Chapter 35: Physical Medicine

and Rehabilitation for the

Management of Foot
Conditions
Physical Modalities and Diseases
Diseases
 PHYSICAL MEDICINE AND
REHABILITATION FOR THE
MANAGEMENT OF FOOT
CONDITIONS
Physical medicine can broadly be defined as that element of health care that
utilizes physical agents such as light, heat, cold, water, electricity, mechanical
agents such as excercises, aids to ambulation, gait training, tests and
measurements in the diagnosis and treatment of disease.
Physical Modalities and Diseases
1. Physical modalities (used for foot conditions)
a. Ultrasound
b. Short wave diathermy
c. Infrared lamps
d. Radiant light bakers
e. Whirlpool
f. Contrast baths
g. Paraffin baths
h. Massage
i. Ultraviolet radiation
j. Electrical stimulation
k. Hi-lo galvanic current
l. Faradic current
m. Sinusoidal current
n. Transcutaneous electrical nerve stimulation (TENS)
o. Cold packs
p. Lasers
q. Traction
r. Intermittent compression
s. Exercise
i. Passive
ii. Active assistive
iii. Voluntary active
iv. Active resistive
v. Coordinative
t. Gait training
u. Crutches/walkers/canes/braces/parallel bars
v. Prosthetics/orthotics
w. Activities of daily living
x. Diagnostic procedures and tests

2. Chronically disabling conditions which usually present with pedal

manifestations:
a. Arthritis
b. Burns
c. Cerebral palsy
d. Cerebral vascular accidents
e. Congenital deformities
f. Dermatomyositis
g. Degenerative spinal cord disease
h. Joint deformities
i. Muscular contractures
j. Muscular atrophy
k. Paraplegia
l. Quadraplegia
m. Peripheral nerve injuries
n. Peripheral vascular disease
o. Anterior poliomyositis
p. Polymyositis
q. Polyneuritis
r. Residuals of severe trauma
s. Scleroderma
t. Spina bifida
u. Spinal cord injuries
v. Stasis dermatitis
w. Ulcerations
x. Chronic renal failure
y. Alcohol/drug abuse
z. Chemical dependency

3. Treatment considerations: Examples of conditions which involve the

foot that benefit from the use of physical medicine and rehabilitation
a. Adhesive capsulitis
b. Antalgic gait
c. Arthritis (acute or chronic)
d. Arthritis with nerve root pressure
e. Ataxic gait
f. Atrophy
g. Burns
h. Bursitis
i. Causalgia
j. Capsulitis
k. CVA's
l. Compression syndromes (entrapments)
m. Contractures
n. Contusions
o. Degenerative joint disease
p. Dislocations
q. Fasciitis
r. Fibrosis
s. Foot drop (peroneal palsy)
t. Fractures
u. Hemiplegia
v. Inflammation (acute or subacute)
w. Multiple sclerosis
x. Muscle spasm (acute. or severe)
y. Muscular dysfunction
z. Myositis
A. Nerve palsy
B. Neuralgia
C. Neuritis
D. Osteoarthritis (acute or severe)
E. Osteomyelitis
F. Osteoporosis
G. Pain
H. Paralysis from nerve disease or injury
I. Paraplegia
J. Parkinson's disease
K. Periostitis
L. Peripheral neuritis
M. Peripheral neuropathy
N. Post joint surgery
O. Quadriplegia
P. Radiculitis
Q. Scleroderma
R. Sesamoiditis
S. Severe or generalized weakness
T. Severe osteochondritis dissecans
U. Sprains/strains
V. Sudeck's atrophy
W. Synovitis
X. Tendonitis/tenosynovitis
Y. Trauma/post-trauma
Z. Ulcerations

Therapeutic Modalities and Procedures

1. Therapeutic cold:
a. Indications:
i. To reduce pain and edema following trauma
ii. To reduce pain
iii. To create a reactive hyperemia
iv. To help reduce inflammatory reactions
v. To provide for local tissue destruction
vi. To decrease local tissue metabolism
vii. To help facilitate muscle contraction in some forms of neurogenic weakness
b. Basic contraindications and precautions:
i. Hypertension
ii. Raynaud's disease or phenomenon
iii. Vascular disease
iv. History of frostbite or pernio
v. Rheumatoid arthritis
vi. Cold hypersensitivity
vii. Any condition that produces a cold pressor response
c. Methods of application:
i. Immersion
ii. Cold packs
iii. Ice Massage
iv. Cryokinetics
v. Contrast applications with heat

2. Therapeutic Heat:
a. Physical agents (superficial heat): These modalities cause a rise in tissue
temperature generally limited to the skin and subcutaneous tissue. The effect is
increased circulation, with histamine release and enhanced phagocytosis and
lymph flow. Also there is a sedative type effect and increased connective tissue
extensibility
i. Hot water
ii. Hot air
iii. Infrared
iv. Radiant light
v. Whirlpool
vi. Paraffin
vii. Hot packs
b. Physical agents (deep heat): These modalities cause the same physiological
effects as with superficial heat agents, but they also have the ability to heep
deep structures such as muscle and joint capsule. These modalities are
extremely useful for helping regain lost motion in contracted joints or shortened
muscles
i. Short wave diathermy:

NOTE* High frequency electrical energy extends from electrode to electrode

through human tissue causing a heating effect. The diathermy may be ii.
either short wave (heating within a magnetic field) or microwave energy
beamed from an "antenna" to, an area of the body
Microwave diathermy: not to be used if a patient has a pacemaker
iii. Ultrasound:

NOTE* High frequency sound produced from the vibration of a piezoelectric

crystal. Sound energy is passed directly through the skin and causes c.
heating at interfaces such as junctions between different tissues. An
example of this is the junction between bone and muscle.
Primary physiologic effects:
i. Hyperemia
ii. Sedation
iii. Analgesia
iv. Increased regional vascularity
v. Increased tissue temperature
vi. Increased metabolic rate
vii. Arterial dilatation
viii. Increased capillary flow and hydrostatic pressure
ix. Increased collagen extensibility
x. Increased tissue inflammatory response
xi. Increased edema
d. Indications:
i. Analgesia
ii. Increased local vascular cutaneous flow
iii. Sedation
iv. Hyperemia
v. Accelerate the suppurative process
vi. Muscle spasticity
vii. Joint stiffness
vii. Contractures
e. Contraindications and precautions:
i. Tendency to hemorrhage
ii. Active hemorrhage
iii. Impaired sensation to pain and temperature
iv. Ischemia and vascular impairment
v. Non-inflammatory edema
vi. During the immediate (24-48 hour) post trauma period
vii. Known malignancies
viii. Patients with coma or paralysis
ix. Use with extreme caution if there is a threat of hemorrhage, in the
very old or the very young, and in those patients who have debilitated or
insensitive conditions
f. Modalities for superficial therapeutic heat:
i. Baths
ii. Electric heating pads
iii. Hot packs
iv. Hot water bottles
v. Compresses
vi. Paraffin
vii. Radiant heat
viii. Lamps
ix. Bakers
g. Modalities for superficial heat by convection:
i. Hot air baths
ii. Moist air baths
iii. Agitated water baths or whirlpool
h. Modalities for deep heat:
i. Short wave diathermy
ii. Microwave diathermy (caution in patients with pacemakers)
iii. Ultrasound
i. Infrared radiation:
i. Superficial heat source
ii. Bulbs
iii. Bakers
iv. Heat lamps
v. Heated carborundum rods
vi. Glowing wire coils with proper reflectors
j. Infrared radiation indications:
i. Subacute and chronic inflammation
ii. Contusions (if no threat of hemorrhage)
iii. RA
iv. Early joint stiffness
v. Degenerative or osteoarthritis
vi. Sprains/strains
vii. Neuritis
viii. Myositis
k. Infrared contraindications and precautions:
i. Acute inflammation
ii. Malignancy
iii. Ischemia
iv. Impaired sensation (pain and temperature)
v. The very young/elderly who are unable to respond to the effects of heat
l. Deep heat (short-wave diathermy) contraindications and precautions:
i. Hemorrhage or suggestion of hemorrhage
ii. Sensory loss
iii. Application over moist dressings
iv. Malignancy
v. TB
vi. Areas of ischemia
vii. Arteriosclerosis
viii. Thromboangiitis obliterans
ix. Metal implants
x. Foreign bodies
xi. Pregnancy/menstruation
xii. Suppuration
xiii. Special care in patient with pacemakers
xiv. Special care in the geriatric and pediatric patient
xv. Metal contact with skin or other tissues
xvi. Epiphyseal and developing bone
m. Deep heat indications:
i. Post trauma (after the threat of hemorrhage)
ii. Analgesia
iii. Pain and spasm
iv. Inflammation (subacute or chronic) associated with: bursitis, periostitis,
arthritis, neuritis, neuralgia, myositis, capsulitis, postfracture care, fibrositis,
tenosyovitis, tendonitis, sprains, strains
v. Rheumatoid arthritis
vi. Postdislocation
vii. Reflex vasodilation
n. Microwave diathermy contraindications and precautions:
i. Ischemia
ii. Hemorrhagic areas
iii. Tumors
iv. Impaired sensation
v. Debilitation
vi. Edema
vii. Use over wet dressings
viii. Metallic implants
ix. Pregnancy
x. Use over adhesive dressings
xi. Special care over bony prominences
xii. P.V.D.
xiii. Synovitis with excessive areas of synovial fluid
xiv. Systemic and local infections
xv. Patients with pacemakers
xvi. Care in the pediatric/geriatric patient
o. Microwave diathermy indications:
i. Deep heating of subcutaneous tissue and superficial musculature
ii. Musculoskeletal system for joint diseases (DJD, RA, bursitis and
tendonitis)
iii. Post trauma if no threat of hemorrhage
iv. Strains/sprains
v. Neuritis
p. Ultrasound indications:
i. Joint contractures associated with immobilization, trauma, scarring, RA
and DJD
ii. Pain
iii. Muscle spasm
iv. Tendonitis
v. Acute inflammation due to trauma
vi. Adjunct to exercise therapy
vii. Phonophoresis with indicated drugs
viii. Subacute sprains/strains ix. Calcific bursitis
x. Resolution of hematomas xi. Neuroma/neuritis
q. Ultrasound contraindications and precautions:
i. Basic contraindications for all forms of deep heat
ii. Avoid large fluid areas
iii. Hemorrhagic diseases
iv. Decreased sensation and insensitivity
v. Vascular insufficiency
vi. Tumors
v. Malignancies
vi. Over epiphyses
vii. Pacemakers
viii. With caution over implants both from a thermal and mechanical
concern
r. Hydrotherapy indications:
i. Muscle weakness
ii. Following amputation
iii. Following joint injury
iv. Paraplegia
v. Burns
vi. Selected post-surgical debridement
vii. Selected spastic palsy
viii. Selected flaccid paralysis
s. Whirlpool bath indications:
i. Chronic post-traumatic conditions
ii. Early joint stiffness
iii. Pain
iv. Painful scars
v. Adhesions
vi. Neuritis
vii. Arthritis
viii. Tenosynovitis
ix. Strains/sprains
x. Painful stumps
xi. Preliminary to massage, exercise and electrical stimulation
x. Burns
xi. Post CVA
xii. After fracture care
xiii. Vascular insufficiency
xiv. Decubitus ulcers
xv. Industrial medicine
xvi. After peripheral nerve injuries
xvii. Dermatologic debridement
xviii. Sports and dance medicine
xix. Post surgical rehabilitation
t. Whirlpool bath contraindications/precautions:
i. Acute phlebitis
ii. Osteoporosis (caution)
iii. Cardiac (caution)
iv. Immediate trauma
v. Excessive edema
vi. Vascular or neurologic impairment
vii. Non-inflammatory edema
viii. Caution in the geriatric/pediatric patient
u. UV radiation precautions:
i. Photo-ophthalmia of patient and operator
ii. Hypersensitive areas (skin folds)
iii. Unusual skin sensitivities
iv. Photosensitive drugs (sulfonamides, tetracyclines, green soap, dyes,
coal tar preparations, oral hypoglycemics, chlorthiazide diuretics,
phenothiazines)
v. UV radiation indications:
i. Local UV radiation for its anti bacterial /fungicidaI effects for superficial
ulcers, infections, dermatophytosis, and sterilization of fresh wounds
ii. Decubitus ulcers
iii. Boils/carbuncles/furunculosis
iv. Burns
v. Eczema
vi. Contact dermatitis
v. Erysipelas
vi. Felon
vii. Granulating tissue
viii. Infectious eczemoid dermatitis
ix Intertrigo
x. Psoriasis
xi. Leukoderma and vitiligo
xii. Urticaria
ix. Diabetic ulcerations (caution)
w. UV radiations contraindications/precautions:
i. Excessive exposure
ii. Photosensitivity
iii. Encapsulated pus without drainage
iv. Acute generalized dermatitis
v. Drug photosensitivity
vi. Malignancies
vii. Sarcoidosis
viii. Lupus erythematosus
ix. Herpes simplex
x. Caution with the cardiac, renal or with hepatic insufficiency

3. Manual modalities:
a. Massage indications: Classical massage, transverse friction massage
i. Relief of pain
ii. Arthritis
iii. Periarthritis
iv. Bursitis
v. Neuritis
vi. Fibrositis
vii. Mobilization of contracted tissue
viii. Reduction of swelling and induration
b. Massage contraindications:
i. Infection
ii. Cutaneous inflammation
iii. Tumors
iv. Burns
v. Skin diseases in relation to contamination and irritation
vi. Clotting disorders
vii. Fractures
viii. Thrombophlebitis
ix. Aneurysms
x. Thrombosis
xi. Fever
xii. Acute systemic disease
c. Manipulation indications:
i. Loss of range of motion
ii. The residuals of long periods of immobilization
iii. The residuals of trauma and/or capsular inflammation
d. Manipulation contraindications:
i. Immediate post trauma
ii. Joint effusion
iii. Acute inflammation
iv. Ligamentous rupture
v. Dislocation (unless used for repositioning)
vi. Fracture (unless used for repositioning)

4. Kinetic Procedures
a. Therapeutic excercise: Prescribed to increase and maintain joint and soft
tissue mobility, prevent adhesions and fibrosis, and to aid in soft tissue healing
i. Techniques:
 Resistive: Isotonic, isometric, and isokinetic (Kin-Com, Cybex, and
Biodex)
 P.N.F.: Proprioceptive neuromuscular facilitation (exercise which employs
combined neuromuscular training techniques
 Neuromuscular re-education (secondary to nerve injury)
ii. Indications:
 Preventing joint contractures
 Preventing joint adhesions
 Increasing joint range of motion due to trauma, muscle spasm, disease,
or states that limit function and mobility and prevent activity
 Arthritis and related conditions
 Post-amputation
 Neuromuscular and collagen diseases that produce contractures and
limited ranges of motion
 Paresis due to multiple conditions, such as CVA,
 Weakness and atrophy due to disuse and/or after immobilization
 Muscular weakness
 To strengthen muscles
iii. Contraindications/precautions/limitations:
 Acute active inflammation
 Active post-trauma
 Severe cardiovascular disease
 Severe pulmonary disease
 Metastatic malignancies
 Nonunion fracture sites (caution)
 Pain in the arthritides (caution)
 Severe joint and/or muscle pain (caution)
 Infection
b. Range of motion exercise:
i. Active: patient exercises on their own
ii. Passive: Joint mobilization or manipulation
iii. Active assist

5. Electrical modalities: This group of modalities delivers an electrical current

to the patient with various physiological effects. Among these effects are pain
relief, reduction of swelling, and muscle stimulation for enhancement of
strengthening or retardation of atrophy.
a. TENS: Used for reduction of pain. The Gate Control theory of pain states that
stimulation of large diameter nerve fibers may effect transmission of a noxious
stimuli before it reaches the cortex. This theory was used to explain TENS for
many years. More recently, other theories of central modulation have been used
to explain why TENS causes a reduction of pain
i. Indications:
 Chronic pain
 Acute pain associated with postoperative control
 Arthritis
 Bursitis
 Sprains/strains
 Tenosynovitis
 Metatarsalgia and related foot pain
 Painful motor and sensory nerve lesions
 Post amputation pain including phantom pain
 Peripheral neuritis
ii. Contraindications:
 Cardiac pacemakers
 Carotid sinus
 Insulin pump
 In the presence of electronic life support systems
 Over denuded skin
b. Iontophoresis: An electrical generator with DC current used for ion transfer
of medication into areas beneath the skin. This is often used for the purpose of
infliltrating a tendon, ligament or joint capsule with an anti-inflammatory or
anesthetic
c. Electrical stimulation: Is a high frequency current used primarily for
enhancement of shortening exercised
i. Indications:
 Injury to the muscles/tendons/joints
 Paralysis
 Sprains/strains
 Postfracture and after dislocation to help retard atrophy and restore
muscle function
 To help restore muscle tone and strength
 To help provide tissue contraction to milk tissues of excess fluids
 To relieve muscle spasm from trauma and associated muscle conditions
 Muscle pain and spasm
 Myositis
 Metatarsalgia
 Post polio
 Muscle re-education
 Following surgery to help prevent clots and embolism
 With ultrasound for trigger points and pain
 Denervated muscles
 To help retard muscle atrophy
 Synovitis
 Disuse
 Fibrositis
 Contractures
 Pain with ankylosis
 Stress and anxiety
ii. Contraindications/precautions:
 Individual patient reactions
 Allergy
 Placement of electrodes over malignancies
 Severe inflammation
 The head area
 Cardiac area
 Pacemakers
 Pregnancy
 Special concerns in the presence of vascular and/or neurologic
deficiencies
d. Galvanic currents:
i. Indications:
 Reduce pain
 Reduce swelling
 Increase local circulation
 Aid in nerve regeneration
 Soften scar tissue
e. Hi-volt: This high voltage, low amperage modality is used for pain reduction,
swelling reduction and muscle stimulation. Tissue impedance is overcome more
easily due to the high voltage, allowing deeper penetration of current. Some
theories state that inflammation may also be reduced by using this modality
f. Interferential: This modality relies on an extremely high frequency (2500-
4000Hz) to allow deeper penetration for the purpose of stimulation of nerves for
pain relief.

MODALITY INDICATIONS PRECAUTIONS

Electrical Stimulation Pain reduction Pacemakers
Monophasic D/C Muscle reeducation and Thrombophlebitis
High volt or interferential strengthening Malignancy
Muscle pump for edema Skin sensitivity
reduction Pregnancy
Increase ROM
Acute inflammation
Fracture healing
Electrical Stimulation Wound healing As above
Low voltage Fracture healing
Monophasic lontophoresis
Electrical Stimulation Pain reduction Pacemakers
Pulsed Muscle spasm Skin sensitivity
Biphasic A/C Increase ROM
TENS
TEAM
Diathermy Improve circulation Metal implants
Short wave Increase local metabolic Pacemakers
Micro Wave activity Malignancy
Increase tissue temperature Wet dressings
Reduce muscle guarding or Decreased sensation
spasm Acute inflammation
Reduce chronic Poor circulation
inflammation Pregnancy
Facilitate wound healing Over the eyes
Analgesia/sedation
Increase connective tissue
stentibility
Cryotherapy Acute inflammation Cold hypersensitivity
Ice Chronic inflammation Cold urticaria
CO2 Vasoconstriction Poor circulation
Cold Compression Control edema Healing wounds
Analgesia Hypertension
Reduce muscle guarding or
spasm
Improve ROM
Reflex vasodilation
Decrease local metabolic
activity
Superficial Heat Vasodilation Acute inflammation
Whirlpool Analgesia/Sedation Poor circulation
Paraffin Reduce muscle guarding or Malignancy
Hot Packs spasm
Infrared Increase metabolic activity
Facilitate tissue healing
Chronic inflammation
Ultrasound Increase connective tissue Infection
distensibility Malignancy
Deep tissue involvement Acute inflammation
Increase circulation Epiphyseal areas
Increase metabolic activity Early fractures
Reduce chronic Thrombophlebitis
inflammation Poor circulation
Reduce muscle guarding or Poor sensation
spasm Over the eyes
Improve healing Over the pregnant uterus
Phonophoresis Medication allergies
Intermittent Decrease edema Pain
Compression Reduce acute bleeding Circulatory impairment
Ultra Violet Acne Poor circulation
Wounds (septic or aseptic) Generalized dermatitis
Folliculitis Renal or hepatic
Tinea Pedis insufficiency
Pityriasis rosea Hyperthyroidism
Psoriasis Lupus
Pellagra
Herpes
Eczema
Diabetes
Psoriasis
Sensitizing medications