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Exploring Cryotherapy and Cold Therapy for Foot and Ankle Pain Management

by Dhriti

Considering the discrepancy in knowledge, lack of clear concise applications, and potential benefits from cryotherapy, it would be suitable to examine its use. The study will look at various indications for cryotherapy in the management of common foot and ankle pathologies and whether it is effective. This information would be especially useful to general practitioners who manage a wide variety of musculoskeletal problems. From this, a translation could be made to patient education so that patients can apply these methods at home in attempts to self-manage problems and reduce further medical consultation.

Foot and ankle pain is a common problem among Americans, and individuals seeking medical advice for this problem can possibly consume a substantial amount of a practitioner’s time. Cryotherapy, specifically the use of ice, is seldom viewed as an important modality in the management of foot and ankle pain. This may be due to the lack of consensus among health professionals and the public regarding its benefits or lack of knowledge in applying cold treatments. Concerns about the disadvantages of using ice may include that it is a relatively cheap treatment compared to ultrasound therapy, which would garner lesser fees, and there could possibly be less recouping of costs by the practitioner. A review found that only 50% of athletic trainers gave instruction in the proper use of cryotherapy to patients, and details for applications were inconsistent. The use of ice would be easily translated to patients for home use, and if proper methods and indications were taught, it may lessen the time-consuming aspect of it. An example would be teaching a patient to apply ice to decrease inflammation of the synovium due to an acute gout attack.

Understanding Foot and Ankle Pain

Impact of foot and ankle pain on daily life Foot and ankle pain can have a great effect on daily life. Pain while walking and with weight-bearing activities can be very limiting. As the foot is the foundation of the body, pains in this area may affect the way you walk and lead to compensatory pain in other areas of the body. This, in turn, may affect participation in various types of exercises and sports, which can have long-term effects on general health. Often, people with foot and ankle pain will become less active, which can lead to other health problems. Employment can also be affected if your job requires long periods of standing and walking. An example of this is a study on nurses with chronic foot and back pain, having it affect job-related quality of life.

Common foot and ankle conditions There are many different conditions that affect the foot and ankle. Some more common ones include: plantar fasciitis, being an inflammation in the plantar fascia of the foot; an ankle sprain which affects the ligaments of the ankle; Achilles tendinitis, being an overuse injury of the Achilles tendon; and osteoarthritis, a degenerative condition of the joint.

Causes of foot and ankle pain Acute injury, overuse injury, infection, or an underlying disease may be the cause of your foot and ankle pain. Acute injuries are sudden traumas, like a sprained ankle caused by a fall. Overuse injuries are a result of repetitive movements and added stress on the joints, tendons, and muscles. An example of an overuse injury is Achilles tendinitis. Infection in the skin and subcutaneous tissues can cause pain and swelling and be difficult to differentiate from an acute inflammatory arthritis. Systemic conditions such as diabetes often affect the feet before other parts of the body and present with multiple symptoms. Arthritic conditions are often a cause of joint pain. The pain may be from inflammation of the joint lining or from damage to the joint surface. Whenever the cause of pain is, it is important to get an accurate diagnosis so that the most effective treatment can be determined.

Causes of Foot and Ankle Pain

Causes are due to sudden injury to the foot or ankle, or due to overuse through long periods of time. It is seldom due to a single event and is more likely attributed to the accumulation of weight bearing forces over time. A good example of this is seen in several study groups of running athletes. The cause of their pain is often a result of constant stress to the soft tissue and bones which exceed their bodies’ restorative ability. Causes of foot and ankle pain can be systemic diseases, such as arthritis or gout, which can cause more pain if left untreated. High-heeled footwear can also cause pain due to the shift of the body’s weight forward, which in turn causes the body to compensate by altering the natural position of the foot and ankle. This places abnormal forces on the forefoot and toes, which can lead to painful conditions. Finally, foot and ankle pain can be referred from other areas of the body, eventually settling in the soft tissue or joints of the foot and ankle.

Common Foot and Ankle Conditions

Common foot and ankle conditions can be broadly broken down into those caused by trauma and those due to the gradual development of structural or biomechanical problems. An allotment of acute injury and overuse syndrome, which is often difficult and possibly misleading in history and diagnosis, is roughly 20% for the specific diagnosis and 80% for a general classification of “sprain” or “inflammation.” With regard to sports injuries, a review found that diagnosis was changed or refined for between 16% and 41% of participants, the most common change being to the site of injury. This illustrates that while traumatic injuries are often relatively straightforward to assess and diagnose, chronic conditions are notoriously difficult and often times speculative in diagnosis. Cold therapies are commonly thought to be more useful for acute post-traumatic pain and inflammation, but may have wider applications. In the management of acute injuries, immediate cold therapy may reduce the extent of swelling and hasten the healing process. A quicker resolution of swelling may allow physiotherapy to be started earlier and result in more effective and rapid rehabilitation. Although the optimal duration and frequency of cryotherapy has yet to be determined for the treatment of acute soft tissue injuries, the application of 10-20 minute ice massages for 3-4 times a day is a generally accepted regimen.

Impact of Foot and Ankle Pain on Daily Life

Foot and ankle pain can have a negative impact on your quality of life. The ability to function and stay active is very important to all of us. Pain in the feet and ankles can stop us from participating in activities we enjoy, which will lead to a decrease in fitness and general wellbeing. For most of us, our daily activities require being able to walk pain-free. Painful feet or ankles can prevent us from taking part in sport, shopping, or walking for leisure. This can lead to avoidance of certain activities and create feelings of depression or frustration. Pain has a psychological effect, and restriction of movement can have a detrimental effect on mood and self-esteem. It is important to recognize these feelings early on, as addressing foot and ankle pain quickly can prevent it from becoming a long-term problem. Long-standing pain and loss of mobility can lead to inactivity, weight gain, and a decline in general health. By recognizing the impact of foot and ankle pain on our lives, we can understand the importance of effective treatment. A reduction in pain and maintenance of mobility will allow us to continue doing the activities we enjoy and prevent a negative impact on our general health and wellbeing.

Cryotherapy and Cold Therapy

Both cryotherapy and cold therapy are used to reduce pain, prevent swelling, and facilitate recovery. This is accomplished by decreasing the tissue temperature, which decreases the metabolic rate of the tissue, thus decreasing the secondary hypoxic tissue injury. It also helps to reduce pain by slowing down the nerve conduction velocity. Cold can be applied using various methods, the most effective and practical being ice massage. A second method is a cold pack around the area, and this technique is particularly effective for covering large bony areas or in the acute phase following an injury. Ice immersion is effective for injuries to a joint such as an ankle or finger sprain. High-risk pathology areas should not be subjected to cold treatment, such as open wounds or people with poor circulation or peripheral vascular diseases. Frostbite can occur, and people with temperature sensation deficits may not be aware of developing skin damage under the treatment. Ice massage and cold pack can be applied for about 5-10 minutes and repeated every two hours. This strategy can be continued up to 48 hours after the injury. Complete cessation of ice treatment is dependent on the pain and return of normal functional activity in the area.

Definition and Principles

Icing is commonly used for musculoskeletal injuries and is considered a standard practice in sports medicine. It is used in the treatment of acute soft tissue injuries and is believed to reduce damaging intra-articular metabolism and decrease histamine release. These effects may lead to a reduction in the amount of swelling and pain, and possibly shorten the time of healing. There are 4 key effects of cryotherapy in reducing pain, of which 2 are neurological. The first is known as the “gate control theory” whereby it is believed that changes in skin temperature can block the transmission of slower pain fibers and subsequently decrease the sensation of pain. The second is termed “pain-spasm-pain cycle interruption”. When an acute injury occurs, muscle guarding will take place to protect the area from further harm. In the case of guarding due to an ankle sprain, this would lead to further tearing of ligament fibers and an increase in ankle joint instability. The fine balance between the roles of ice and immobilization in the RICE regime and early mobilization in functional rehabilitation is complex. However, by decreasing the amount of pain, it is hoped that mobilization can take place without further harm to the injured area using cryotherapy. The direct physiological

Benefits of Cryotherapy and Cold Therapy

The primary reason for applying cryotherapy is to use the body’s natural defense mechanisms to decrease the environmental temperature of the tissue in a specifically localized area. This is achieved via the major reflex vasoconstrictor, which causes a decrease in the diameter of the blood vessels in the area. The fall in tissue temperature results in a decreased metabolic rate caused by a reduction in the enzyme activity. The effect is temporary as the body has a strong intrinsic ability to heat itself up. This stage can last from 2-3 minutes when using ice massage up to 20 minutes using a chemical cold pack. The main aims of using cryotherapy are to decrease pain, increase the pain threshold, and to facilitate an increase in the rate and force of muscle contraction. A secondary reaction to cryotherapy is a decrease in muscle spasm due to the physiological effect cold has on the nerve pathways involved in the stretch reflex. This is an important step for someone with a grade 2 muscle strain, and can lead to more effective micro-tearing during the inflammatory phase. This follows with new tissue laying down in a more organized way which gives it greater tensile strength. The formation of ice and subsequent healing can be used to control many foot pathologies from acute injuries to chronic conditions. With the ability to prevent and control many problems at various stages, systematic net benefits and well-controlled protocols of cryotherapy can be a valuable asset for a foot health practitioners.

Application Methods

An injury should be cooled as soon as possible after it has occurred and should be continued for at least 10 minutes and up to 20 minutes. In cases of ligament sprains or other more serious injuries, immobilizing the injured body part and cooling at regular intervals for the first 72 hours is recommended. Costs and practicality may affect the type of treatment a patient can use, but the main focus should be to provide control in temperature and duration of cooling. A well-controlled cooling regime will provide the most beneficial effects to tissue repair.

An important concept in cryotherapy treatment is the frequency and duration. Research has shown that during cooling, vasoconstriction is maintained for the duration of the treatment, but vasodilation immediately returns upon cessation. However, during rewarming, vasodilation is maintained for a period, so the reapplication of cooling after short intervals of rewarming can prolong the overall duration of vasoconstriction. The consequences of this in relation to injury are not well understood, but it is thought that vasoconstriction reduces local metabolism and this may prevent secondary damage to tissues in cases where there is a compromised blood supply. Although acute inflammation is considered to be beneficial to healing, prolonged inflammation can cause tissue damage, so preventing secondary damage by limiting the temperature sensitivity of enzymes and reducing metabolite levels may help to facilitate a more rapid progression to the latter stage repair and regeneration of damaged tissues.

Cryotherapy involves the use of any form of cold treatment. This could range from a bag of frozen peas to a cold water pool to ice massage. Most commonly, ice packs or immersion in a container of ice water are used. Ice packs have the advantage of being cheap, easy to use, and only need to provide short-term relief so they can be re-used. Ice massage is reported to be more effective than ice packs. The ice is rubbed over the affected area for 10-15 minutes. This causes a feeling of discomfort, succeeded by numbness and then pain relief. The disadvantage is that the ice melts and it can be a messy procedure. Immersion in cold water or ice baths is said to be the most effective way of cooling body tissues and it is widely used in medical practice. Cooling a body part in a cold water bath can provide much more intense and rapid cooling than ice packs or cooling gels. A recent study found that a 10°C drop from skin temperature could be achieved in 8.75 minutes with the use of an ice-cold water immersion compared to 11.5 minutes using an ice pack. This method is often used in sports injuries as it is easy to administer on the field and most effective in the first 24 hours post-injury. However, it is not always practical for home use and there is a risk of frostbite if ice is added to the water. There is no hard evidence to suggest that any one method is more effective than the others.

Cryotherapy and Cold Therapy for Foot and Ankle Pain Management

Cold may be applied using a cold pack, crushed ice, a bag of frozen vegetables, or a commercial cold pack. The advantages of using a commercial cold pack are that they remain pliable and do not get too cold or hot, and do not leak. Cold packs are commercially available for purchase from many sources. Whichever type of cold is chosen, it should be applied over the painful area for 20 minutes. This should be repeated every 1-2 hours (or until the patient goes to bed) for the first 48 hours after injury. Fast freezing spray is not recommended to be used as an anesthetic over a large area as it can cause a chemical burn. Ice massage is also a viable alternative form of applying cold to an isolated and very small painful area. It is performed by freezing water in a small paper cup, then peeling off the top of the cup to expose the ice, and rubbing in circles over the painful area for 7-10 minutes. It is important to keep in mind the intended duration and the presence of any superficial sensory deficits when using cryotherapy, so as not to cause an ice burn.

Cryotherapy is a simple and time-proven modality for managing pain and inflammation. It is an essential part of any pain management regimen. Although applying cold to the injured or painful tissue cannot be considered a cure, it can decrease pain and swelling and allow for greater manual therapy and exercise/rehabilitation effectiveness.

Efficacy of Cryotherapy and Cold Therapy

Without a doubt, clinicians are using a form of cryotherapy on a day-to-day basis, as it is often suggested for people to put ice on an injury. Although it is commonly suggested by doctors, patients are not always given proper instructions or an understanding of what it could do to help their injury. Local ice pack is most commonly used because it is simple and cost-effective. It is common for patients to use a bag of frozen vegetables as many do not own an ice pack. The desired application time for a bag of frozen vegetables is about 20 minutes, and the bag of vegetables should be displaced within the first 4 hours of the acute injury. A plastic bag should be used on the ice pack to avoid getting water on the skin, and the pack should be wrapped in a towel to avoid frostbite and skin irritation. This technique is used by many injured patients, but people do not realize that there are better ways to use an ice pack and other forms of cryotherapy that would be more effective for their ailment.

Cryotherapy is a therapeutic technique which is known to be one of the oldest methods used in therapeutic medicine. Many studies have been done about its efficacy, and there are many different forms of cryotherapy that can be used to help aid musculoskeletal injuries. The forms of cryotherapy that will be discussed are local ice pack, ice massage, vapocoolant sprays, and ice water immersion. We hope to give readers an understanding of cryotherapy, how we use it on a day-to-day basis, and the types of cryotherapeutic applications that are available to us.

Recommended Treatment Protocols

Cryotherapy has been reported to be particularly effective in reducing acute pain and inflammation following musculoskeletal injuries and surgery. Advised timescales for the use of cryotherapy during the acute phase of tissue injury are as follows: ice applied for 20-30 minutes every 2-3 hours for the first 24-48 hours post-injury. This is dependent on the level of tissue cooling, with shorter times required when using methods that cool tissues more rapidly, such as ice massage. The self-treatment and professional use guidelines provided use the same 20-30 minute duration of treatment on an acute injury, but an increased frequency of every 1.5-2 hours. Duration of treatment will depend on the method of cooling and access to equipment, but typical recommendations are between 2-7 days or until signs of inflammation have subsided.

A suggested approach to the duration and frequency of cryotherapy treatment in chronic musculoskeletal conditions has been proposed using an evidence-based, clinical decision-making framework. It is argued that the prescription of cryotherapy should be determined by the underlying pathology and is categorized into four clinical scenarios. These are a) acute inflammation following an acute musculoskeletal injury, b) chronic inflammation in a musculoskeletal injury, c) acute episode of pain in a chronic pathology, and d) as a modality to relieve pain in a disease with no inflammatory component. Based on the scenario, recommendations are provided for intensity of treatment, frequency of treatment in 24 hours, and duration of treatment.

Safety Considerations

Ice wraps or cold pack applications should not be used for more than 15-20 minutes at a time because prolonged application can lead to nerve damage. Conversely, 10 minutes is the minimum time to ensure tissue is cooled sufficiently. Ice should not be applied directly to the skin, but should be wrapped in a tea towel or similar. This is because while the intention is to cool the tissue beneath the skin, an ice pack can be cold enough to cause an ‘ice burn’ or frostbite, particularly in more peripheral injuries. Compression of the ice wrap is believed to be beneficial for reducing edema as the constriction of blood vessels can limit inflammation. Elevation is equally important to limit blood flow to the injured area and consequent inflammation. Caution should be used when applying cryotherapy to an insensate limb as the patient will not be able to detect when the ice pack causes an ‘ice burn’, so regular skin inspection is required. A study concluded that although pain relief was similar in both cryotherapy and NSAIDs, the preference was cryotherapy due to fewer side effects and, of course, economic implications for the patient. Sudden death of fat cells due to localized freezing is a rare side effect of cryotherapy, which in turn can cause localized adipose necrosis. However, the potentially most significant risk of cryotherapy is delaying the healing process of a muscle strain in which blood flow must be promoted to the area for efficient repair.

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