Before moving on, let us first define what non-invasive treatment is. Non-invasive treatments are the ones that do not require a break in the skin. Examples of non-invasive treatments are immobilization (such as with a boot or a brace), physical therapy, orthotic devices, and medication. An injection or aspiration is also considered a non-invasive procedure. A procedure that breaks the skin is considered invasive. This can be confusing to some as a surgical procedure with no incision or a very small incision can still be considered a surgical or invasive procedure.
Foot and ankle pain are common complaints that can affect the quality of life for many individuals. The foot and ankle are complex structures that can be affected by a wide variety of conditions. Often, the treatment of these conditions requires a prolonged course of conservative therapy or even surgery. However, many foot and ankle conditions can be effectively treated with non-invasive measures. Non-invasive treatments are often underutilized because of a lack of understanding by both the patient and the healthcare provider. The purpose of this article is to educate the reader about the options and benefits of non-invasive care for foot and ankle pain.
Non-Invasive Treatments for Foot Pain
Benefits: Physical therapy is a great way to correct foot pain without surgery or medication. A therapist can come up with an exercise treatment plan specific to an individual’s needs. This is something that can be carried out on your own time in your own home. PT is also a proven way to avoid pain and/or dysfunction that may result in further disability later on.
Physical Therapy Physical therapy is one of the most common forms of treatment for foot pain. A physical therapist will evaluate the underlying causes of the pain and develop a treatment plan which may include various modalities such as ultrasound, whirlpool baths, paraffin wax, and the use of an electrical stimulator. Physical therapy exercises are a mainstay of the treatment plan. Often the individual will be instructed to perform a flexibility, strengthening, or a conditioning exercise for a certain amount of time. PT is a great way to correct foot pain without surgery or medication.
Physical Therapy
A second approach to physical therapy involves using a variety of modalities including ultrasound, electrical stimulation, and iontophoresis (a process involving administering anti-inflammatory medication through the skin using electrical currents). While there is evidence supporting the use of these modalities for certain foot pain conditions, the small number of high-quality studies call for cautious interpretation of results. Given the relatively low risk and cost of these treatments, they may be worth attempting if more conservative treatments have failed. A trial and error approach using these modalities under the guidance of an experienced physical therapist can help patients determine their efficacy for particular conditions.
While in some sense, physical therapy is a rather broad category of interventions for foot pain, our focus here is on a particular form of physical therapy – manual therapy. This is a relatively new approach to treating foot pain in a conservative (non-surgical) manner. A 2006 meta-analysis in the Journal of Orthopaedic and Sports Physical Therapy by Pim Fouche and his colleagues identified a number of randomized clinical trials comparing manual therapy to other forms of conservative treatment. The conditions treated in these trials varied, but several directly pertain to foot pain (plantar fasciitis, Morton’s neuroma, and hallux limitus). A review of the medical literature on these specific conditions yields a great deal of anecdotal evidence in support of manual therapy, but little substantial research. Considering the amount of success manual therapy has had in treating similar soft tissue dysfunctions, it is reasonable to think that it may well help alleviate foot pain. Further research in this area is definitely warranted.
Orthotics
A number of orthotic devices have been proven to be effective in offloading plantar foot ulcers in patients with diabetes. This can aid in reducing the risk of ulceration extending to the level of infection. It can also improve the rate of healing if the ulcer is not infected. An off-the-shelf device with custom modifications or a custom-made device can be effective. It depends on the shape and size of the ulcer and the level of force under the foot where the ulcer is located.
Functional and accommodative orthoses correct the biomechanical issue by changing the properties of the device. For example, a functional orthosis to correct pes planus in a child could consist of a device made from a rigid material with a medial heel wedge and metatarsal pad. This would hold the foot in the corrected anatomical position and prevent further deformation. A custom-made orthosis for an adult with posterior tibialis dysfunction could be made from a softer material with a molded arch to effectively support the weak and painful foot.
The mechanical devices are the most effective in achieving this aim. The simplest orthosis is a flat insole, which is particularly useful to provide cushioning and support in a patient with rheumatoid arthritis. Other simple orthoses include wedges placed into the shoe, such as a medial heel wedge to reduce load on the medial aspect of the knee and ankle. A molded insole is a step up from a flat insole and is used for a variety of pathologies. It is particularly useful for foot pain caused by abnormal foot biomechanics. The risk factors information about the patient’s foot and ankle is sent to the manufacturers, who then make an insole specific to that person.
Orthoses, or orthotics, are devices placed inside the shoe to change the mechanical function of the foot and ankle or to add cushioning and support. The purpose of these devices is to reduce pain. It is not always possible to achieve pain-free feet, but it is generally achievable to reduce pain to a manageable level.
Stretching Exercises
Stretching exercises are effective in improving flexibility, which can decrease the strain on the tissue surrounding your Achilles tendon. Only a few people are aware of the importance of calf muscle flexibility in the treatment of Achilles problems. It has been shown that increasing the flexibility of the calf muscles is very important to prevent and reduce the symptoms of Achilles tendon problems. This is because the main function of the calf muscles is to raise up onto the toes. Therefore, if the calf muscles are tight, this increases the load on the Achilles tendon, which in turn places more stress on the tendon where it attaches to the heel. This ultimately leads to a higher chance of injury and a longer rehabilitation period. Stretching both the upper and lower calf muscles has the benefit of reducing the tensile force on the tendon, so there is less relative overuse of the tendon. Retaining calf flexibility is also crucial in preventing recurrence of Achilles tendon problems.
Non-Invasive Treatments for Ankle Pain
The best way to measure the success of the RICE method is whether regular use of the injured area is possible. As pain and swelling decrease, it will be easier to put more weight on and begin to move the area. Your ability to use the area should be increasing each day until it returns to normal use. Be careful to monitor pain level with increased activity because it is possible to aggravate the injury. Inactivity will cause muscle and strength loss, so it will be necessary to find a balance between activity and continuing to heal the injury. It is important to listen to your body; it will often let you know whether you are helping or hurting the situation.
Elevation. Elevate the injured area to reduce the swelling. Ideally, the area should be elevated above the level of the heart. A pillow or something soft should be used to avoid placing direct pressure on the injured area. Body movement also may help to reduce swelling. Remember to check the area often to ensure that swelling does not return. If swelling does return, repeat the previous steps.
Compression. Compression of the injured area can help to reduce the amount of swelling. Elastic wraps or bandages can be used to wrap the injured area. Make sure not to wrap it too tight, as it can cause additional damage below the area. Loosen the wrap if the pain increases distally (farther from the center of the body).
Ice. Applying ice to the injury will help to decrease the amount of swelling and reduce the pain. Cold can slow the circulation and fluid build-up to the injured area. Apply ice as soon as possible to the injured area and continue to use it for the next 48-72 hours. Apply the ice in 10-20 minute intervals. A bag of ice, a cold pack, or a bag of frozen vegetables can be used, but avoid overcooling the area.
Rest. In order to reduce the pain, one has to take pressure off of the injured area. Using crutches, a brace, or some other form of support may be necessary. In some cases, it may be sufficient to simply stay off the area, or at least reduce activity level, for it to be considered rest. The amount of rest required will vary based on the severity of the injury.
RICE stands for Rest, Ice, Compression, and Elevation. This is a popular term among athletes. It is a simple and often effective method for treating an injury. Whether the injury is from a sprained joint or post-operative soft-tissue swelling, the R.I.C.E. treatment can speed recovery and, in some cases, reduce the amount of tissue damage. A physician should be consulted to establish the severity of the injury. The RICE method is beneficial regardless of the severity.
RICE Method
The R.I.C.E. method is said to be effective due to the minimization of edema and bleeding in the injured tissue and the chic guidance of repair during the early proliferative phase of healing.
The use of ice provides a vasoconstrictor response, which limits the amount of swelling and subsequently decreases pain. Also, ice is a localized painkiller. It decreases the conduction velocity of nerves, decreasing muscle spasm, and has a relieving effect on pain. Compression with a bandage also leads to reduced swelling, as well as giving the feeling of increased stability to the ankle. This can be psychologically beneficial to the patient, and as a result, it may reduce pain. Finally, the elevation of the ankle above the level of the heart seeks to take advantage of gravity in an effort to assist with the reduction of swelling.
Rest is an essential part of the injury recovery process. Without proper rest, continual strain is placed on the ankle, which keeps the tissues in the injured state. Resting the affected ankle permits the damaged tissues to repair themselves. Further damage is prevented through inactivity, and pain is also alleviated by not walking or standing on the injured ankle.
The ‘R.I.C.E.’ method can be an effective treatment for ankle injury and pain management. It is usually one of the first treatments used for ankle pain. R.I.C.E. stands for Rest, Ice, Compression, Elevation.
Ankle Braces
There is a wide variety of ankle braces to choose from depending on the kind of support you need. Lace-up braces are usually made of a sturdy nylon, are easy to apply, and with figure-of-eight straps are able to provide more support than a stirrup brace. Stirrup braces are lighter, less bulky, and allow for more normal activity such as walking or running. They are less supportive than lace-up braces and are often used in mild ankle sprains. A hinged rigid brace is designed to strictly control unwanted motion and is often used in post-surgical or post-injury treatment. This type of brace is not recommended for daily long-term use. A soft brace is an elastic sleeve that provides compression and support and is often used for mild ankle sprains since it is comfortable and easy to get into wide shoes. Boot casts are a brace made of hard materials and are designed to isolate the lower leg and foot in order to prevent any movement. The hard rocker bottom sole further immobilizes the ankle. This type of brace is often used for severe ankle sprains and stable fractures.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs have been proven to be successful in the treatment of ankle sprains, although a recent article published in Australia has caused controversy and debate when its authors suggested that the evidence to support the effectiveness of NSAIDs in the treatment of acute ankle sprain is weak. Their suggestion that the routine use of NSAIDs to treat ankle sprains can no longer be supported has been a statement which has met resistance from many healthcare professionals. Other studies have also highlighted negative points regarding the use of NSAIDs, regarding their side effects to be a major cause for concern and that its associated cost in treating ankle sprains is not cost-effective. Despite this, much of clinical practice remains unchanged and still advocates using NSAIDs to treat an acute sprain, especially in the first instance to control the pain and inflammation. Later use of the drug may be supplemented with other treatment techniques to aid rehabilitation.
NSAIDs are the most widely used group of drugs to relieve pain and reduce inflammation. NSAIDs work by inhibiting cyclooxygenase (COX) enzymes. There are two subtypes of COX enzymes that play a role in the inflammation process. The aptly named COX-1 is the enzyme which retains the regular maintenance of the stomach and kidney lining, while COX-2 is the culprit for causing pain and inflammation. Traditional NSAIDs tend to inhibit both subtypes resulting in an increased risk of gastric irritation and ulceration. Recently, new generation NSAIDs have been developed which primarily only inhibit COX-2. This new class of drugs called COXIBs have the same effectiveness but cause less irritation of the stomach. Unfortunately, new generation NSAIDs have also been found to be associated with an increased risk of clotting and a poor cardiovascular profile.
Benefits of Non-Invasive Treatments
Medical intervention is often aimed at symptom relief as opposed to correcting the underlying cause. Non-invasive treatments are often a better way of achieving the desired long-term goal. By avoiding symptomatic measures such as cortisone injections for conditions like plantar fasciitis and instead using orthotics and stretching exercises, we can reduce the risk of further damage to the soft tissue and prevent the condition from becoming chronic. This is critical, as chronic states can often lead to surgical intervention and can have a very negative impact on quality of life.
Non-invasive treatments offer many distinctive benefits beyond just treating foot and ankle pain. To begin with, one of the primary advantages is the potential to avoid surgery. This is often appealing to patients because surgical procedures often require a lengthy rehabilitation period before they can get back to their normal activities. For example, a patient undergoing surgery for a bunion deformity will be required to stay off their foot for at least a few weeks, a tough task for a working mother of three. On the other hand, non-invasive treatments such as orthotics, shoe modifications, and padding can allow the individual to continue with their daily routine while minimizing the symptom and the impact it has on their life. Additionally, there are no guarantees with surgery, and it’s possible that it will not fully alleviate the symptoms, making the option to avoid surgery much more appealing.
Avoiding Surgery
Non-invasive treatments are those that do not require entry into the body, usually in the form of surgery, and do not involve significant risk or harm. Avoiding surgery can be seen as a benefit in its own right and is a significant reason patients will often choose non-invasive, conservative methods over more invasive treatments. Surgery often requires a difficult recovery process and involves time away from work and family. It can also carry the risk of certain complications that are inherent to entering the body and using anesthetics. Such risks may be unacceptable to certain patients, relative to the potential benefits from surgery. A further reason many patients are reluctant to undergo surgery is the fear of what the surgeon may find when they begin the procedure. This can weigh heavily on a person’s mind and cause them to imagine the worst-case scenario, regardless of the probability of such an event occurring. If a proper diagnosis has been obtained and surgery really is the best option, there is always the possibility of surgery at a later date, making a trial of non-invasive methods an acceptable risk. By avoiding surgery and trialing non-invasive treatments, the patient is not losing anything in terms of potential pain relief and increased function. This can often lead to a greater improvement in the patient’s mental state and reduced stress regarding their condition, which can have an effect on their general health and well-being.
Minimizing Risks and Side Effects
Massage therapy: Is considered relatively safe, although use of some techniques may need to be modified or avoided in certain patient groups. Deep tissue massage, for example, may not be suitable for patients with bleeding disorders or those taking anticoagulant medication. Friction massage has been reported to cause mild, transient discomfort in some patients, with skin flushing in 23-50% of cases. If massage is painful or uncomfortable during treatment, there may be a tendency to use less pressure, potentially compromising the treatment effect. Using precise and efficacious techniques at a comfortable level for the patient is an important aspect of treatment prescription and delivery. In general, massage therapists should be educated to degree level, and may need to work closely with other healthcare providers to ensure patients are receiving the most appropriate care.
Background: Non-invasive treatment of musculoskeletal conditions is intended to minimize risks and side effects, enhance the safety and tolerability of treatments, and increase the likelihood of favorable outcomes. Regardless of technique, these methods share the common advantages of being less risky and often less costly than invasive procedures, such as surgery or steroid injections. Non-invasive treatments generally have a low incidence of adverse effects, making them a reasonable first-line treatment for many patients. If they are not effective, more invasive measures can then be considered. Patient safety concerns have become a driving force for the development of new non-invasive treatment techniques and technologies. Although all treatments and healthcare interventions have an element of risk, minimizing that risk is a priority for patients, clinicians, and healthcare organizations.
Promoting Natural Healing
Pain is the body’s signal that something is wrong. It is unpleasant but serves the purpose of telling the brain where to direct its attention. Pain after a foot or ankle injury is usually due to inflammation in the soft tissue and damaged cells or nerve endings in the joint. Invasive methods of therapy can sometimes produce a greater inflammation response from the body as it tries to heal the trauma caused by the surgery. Additionally, due to the invasive methods reaching the damage in the joint, pain can sometimes persist or become arthritic due to further damage of the joint surface. By contrast, non-invasive therapy aims to reduce pain at the site and can often reduce or eliminate pain faster than would occur post-surgically. This is often a very important factor for patients.
The most important benefit of non-invasive therapy is the promotion of natural healing. In any injury, the body’s natural healing process relies on an adequate supply of blood and nutrients to the damaged site. It is a well-known fact that the use of surgical methods in invasive therapy can damage tissue, and in the case of foot and ankle surgery, this can involve long periods of immobilization and extended recovery times. With an extended period of immobilization, muscles can waste away, and if there is extensive damage to the muscle, ligaments, and tendons surrounding the joint, mobility and stability of the joint will be severely reduced. Clearly, these are to be avoided if possible, and non-invasive therapy aims to maintain the body’s normal healing processes.
