There does not have to be a particular injury per se, but if there is pain that brings a patient to your office, you must understand the Phases of Rehabilitation well to do a good job getting them better. What are these Phases? They are:
- Immobilization/Anti-Inflammatory Phase
- Re-Strengthening Phase
- Return To Activity Phase
What are the Goals of each Phase?
- Immobilization---rest the injured tissue and get the pain level to 0-2 VAS
- Re-Strengthening---continue some protection as the injured tissue is re-strengthened
- Return to Activity---gradually introduce stress to the injured tissue until full activity resumes
What are some of the components of rehabilitation using these phases? The general rules I use:
- Cross Training extends across all 3 Phases
- Strengthening extends across all 3 Phases
- Immobilization Phase when you need to Rest the Injured Tissue
- Immobilization Phase is when the pain is consistently over the 0-2 VAS and you must bring it down
- Immobilization Phase can have strength gains with Active Range of Motion and Isometrics
- Re-Strengthening is when the Injured Tissue needs to be strengthened to accept greater loads with upcoming activities (you are starting to regain function)
- Re-Strengthening is where most of the patient's strengthening work occurs
- Re-Strengthening is when the Pain is consistently 0-2, but the patient is not ready for their activity yet (basketball, dance, running, ice skating, etc.)
- Re-Strengthening consists of progressive resistance exercises, isotonic, isokinetic, and other functional exercises
- Return to Activity means that the pain levels are kept at 0-2 and the patient is introduced to a gradual loading or stress to the Injured Tissue
- Return to Activity now starts a runner running, a dancer dancing, a golfer golfing.
- Return to Activity programs all have a gradual increase in sport specific activities (like the famous walk run programs for a runner, or dancers leaving the barre and beginning center work with small jumps, and the golfer can leave the punting greens and go to the driving range)
When I treat patients, I want steady progress. With each passing month, the tissue should be less and less sore, the strength of the injured area improved, and the function should be improved. The gains can be small in complex problems, but still gains! If there is a plateau of symptoms, or a worsening of symptoms, changes to my treatment plan must be made. Changes in mechanical support for more or less immobilization, changes in anti-inflammatory treatment, changes in neuropathic treatment, all to bring down pain and increase function. Sometimes you have to work on the pain first, before you venture into increasing function. Most of the time you can work on pain and function at the same time.
So, a patient presents with heel pain. They limp, relate 6-8 pain levels with walking, and have negative x-rays from their primary care physician. What is the phase we need to put them into? What are 3 common treatments? Is there other imaging you will want? And, what do we expect in our one month followup (there may be one visit in between for image review)?
Answers to Above Questions:
- What Phase? Immobilization
- 3 Common Treatments now? Permanent or removable cast (CAM walker), Crutches, Icing above the posterior knee TID if in permanent cast or just on the heel, Evenup for the other side
- MRI to rule out calcaneal stress fracture or Stage 2 or 3 Plantar Fascial Tearing
- 1 month Followup Expectations: Less Swelling, Pain Level 0-2 consistently, No Need for crutches
Too often these problems are just given plantar fascial protocols and then made worse. One of the main reasons is a plantar fascial tear should not be stretched, where plantar fasci(itis) is an inflammatory program and can be stretched with some success.
