge) that can be stored forwarded asynchronously and modeled conceptually to gain understanding (blooms level 2) through further analysis ( level 4) and evaluation (level 5) and then relooped into the learning ecosystem as creative communication/publication (level 6). This learning is cyclic and one can keep moving in and out of these levels at any entry or exit point regardless of level numbers.

Ref 32 :https://medicinedepartment.blogspot.com/2023/12/ongoing-project-draft-optimizing.html?m=1

https://medicinedepartment.blogspot.com/2024/11/technology-end-user-driven-ecosystem.html?m=1

Asynchronous communication of knowledge: asynchronous intelligence aka primordial AI and subsequently academic intelligence AI and finally current artificial intelligence AI

More here: https://medicinedepartment.blogspot.com/2021/06/introduction-to-evolution-of-human.html?m=0

Image CC licence: https://commons.m.wikimedia.org/wiki/File:Rock_Shelter_8,_Bhimbetka_02.jpg#mw-jump-to-license

Rhetoric: Human animals invented AI beginning with asynchronous intelligence through their ability to use cave painting tech to convert multidimensional real life data into two dimensional data in an xy axis cave wall that later evolved to paper and electronic media so that they could eventually manage their lives better as artistic modelling was easier in a two dimensional virtual plane than a multi dimensional real plane!

Let's look at where we have come all the way from primordial AI (aka asynchronous intelligence) to modern AI that models primordial AI to produce some currently interesting results particularly if the data capture is asynchronously hyperlocal.

Link to the actual lecture around this slide:

https://youtu.be/1e0cgvtQ2Ow?feature=shared

[15/08, 20:55]: Is there a philosophy of dimensionality reduction as in reducing multidimensional real world data to a two dimensional academic flat land data?

[15/08, 20:55] Meta AI: Yes, the concept of dimensionality reduction can indeed be explored philosophically, as it reflects a deeper epistemological tension between the complexity of reality and the simplifications we use to understand and communicate it. Here’s a breakdown of how this idea can be philosophically framed:

---

1. The Philosophy of Abstraction and Simplification

Dimensionality reduction mirrors the philosophical process of abstraction, where we strip away details to focus on the "essence" of phenomena. In doing so:

- *Strengths*: It allows us to create models that are interpretable and communicable, much like reducing real-world complexity into simplified academic frameworks (e.g., graphs, tables, or theories).

- *Limitations*: It risks losing nuances, context, and emergent properties of higher-dimensional systems. Philosophers like Alfred North Whitehead warned of the "fallacy of misplaced concreteness," where abstractions are mistaken for the full reality they represent.

---

2. Flatland and Dimensionality Reduction

The concept of "Flatland," popularized by Edwin Abbott's novella, serves as a metaphor for dimensionality reduction:

- *Flatland as a Reductionist Trap*: In reducing multidimensional data (or reality) to two dimensions, we risk oversimplifying and misinterpreting phenomena. For example, reducing a dynamic, interconnected social system to a single graph might obscure the complexity of human behavior.

- *Flatland as a Tool for Understanding*: At the same time, the reduction to "flatland" is a necessary step for human cognition, as we can only process and analyze so much complexity at once.

---

3. Trade-offs Between Complexity and Interpretability

Dimensionality reduction reflects the philosophical trade-off between complexity and interpretability:

- *Kantian Perspective*: Immanuel Kant argued that human cognition is inherently limited by the categories of understanding (space, time, causality). Similarly, dimensionality reduction acknowledges our cognitive and computational limits, reducing data to manageable forms.

- *Pragmatism*: Philosophers like William James or John Dewey might argue that dimensionality reduction is justified if it serves practical purposes, even if it sacrifices some fidelity to the original complexity.

---

4. Ethical and Epistemological Implications

- *Bias and Oversight*: Dimensionality reduction leaves room for bias in what dimensions are "reduced" and how. For instance, in reducing real-world diversity into academic metrics, whose perspectives and dimensions are prioritized or ignored?

- *Epistemological Humility*: Philosophically, dimensionality reduction reminds us of the limits of human knowledge. The act of reducing dimensions is a recognition that we are always operating with partial truths.

---

5. Philosophical Analogies in Science and Art

- *Science*: The scientific method itself is a form of dimensionality reduction, distilling complex phenomena into laws, models, and theories (e.g., Newton’s laws or Einstein’s equations). These are not complete representations but tools of approximation.

- *Art*: In art, dimensionality reduction occurs when artists convey the essence of multidimensional experiences through limited media (e.g., a painting or a poem).

---

6. Reconciling Reductionism with Holism

Philosophically, dimensionality reduction can be seen as part of a broader tension between reductionism and holism:

- *Reductionism*: Breaking down complexity into simpler, lower-dimensional components for analysis.

- *Holism*: Recognizing that the whole often has properties that cannot be fully understood by its parts alone.

Dimensionality reduction, when used wisely, can serve as a bridge between these approaches, helping us approximate the whole while acknowledging the limits of reductionism.

---

Conclusion

The philosophy of dimensionality reduction is ultimately about balance: how much of reality can we afford to simplify without losing its essence? While it is a powerful tool for understanding, it also serves as a reminder of the inherent incompleteness of human knowledge. In this sense, dimensionality reduction is not just a mathematical or computational technique—it is a philosophical exercise in humility, abstraction, and the pursuit of meaning amidst complexity.

UDLCO CRH: What is the efficacy of antivenoms as a pharmacological intervention in the management of acute snake envenomation?

Summary:

This conversational data reflects frontline and experiential insights on snakebite envenomation, particularly in Indian rural and urban settings. It highlights the risks of venomous snakes like vipers, cobras, kraits, and discusses the challenges in managing bites, including anti-snake venom (ASV) availability, misuse, and variable efficacy. The necessity of timely ASV administration is emphasized along with supportive treatments like dialysis and ventilation. There is discourse on traditional healer roles and AI-assisted diagnostic tools (like image recognition apps) to distinguish snake species for accurate treatment. The discussion also reflects skepticism toward western evidence-based medicine models while valuing empirical knowledge in local contexts. Key complications such as delayed venom effects and ARF (acute renal failure) emerge as critical concerns in treatment outcomes.

Keywords:

- Snakebite envenomation  
- Anti-snake venom (ASV)  
- Viper, Cobra, Krait, Python  
- Hemotoxic, Neurotoxic venom  
- Acute renal failure (ARF)  
- Supportive care (dialysis, ventilation)  
- Traditional healers  
- AI diagnostics in medicine  
- Empirical vs. Evidence-Based Medicine  
- Public health and snakebite management  

Conversational Transcripts:
[04/08, 05:35]hu1: Facing a snake 1st time in my life
[04/08, 05:35]hu1: Not going to hide it. Saw death with fear in my eyes. Was already calculating money will and which hospital would be best for ASV - Anti Snake Venom
[04/08, 05:35]hu1: ASV is manufactured only in King Institute, Guindy. Due to lack of expertise in treating snake bites, Dr especially in ICUs tend to overuse it. Stock runs out fast
[04/08, 05:35]hu1: Simply coz their venom is deadly. Vipers are hemolytic cobra krait are neurotoxin. 30 max, it kills. They evolved to use it to hunt for food. We are the one intruding on their environment
[04/08, 05:35]hu1: This fellow is a baby python. 3 foot Mama had visited kutchen few weeks ago. So I told thomas to call the local snake catcher and find their nest. Atleast 20 eggs and babies will be there for sure
[04/08, 05:40]hu1: RFS - reason for sharing: Google AI was used by a friend to parse my video and correct me that this is a baby reticulated python and not a viper.
How can we deliver this in my ED? Every practising Dr should have this astra in kitty to assist. Isabel healthcare was a beginning, POEM & PROSE were tried, Infobutton was cool, Watson was to send all doc home. Aint happen 😉🤔😆
[04/08, 05:40]hu1: AI HAL built into an app that any doc can download that can read a pic or video and give DD
[04/08, 05:42]hu1: Hence dogs have been with man since stone ages for their pure loyalty. Unbelievable how this 14 year old grandpa protected us, ignoring his masters commands
[04/08, 08:46]hu4: Reminds me of my days at Amrita, you know snakes just get into the house and go to the opposite side and it's very common. These include Cobra too!
My son was 6 months old and one day a snake passed by, i was in hospital and my wife's shouting made my neighbours rush in. Thier first reaction was: laughter! 
They said it's very common for snakes including venomous ones to come into home but nothing to be worried. 
After that we have had 4 encounters in 6 months!!!!
[04/08, 09:01]hu3: Traditional healers also treat snake bites. Using herbs. Covered under QCI certification schene!!!
[04/08, 09:42]hu1: I don't know what they treat. I can tell you if bitten don't experiment. Atleast we know ASV works
[04/08, 09:49]hu3: Someone shld study what they do!!!
[06/08, 06:34]hu1: Google helped allay my fear that it could be a viper. This is baby python
[06/08, 06:34] ATP: Try it. Just check with perplexity or grock
[06/08, 08:44]hu2: Pythons move sluggishly while vipers are swift
[06/08, 09:02]hu1: True
[06/08, 09:01]hu1: Viper venom is hemotoxic, kills in few hours
[06/08, 09:15]hu2: Yes we regularly manage these patients.
Here's a past case report from our open EMR archive 👇
https://nikhilasampathkumar.blogspot.com/2023/07/introduction-this-is-online-e-log-entry.html?m=1
After 4 days:
[11/08, 06:38]hu1: Grew up on CLRI campus. Have been exposed to snakes since childhood, have a healthy respect for them. We intrude into their space. Never the other way. As a medStudent and intern managed many cobra, krait, sawtooth scaled viper and russels viper victims in Porur. It was a very rural ecosystem at that time. These are the 4 species that are poisonous. Rest are safe. Indian python is not big enough to be a threat to us. Those in South Asia and Brazil are evil. Anaconda is similar.
My fear of snakes hence is from knowing the consequences of a bite. I think we all should be safe rather than sorry.
[11/08, 06:38]hu1: https://chennaisnakepark.in/
[11/08, 06:44]hu1: These are the points where a reliable authentic source of information both for the healer and the one seeking help goes a long way in allaying unnecessary fear.
We have seen people horrified after a snake bite. Sometimes the venom is retained in muscle and gets released when we mobilize patient in wards. I have seen patients die after 10 days of cobra bite.
Our Kings Institute Guindy Chennai produces ASV - Anti Snake Venom by injecting venom from these 4 dangerous species unto horses. Their body produces antibodies that are then purified and used to help manage human snake bites.
Cobra Krait are neurotoxic. Vipers are hemotoxic. Pythons and Anacondas are constrictors. All of them have this capability to hunt prey and feed. We come in the middle...and then complain 🙄
[11/08, 06:48]hu1: My military school seniors were having a laugh saying: ithna chota snake se darr gaya. Don't be fooled by size. Vipers are about 20 cm but easily take down a man.
Both are very painful death, whether neuro or hemo toxic. ASV is not 100% effective and some patients react to this foreign protein.
Prevent 》Treat. Always
[11/08, 08:32]hu2: We have lots of cobras in our garden! 
https://www.facebook.com/share/v/19cQmkXXPN/?mibextid=oFDknk
[11/08, 08:34]hu1: U r a brave man. The hatchlings carry venom like their mama. Don't make me come to kukatpally to treat you. 🤦🏽‍♂️
[11/08, 08:39]hu1: ASV is not effective at all!
Most of the successes of snake bite management appears to be due to supportive management like dialysis and ventilation. People have brought down the dose of ASV by 50 to 70% in controlled trials and the effect appears same. http://www.ncbi.nlm.nih.gov/pubmed/10778516, http://www.ncbi.nlm.nih.gov/pubmed/15909856, http://www.ncbi.nlm.nih.gov/pubmed/15633711, http://emj.bmj.com/content/22/6/397.abstract
The above are trials based in India. It is possible that the low dose anti-venom could have been gradually in subsequent trials brought down to zero!
[11/08, 08:40]hu1: We live far from Kukatpally, in a village near Hyderabad
[11/08, 08:44]hu1: I object milord. ASV does save lives. Dialysis and Ventilation are like 7th 8th step in a path from 0 to 10. I despise going there
[11/08, 08:45]hu1: Keep away from those critters Prof. Your students ❤️ you
[11/08, 08:46]hu2: Check out the evidence!
[11/08, 08:46]hu2: Yes cobras are very sensitive creatures. Even when we work in the garden they either slither away further or provide a distinct hiss like warning
[11/08, 09:23]hu1: I am a practioner of empirical & experience. EBM is a western concept. We can debate how much it is relevant to the orient. Occidental <> Oriental are north and south poles. Twine rarely converge.
Conversational Transcripts from another group:
[15/08, 10:01]hu5: Real snake bite
[15/08, 12:52]hu2: Did they see the snake or bring a picture of it?
[15/08, 13:11]hu5: Yes they killed it, person who got bitten ran back and killed the snake
[15/08, 13:27]hu5: Our patients often bring their snake's photograph that helps to plan their care pathway in a better way👇
https://pajrcasereporter.blogspot.com/2025/08/snake-bite-projr.html?m=1
[15/08, 14:27]hu5: Same description patient was giving
[15/08, 14:28]hu5: Russell's viper?
[15/08, 14:31]hu5: Many differentials:
 https://researchmatters.in/news/current-antivenom-ineffective-against-saw-scaled-viper-bite-finds-study
Difficult to confirm without a picture.
The above link again took us back to anti-venom RCTs and here's some discussion Transcripts from decades ago:
From Hu2
Date: Tue, 19 Feb 2008, 21:59
 
We used to see a very interesting envenomation in Nepal which was from a semi poisonous green pit viper. 
 
The envenomation was chiefly manifested in local swelling and a deranged coagulation and was never life threatening.
 
We also had the opportunity to report an unusual complication of antivenom (the use of which was perhaps as we learned gradually not required for that kind of envenomation and the local physicians never used it). The report is available here: 
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1368-5031.2004.00201.x
 
Now that you mention it I wonder if it had anything to do with quality control issues although the antivenom in question was from Serum Institute of India, Pune.
 
The other issue I had in mind was the rationale behind antivenom (although I guess it may not be relevant to the topic but would be glad if somebody threw more light on it). The antivenom which we so very unquestioningly administer in snake bites ( presumably poisonous) has often been challenged to be of dubious value as there have been no RCTs (randomised control trials) to demonstrate its efficacy (which again cannot be conducted for obvious reasons). It has been postulated that the management of snake bite may be very well accomplished by supportive therapies such as ventilators for respiratory paralysis and dialysis for renal failure. Perhaps we could have a quick feedback on this before we move on to the issues enumerated by Hu7
Hu2 on August 15, 2011
Hu9 it would be great if you could search this issue of 'antivenom evidence' further. I can provide whatever articles i have on the topic.
Also wonder what is the evidence on 'nitroglycerine?'
Hu2 on August 15, 2011
Hu9 it would be great if you could search this issue of 'antivenom evidence' further. I can provide whatever articles i have on the topic.
Also wonder what is the evidence on 'nitroglycerine?'
Hu2 on August 15, 2011
Hu9 it would be great if you could search this issue of 'antivenom evidence' further. I can provide whatever articles i have on the topic.
Also wonder what is the evidence on 'nitroglycerine?'
Hu2 on August 15, 2011
Hu9 it would be great if you could search this issue of 'antivenom evidence' further. I can provide whatever articles i have on the topic.
Also wonder what is the evidence on 'nitroglycerine?'

Hu2 on August 15, 2011
Hu9 it would be great if you could search this issue of 'antivenom evidence' further. I can provide whatever articles i have on the topic.
Also wonder what is the evidence on 'nitroglycerine?'

:-)

regards,

From Hu8 

Date: Mon, Aug 15, 2011 at 3:23 PM
Subject: Russell viper bite

This one is for sharing.

today morning when we unfurling the national flag, this 18 year old girl came at 9 am after being bitten by a juvenile of Russell viper , called Naunakhaa, bit at 7a m, 1st WholeBloodClottingTime was normal, and the one at 10 am , read at 1025 was abnormal. ASV started at 11.05 am, developed a hypersensitivity at 11.28, managed, restarted at 11.52 am, finished at 12.35 pm, meanwhile had gum bleed and some pain abdomen at 11 20 am, responded after the 10 vials of ASV. The bleeding has stopped. Lets see if she gets ARF, or recurrence of bleed. We do the next WBCT at 630 pm platelets were 98000. creat 0.7, no local bleed, though a modest swelling was there locally.

did you know that russell viper is almost the most poisonous snake that is known. and can cause ARF even if one starts the ASV for hematotoxic effects within 2 to 3 hours?

Date: Mon, Aug 15, 2011 at 6:42 PM
Subject: Re: Russell viper bite

we started a selling of torchlights programme at a big level. and are making available a CD on its prevention that we are distributing at each village level. also keeping  nitroglycerine ointments at the village level.

On Mon, Aug 15, 2011 at 4:04 PM, Hu 9 wrote:
Snake bite seems a real menace there. Any thoughts about prevention (?vigilance ?protective wearing ?habitat)...

Hu2, October 2011

Thanks for this very interesting email.

I had noticed his web site during a recent discussion on krait bite on 'tabula rasa' around one of our patients of sudden abdominal pain followed by ptosis and quadriparesis without a history of snake bite. I was wishing we could invite him to join the discussion.

He is quite convinced about AVS and i am not sure if we can get him to search the evidence around it but nevertheless it would be worthwhile to discuss this issue with him as he seems quite passionate and enthusiastic about the topic.

Would you like to invite him with the snake bite CFP to see if he can organize a few reviews around the topic and co-edit/organize the issue with you? Perhaps you could also forward him our discussions with Prof ... and Prof ... (representing two opposing world views).

Would be great if you can manage the time to do it. Hope your USMLE preparations are going good.

regards,

On Sun, Oct 2, 2011 at 8:01 PM, Hu10 wrote:

I receive mails from someone called Dr  because one of our Ids which I am in charge of is a part of his mailing list. He has shared some interesting perspective about management of snake bite cases and also the use of anti venom. Am sharing it with you for your opinion on this and if he could be a part of the debate for/against the use of AVS in India. There is another email of his in which he has made a protocol which can be followed in case of a case of snake bite. 

Have you heard of him and his work?

Look forward to hearing your inputs.

Best,

Date: Fri, Sep 30, 2011 at 6:25 AM
Subject: Viper Bite Cases
Hu11

Respected and Dear All, Starting with a good news that, our veteran coworker( 53 yrs) of ... is doing well without any dialysis . He was bitten by a Russell’s Viper at a remote island of ... while he was in a scientific show with snakes. He was bitten at 3.25 PM , and AVS treatment was started at  Hospital at 5.50 PM on 26^th Sept 2011. Though he suffered a fainting attack in the boat on the way to hospital and developed bleeding disorders , he was perfectly managed by the S D Hospital. We shifted him to tertiary hospital on 27^th for monitoring of Kidney function. He is all right till 29^th evening.

   On the contrary , 46 yrs, M, of Nera village , near ... was admitted at rural Medical College on 26^th Sept  at 4 PM with definite signs of Viper bite. He did not get any AVS till 8 PM on 27^th and developed kidney complications , transferred to tertiary hospital, no bed there , got a floor bed at another Hospital last night , waiting for dialysis.

 Another , 34 yrs , M , of Village of ,  was bitten by a Viper on 26^th . No AVS at  Block PHC , nor at S D hospital , developed Kidney complications . Admitted in floor bed in tertiary on 27^th for dialysis.

 Who will teach our  friends that, timely AVS treatment is the main thing for Viper bite , not Dialysis ? 

 Thematic Analysis:*

1. **Epidemiology and species identification** – Differentiating venomous snakes (viper, cobra, krait) from non-venomous (python), and importance for treatment planning.  

2. **Clinical management challenges** – ASV supply limitations, overuse by inexperienced clinicians, adverse reactions, and need for timely administration.  

3. **Role of technology** – AI and digital apps to aid rapid and accurate snake species identification to improve decision-making in emergency care.  

4. **Traditional vs Modern medicine** – Debate on herbal/traditional remedies and the challenge of integrating these with evidence-based treatments.  

5. **Supportive care importance** – Dialysis, ventilation vital for severe envenomation, but prevention and early intervention crucial.  

6. **Public awareness and education** – Community encounters with snakes, fear management, and importance of accurate knowledge dissemination.  

*Project Plan (IMRAD format):*

- *Introduction:*  

  Outline the burden of snakebite envenomation in India, highlight species involved, clinical implications, and gaps in management including ASV use and diagnosis challenges.

- *Methods:*  

  Mixed methods including qualitative data from frontline healthcare workers’ conversational transcripts, review of existing literature on ASV efficacy, and pilot testing AI diagnostic tools on snake image recognition.

- *Results:*  

  Identification of frequent misclassification of snake species causing treatment delays, ASV stock management issues, and emerging role of AI to enhance diagnostic accuracy. Evidence from transcript suggests that supportive therapies complement ASV treatment. Traditional practices lack systematic study.

- *Discussion:*  

  Integrate findings with literature pointing to the need for improved ASV protocols, incorporation of AI diagnostics, critical appraisal of traditional methods, and education campaigns for healthcare providers and communities. Discuss challenges of balancing empirical experience with Western evidence-based medicine in the local context.

CC licence: https://commons.m.wikimedia.org/wiki/File:Snake_Milking.jpg