Pokin and proddin at the PT
Dear me…
In the doldrums of my current chronic injury I have acquiesced to a round of PT. That’s how insanely sick of this injury I am. I’m willing to put myself through something, and pay for something that I really don’t put much stock in.
There are elements of PT that I like. I love massage and the manual manipulation of creaky bits by some stranger with warm, strong hands. That has some wonderful healing power in it. I do like the careful physical examination of how all the muscles and tendons and joints work together.
I’m suspect of all the rest.
There seems to be a great variability in skills, knowledge and engagement for practitioners of this therapy. Some of the folks I get are quite knowledgeable and engaged. Others have no idea why they are doing what they do and seem to have fallen into the job as the only thing they could find after school. They seem to be putting up with me as much as I’m putting up with them.
I’ll be the first to admit that I’m a bad patient. I want to know why. I feel free to disagree. I’m probably different from the stream of bent and broken normal people who come through the door each day.
How does the PT appointment go for me?
First they have me warm up for a few minutes on the bike or elliptical. This is good. You want to be warm when someone is tugging and poking at your old muscles.
Next I get on the table and the practitioner manually manipulates the Plantar Fascia. I’ve had 3 different practitioners for this and each did it differently. Two of them used the Graston tool to dig into the fascia. This tool is nothing special. It’s just a 8-inch, sturdy bit of metal that allows them mechanical advantage over the plantar. This makes sense to me knowing what I do about that stubborn piece of gristle.
Of the two there was a guy and a girl. I liked the guy better because he seemed to have the hand-strength to make a dent, whereas the young lady didn’t seem to be making much impact. Then again, I’m a misogynous old fart. (Insert ironic self-deprecating smiley here.)
The third guy uses his thumbs to get in there. I had my doubts but he’s pretty good.
When they first see you they put you through an evaluation. This includes flexibility and strength. I got some benefit from the flexibility tests. I realized I really haven’t been stretching as much as I think. This flexibility is important in recovery and injury prevention. This was a good reminder.
The strength evaluation pointed out some weakness in my inductors and abductors and hips – but these are relative weaknesses, not clinical weaknesses. I’m not about to fall over sideways from abductor weakness.
Once they identify your perceived relative weaknesses they recommend exercises to strengthen and balance. This is the first place they lose credibility with me. I work out 6-7 days a week. Some of that is core work. It is a total waste of my time to be doing some sort of wiggly rubber-band exercise meant for octogenarians and house-fraus. I’m not looking for nice-to-haves in my life. I don’t have time for it.
Then I go through my stretching routine with a few targeted at the plantar. Deep stretches of the whole chain with use of the incline stretching board. I think this is probably the most valuable part of the whole hour. The rest is basically PT smoke screen.
Next we go to the laser treatment. In this treatment they give you protective glasses and shoot a laser at the heel. I asked what this was supposed to accomplish. They said, and I’m not making this up, it “activates the healing mechanisms in the cells”. Oh really? So some magic little helper-elves in my plantar cells get all excited and start healing away? When pressed for more detail he told me that the laser energy adds energy to the cells allowing them to activate.
As far as I can tell it is an infrared laser and what it is doing is adding local heat to the injured tissue. This, I suppose is technically ‘adding energy’ but really what it is probably doing is causing better blood flow to where he just dug around. This would conceivably help the healing process by bringing in a fresh blood supply to the area post-manipulation.
Then we hook up to the electric stimulation machine. This device drives electrical current through the injured area. Why this helps, no one knows. The way it works is very simple. An electrode patch is placed on one side of the injury and another, the anode I suppose, is placed somewhere nearby. An electric current is induced to flow between them and we hope it goes through the injury.
I did not ask but I’m sure that this treatment also activates the healing process in the cells of the injury. At this point I’m far enough into the injury cycle that they could sacrifice a chicken to my foot and I’d be on board.
Looking around I see the clientele is not endurance athletes. It’s high school athletes and middle-aged people who have torn something playing golf or lifting groceries. I think much of what they do is to fill the available hour. It’s almost like they need something else, some sex-and-sizzle to keep people engaged and feeling like they have gotten value from the process. It’s sexier to strap you to some machine with electrodes than to stretch and massage.
The value I get is from the stretching and the manipulation. The rest has a questionable value add to me.
I’ll go to my last session tomorrow.
The heel is feeling better but one has to wonder whether it is just heeling itself with time.
I don’t doubt that there are individual physical therapists that work miracles and are caring, curative influences in the lives of their clients. I don’t doubt that there are people who have their broken bodies healed by these practitioners.
It does very little for me. I’m probably unique in a couple ways. First is that I am unwilling to abdicate the responsibility for my own body and it’s healing to someone else. I probably know more about my body than most people who walk through their doors. I already know how to stretch and how to heal. In a sense I’m over-qualified for PT. I’m an outlier in their world.
But, then again, with all my smug, self-satisfied knowledge I’m the one who’s injured and coming to them, aren’t I?
I also need to turn off the grumpy old man and approach these things with an open mind. I need to look at each new practitioner as an opportunity to learn something.
Maybe they could set up a separate ‘advanced’ practice for people like us?
After having my pelvis fractured by a Buick, I started over a year of work with a physical therapist. I return to her every so often for tune-ups.
Finding the right person is key. My PT is a runner who does ultra events. She understands me and isn’t going to tell me nonsense like, “You should give up running.” She also understands that I am not her average patient. She not only knows this but loves this. she understands that often I don’t need to be pushed – I need to be reined in a bit.
Sounds like you need to find the right person.
It manifested in June.
I agree PT for PF tends to be a lot of fluff. I think stretching on the incline board and massage are the best parts as well. How long has your heel been bothering you? I haven’t walked w/o pain since beginning of OCT and i”m wondering if there is an end in sight. I’m trying a calf/foot massage later today and a cortisone shot next week. Not looking forward to the latter.
Oh, this post made me sad. I’m a PT, and I wish the PTs and PTAs you’ve seen had done a better job explaining some things to you. PTs have a lot of education, either a Master’s degree or Doctorate coming out of school. Manual therapy skills, exercise prescription, gait analysis, and extensive anatomy and physiology are included. PTAs are educated at a 2year associate degree level. The first person you see (PT) does your eval and establishes the plan of care, which is carried out often by a PTA. If the PTA can’t explain why you’re doing something, you should ask the PT.
I think most people are much more likely to be on board with a plan if I understand why it’s being done. A good example of this is hip abductor/adductor strength. If there is a relative weakness there, it can have a big impact on the angle the foot hits the ground. This may or may not have to do with your particular plantar fasciitis, but those strengthening exercises can be key in keeping an injury at bay once the inflammation has settled down. Those exercises are not just fluff.
The laser and e-stim might be, though. Most of the appointments I have during the day are 30 minutes. We do manual treatments, exercises, and patient education. Very little of what are termed modalities, those machines you get hooked up to while the PTA starts his or her next person. Ice, of course, which is not charged for (“of course not”, you say, but this is modern medicine, and the payment system is insane). I bet the productivity of the PTs you work with is better than mine.
We do use electrical stim for muscle spasm or neurogenic pain, to allow someone to complete ROM or stretching with less pain. Very little infrared laser treatments. IMHO, the research supporting laser is just not there. It may help through heat, as you mentioned, and light’s effects on the tissues… but I want more research before I go using it on my patients. Especially because most insurance companies won’t pay for it (experimental), and the patient ends up paying for it fully (in our clinic $30 a pop).
So, I guess like any profession there are good and not-so-good PTs. But I find the great majority are smart and excellent at what they do. The ones you’re seeing might not be so great at taking the time to explain, though. Maybe you could talk through the big picture, what will prevent this problem recurring long-term. Maybe you could ask to spend time doing that instead of the laser or e-stim. Maybe you could find out if you are working with a PT or PTA, and if your insurance covers that laser. Maybe do that before mentioning the chicken. Good luck.