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Sunday, May 13, 2012

Heat vs Ice: Accupuncture vs PT (Email Exchange)


The following is an exchange with Ahab following his injury to the sesamoid bone under his big toe. Ahab later finds out the sesamoid bone is broken. 


Hi Dr. Blake
I took 2 tablets of aleve twice a day
for 3 and half days
it brought down the swelling, but i was having
reactions to the meds
should i just reduce the quantity ?
is it really going to reduce inflammation for good?
or is it just while the drug is in my body?

Any thoughts?
Or thoughts on ice/heat?
Some say never ice - because it prevents blood flow?
others say ice forces blood to flow later?

Thanks,
Ahab


 Dr Blake's response:
Ahab, 
Still not sure what your diagnosis is? Rich (Ahab was able to send his MRI Report noting a fractured tibial sesamoid under the big toe joint)



Thank you very much for you responses. I know I can't look back - but I was being very conservative
for two months - then i thought 'maybe i need PT' - the podiatrist gave me a prescription over the phone

withouts seeing me - even thought I told him - 'how do i know if i'm ready for pt'? 


Dr Blake's comment: At this time no one knew the sesamoid was broken.

he told me the PT he send me too only worked on feet. She was super confident and told me

to drop the boot and cane, to wear regular shoes, and she manipulated the big toe, wrenching it

painfully to "get it moving again' - then she had me walk directly on it - saying that it would get the 

blood flowing, and that the pain was ok. I walked directly on it for a week in regular shoes - until I 

couldn't do it anymore and questioned her reasoning. I saw her one week later - and at that point 
the foot was very very swollen - that's when I asked for crutches, and that's when the podiatrist gave
me a prescription for an MRI. My question is: obviously the PT did the wrong thing, not knowing
that my sesamoids were injured - how much damage did she do? Is this going to make the recovery 
take longer? she also had me lifting marbles with my bad foot, and she said : "bend it as much as possible,
you can't hurt it by bending it" - I was trying to make it bend like the good one. 

Do you think turned back a lot of the healing which had taken place  in the first two months?

An acupuncturist recently said to me that 'ice is for dead people' - and to not ice the foot. I've stopped
icing recently, and there is a lot of swelling. I've been told that this is the body's natural way to
heal the injury. Is that correct?

Dr Blake's comments:

Ahab, You are basically getting advice that is canned (meaning protocol driven, with little to no thought behind it). A thoughtful PT does not increase pain, and understands that without MRI the diagnosis is unclear and caution must be taken. With sesamoid injuries, without a clear diagnosis of the extent of damage, you have to treat the worse case scenario (ie fracture). PT can be used to reduce inflammation, gradually start you strengthening your foot, etc. The PT did not damage you further, may have forced the issue in getting the MRI you needed, but definitely caused a setback (we don't need these physically or emotionally). I try things all the time to help problems, that cause another problem that I have to deal with, or aggravate a condition, so I do not like to cast the first stone. The accupuncturist should become a healer. No acupuncturist that I know will recommend ice. It is not in their training. But, it I practiced at the level of my training 30 years ago, I would not being doing a good job. Golden Rule of Foot: When what you are taught doesn't work on all patients, discover when to use your skills, and when to modify them.  Have them read the literature on the effectiveness of ice. Hunter's Response is proven. Ice reduces inflammation and helps healing period (end of sentence). I know when accupuncture will work for foot problems and when not. I love accupuncture to reduce swelling and relax nerves, etc, but all my patients who go to accupuncture ice pack the area when they get home. Rich

My Niece Kelley many years ago in an Ice Bucket


Rich,

You have obviously treated many sesamoids - so I am leaning towards your advice.

I have been icing continually - and the swelling was down. Ice seemed to mask the pain.
I read something about - 'inflammation is the body's natural way to heal' - so stopped icing
on friday night. By this morning the foot was all swollen again. If you say to continue icing,
 I will do that. I'm seeing another podiatrist on Monday who has supposedly treated many 
sesamoids - this podiatrist wants to see the images with me - which I think may be a good 
sign. The podiatrist who ordered the MRI didn't even mention the word fracture to me - 
I had to order the report myself to see that word - he later told me "Patients don't like to hear
the word fracture." - If he's trying to avoid giving accurate information - I don't know. He didn't
even recall how I received the injury when I went for a follow up after the PT. He thought I just
stubbed the toe, instead of going straight up on it. 

My question is - you recommend icing for your patients with sesamoid issues with the purpose
of having new blood flow into the injury? Is that correct? Icing certainly makes the foot look
less frightening 

Is the sesamoid bone actually inflamed? If it's not displaced, then why does it seem to be 
pushing out further on the injured foot as opposed to the uninjured one? Or is it the tendon
around the bone which is inflamed and giving the appearance that the bone is pushing out?

Extremely grateful for your help,
Ahab

Dr Blake's comment:




Rich,

Thank you for these links. I put ice on my extremely swollen feet, and they were immediately feeling better.
When I don't ice the swelling can be so great that it is clear, or seem to be clear that 'something must be done' - if it's not 
ice, then it has be another method - perhaps an acupuncturist would know. I can apply ice myself. 

this was a response (not to your icing links - but to your email mentioning Hunter's  Response from an acupuncturist) - 
do they make any sense to you?

"Ice is very useful for preserving things in a static state. It slows
or halts the decay of food and dead bodies but does not help damaged
tissue repair itself. Ice does reduce the initial swelling and
inflammation of a fresh injury, and it does reduce pain, but at a
cost. Contracting local blood vessels and tissues by freezing them
inhibits the restoration of normal circulation. The static blood and
fluids congeal, contract, and harden with icing, making them harder or
impossible to disperse later. It is not uncommon to see a sprained
ankle that was iced still slightly swollen more than a year after the
original injury.

Cold causes contraction of the muscles. When you go out on a cold day,
the muscles contract automatically to produce warmth. You can feel how
the body literally draws into itself when exposed to the cold. Every
athlete knows that it is harder to stretch and easier to pull a muscle
in cold weather. Icing an injured area causes further contraction in
muscles, ligaments, and tendons that are already contracted in
reaction to being overstretched. This further slows the natural healing
process and prevents the return of normal movement.

Acupuncture has five effective alternatives to icing: emergency
acupoints to move energy, kill pain, and stimulate circulation;
cupping and bleeding the local area to actually draw out and disperse
blood and fluid that is coagulating and blocking normal circulation -
often reducing pain immediately; self-massage with liniments such as
trauma liniment that move blood, reduce inflammation, and kill pain - 
removing static fluids and blood and reducing swelling; energetically
cooling herbal poultices and plasters that reduce inflammation and
also stimulate circulation and help torn muscles and tendons heal; and
herbal pills or powders that are taken orally to promote blood
circulation and prevent blood from stagnating further.

If you ignore all of this and decide that you simply must ice, try to
apply it for only ten minutes every hour. This will help to reduce the
swelling while minimizing negative side effects as listed above."

Dr Blake's comment: I love acupuncture (even though I rarely spell it correctly), and this discussion is really not about Amir getting acupuncture, it is about when during each day during these next 6 to 12 months of healing should he use ice. 

Thanks,
Ahab

Dr Blake's response:

Ahab,


 Thanks for the fun exchange. Just remember that you should always feel better after icing or heating an area. In sports medicine, ice and heat are used a lot and in many different forms. Accupuncture is wonderful tool to help in many ways. I look at ice therapy and accupuncture as both ways to improve circulation and healing when done at the appropriate time for an injury. Since you get injuried, then go through various periods or moments of re-aggravation ice can be used following these flareups for many months. I had to ice my shoulder after I played basketball for 7 months, but it allowed me to keep playing. I would heat the shoulder up before, and then ice it down after. This is very common. Golden Rule of Foot: When In Doubt, Ice. Heat  when used at the wrong time is the cause of too many set backs. Ice, as long as you do not produce frost bite, rarely causes the increased swelling which is our Enemy in a sports medicine practice. Golden Rule of Foot: Swelling slows healing and must be treated daily. A great form of anti-swelling measure is Contrast Bathing. It can be started 4 days after an acute injury, and normally several days after each flareup like you had. Make sure you learn this powerful tool. Rich Good luck. I will place these emails on my blog because it is a common battle. I hope both sides are laughing alittle. Listen to your body after you try anything. Know that as your symptoms change daily/weekly, you may have to change how you are using heat and ice at home, or with a health care provider. Rich If ice feels great, so be it. If ice irritates, and you do not know how to change the method of application or time utilized, change to one of the many forms of heat. I do not believe however that chronic swelling after an ankle swelling can never be proven to be linked to the ice program. How is that possible to make that correlation? LOL I hope at least one of my readers can see how wonderfully gifted health care providers can get caught on generalizations, and won't change when the exceptions walk into the office. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.