Heel Pain and Physical Therapy Modialities

The following video briefly goes over some physical therapy modalities commonly used in the treatment of heel pain, such as plantar fasciitis and plantar heel bursitis.





Ultrasound is commonly used as a source of deep heat.

Ultrasound is typically used for 5 minutes.

Ultrasound must be kept moving to prevent burns.

Interferential is used to reduce pain, swelling, and muscle spasm.

Interferential must be diagonally crossed.

Interferential is typically used for 15 minutes.

Deep tissue work is used to breakdown scar adhesions. A skilled manual therapist can even break down a bursae, but it is very tricky to not inflame the bursitis further.

Hallux Rigidus/Hallux Limitus: Self Mobilization Technique

     The above video demonstrates the 4 common self mobilization maneuvers patients can do to create more motion in their big toe joints (first metatarsal phalangeal joints). The most important points to remember are:

1. Mobilization maneuvers are not the normal motions of a joint.
2. Mobilization maneuvers are over very small distances
3. Mobilization maneuvers should never hurt. If they hurt, the joint will be tighter when you finish then when you started.
4. Mobilization maneuvers occur to only one-half of the joint, you must stabilize the other half.

The 4 maneuvers mentioned are:

• Long Axis Extension (joint distraction)
• Dorsal Plantar Glide (up/down motion)
• Counterclockwise and Clockwise Rotation (joint rotation)
• Abduction Adduction (side to side motion)

These maneuvers involve moving the hallux (big toe) on a fixed first metatarsal. The bone, not skin, must be grabbed on both sides. The big toe has two bones and a joint. You want to grab the bone closest to the big toe joint. Each motion should be done 2 or 3 times only with quick motions as you get good. These maneuvers should be done once daily. Normally, after 50 times, increased joint motions are noted. Some patients will do after a hot shower, or in a warm water soak, jacuzzi, or Bikram Yoga session. If pain is produced with the mobilization, ice for 20 minutes afterwards. You can get further advice from a physical therapist or chiropractor skilled at foot manipultions. I hope this helps you gain motion in your stiff big toe joints from Hallux Limitus, Hallux Rigidus, post bunion repair (find out from surgeon when safe to do), and other injuries to the big toe joint.

Heel Bursitis (Plantar/Bottom of Heel): Typical Physical Therapy Regimen

9/6/10
Hi Dr. Blake!
I hope you have a fun-filled long weekend planned!.
I'm checking in at the two week mark as we discussed. My stubborn little
calcaneous bursitis is still causing me grief. I did try the contrast bath -
but it seemed to irritate it, so I've stuck with icing. I have not been jumping
in dance class or standing in spin. In fact, releve seems to bug it as well, so
I've eliminated turning. Since I wasn't making the progress I'd hope to on my
own, I thought I'd finally book the PT. I work in SF, so I would
consider coming over to St. Francis, but if you know of another good place in
the East Bay, it might be more convenient.
Thanks so much! It really is wonderful having someone I've known for 24 years
(!!) I can come to with these bothers. And even though it's an injury that
brings me in to see you, it is always great to see you! ;-)
Have a fabulous weekend and talk soon,

Tracy

Tracy, Physical Therapy for calcaneal bursitis (under the heel) should be done twice weekly for 4 weeks and should include in this order: Ultrasound as a way of producing deep heat to the bursitis tissue making it vulnerable to the next two treatments. The ultrasound is following by deep friction massage to break down the bursae. The deep tissue work is following by 5 minutes of vigorous ice massage to calm down any aggravation of the inflammation and further the breakdown process. Since plantar fasciitis is normally part of the problem, the PT may address part of the treatment for that also. If calcaneal bursitis is a major part of the pain, make sure that the 3 components in the order of ultrasound, deep friction massage, and icing are the central part of the treatment. I will see you following the first 4 visits to make sure we are all on the same page. Good luck, and great to see you again as always. Rich

PS. During the time you are in physical therapy, you must continue to ice massage 3 times a day (since the contrast bathing did not help), and do as much physical activity as you can without flaring up the symptoms. It is normally a mistake to go to physical therapy at the same time you are resting an injury completely. The physical therapist never gets a good feel of your improvement, or lack of improvement. Use the information on the post Good Pain vs Bad Pain to base your Activity Modification Program.
http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Also, the next step with calcaneal bursitis is cortisone shots, but that requires 2 weeks off activity/shot, and could require up to 3 shots (the response to the shot is evaluated in 2 weeks), so most athletes try to avoid with a passion. Please see the separate post on the thought process behind cortisone shots.
http://www.drblakeshealingsole.com/2010/05/cortisone-shots-thought-process-behind.html

Good luck Tracy, email me after 4 physical therapy visits.

Plantar Fasciitis or Plantar Heel Bursitis: Rolling Ice Stretch

The Most Time-Effective Treatment for Plantar Fasciits is a 5 minute Rolling Ice Stretch. It combines anti-inflammatory, mechanical massage, and plantar fascial stretch all beneficial in helping plantar fasciitis. If there is a plantar bursitis, an additional 5 minutes of massage just to the bottom of the heel is performed. A plastic bottle of any shape (patients do have their favorites) is filled 1/2 to 2/3 full of water and then frozen. The water will expand with freezing. Then, a towel is placed on the ground, and from a sitting or standing position (I personally like standing but not with full body weight), the arch from heel to toes is gradually massaged from 5 minutes. Patients are told to gently massage the skin for the 1st minute, the 2nd minute they can massage a little deeper into the soft tissues, and the 3rd to 5th minutes the massage should get deep into the deeper tissues (fascia, muscle, and tendon). This treatment should be done three times daily. The bottom of the heel gets its own 5 minutes if a bursitis is present. Remember with icing the 4 to 1 rule. If you ice for 5 minutes, the tissue is tight for the next 20 minutes, prone to pull if used, so be careful to go easy on it during the thawing-out phase. This treatment can be used for many months until the final healing of the plantar fasciitis.