MASSAGE and FOOT THERAPIES

Medicare recognizes the benefits of massage as a form of physical and/or rehabilitative therapy and reimburses for this treatment for many conditions seen in the typical Podiatric practice. Medicare uses the “Scope of Practice” as a benchmark in deciding whether a specific code or bundle of codes should be part of the practitioner’s fee schedule. Given that the Podiatrist is the ultimate arbiter of the foot, and that massage within our anatomic boundaries is within the “standard of practice” and reimbursable, we should examine this established and well-appreciated practice and see when it fits into our patient treatment plan.

Read Massage, Manual Therapy and Podiatry by Dr. J.D. Segel >

BENEFITS and INDICATIONS

Massage has long been used to aid healing, improve circulation, reduce pain, decrease swelling, increase range of motion, extend endurance, normalize gait, reestablish subluxed joints, nourish skin and break up scar tissue. Additionally, my Peripheral Neuropathy patients consistently report more feeling in the lower limbs after massage treatment. Combined, these great benefits bring about improved posture, balance and confidence. After the foot has been housed in an often cramped environment for long periods of time, it accommodates by contracting and existing in an almost tetany-like state. This condensed foot form is a poor shock absorber and is less able to accommodate uneven surfaces. By massaging the foot to a relaxed state, more surface area is allowed to interact with the ground improving function and shock absorption while making the foot and body less susceptible to macro traumatic events such as falling. By relaxing the foot in this manner, the vasculature also eases leading to increased lumen diameter, improving local arterial blood flow.

The preventative medical and biomechanical benefits shouldnot be underestimated. For those patients or practitioners that may doubt the efficacy of massage, nothing proves the point like the diagnostic ultrasound. Image an arthritic joint in motion and demonstrate the narrowing or malaligned joint space, then, add retrograde traction and watch the joint space open up and range of motion increase. Stretching and reeducating those tissues that would bind the joint becomes a demonstrable goal toward which both patient and doctor can work.

For some time now Podiatry Schools have been emphasizing the concept of conservative treatment first, such as massage, ultrasound, electrical muscular stimulation, shoe change and orthoses before reaching for the needle or the blade. Personally, I have been able to resolve many patient chief complaints through a regular course of physical therapies, shoe intervention and gait alteration. Disease processes I have treated with massage and have received Medicare reimbursement include; Degenerative Joint Disease, Plantar Fasciitis, Tendonitis, Vascular Disease, Diabetes Mellitus, Hallux Rigidus, Contracted Digits, Hallux Abducto-valgus, Parkinson’s Disease, Lymph edema, Peripheral Neuropathy, Polymyalgia and Seronegative Arthropathies. Massage in conjunction with other therapeutic modalities are also helpful for those patients with overuse syndromes, old injuries, and status post foot/ankle surgical recipients. It’s important to point out that in the patient with severe systemic problems in addition to the Podiatric complaint, massage may be the only therapy option to consider since modalities like electrical muscular stimulation have a number of contraindications.

An important piece of information to share with your staff and patients is that therapy codes carry with them a combined calendar year cap of $1,780 based on what Medicare approves, not the 80% they pay. There is a “KX” modifier which can be used for special situations or extenuating circumstances to breach the $1780 therapy cap. These “automatic” exceptions are appropriate when billing after the cap has been met and for patients with diagnoses/conditions commonly seen by Podiatrists including; Diabetes Mellitus, Obesity, joint replacements, abnormal gait, difficulty walking, Parkinson’s Disease, neuropathies, paralytic syndromes, arthritities, contractures and many more.

Massage Techniques

The appropriate preludes to therapeutic massage are a systems update, meds review, allergy check, then local exam. Inform and educate the patient on the care plan, topicals to be used and techniques to be employed.

Providing effective medical massage and foot therapy begins with a strong knowledge of anatomy, physiology, tissues planes and pathomechanics. Given that the foot is, for the most part, a logical appendage and the facts are known or knowable, the technique often dictates itself. For example, an arthritic patient may benefit from a distraction focus massage with anti-inflammatory topicals whereas a patient with overuse syndrome might respond better to deep tissue work with defatigant style topicals. Patients with edema usually respond well to vasodilatory topicals with drainage techniques; yet those same topicals, in a dependent leg position with percussive techniques tend to yield an improved local blood perfusion. Often, patients present with multiple related pathologies and so, components of each massage discipline may be used to produce any number of beneficial results such as an increase in circulation and range of motion while decreasing edema and pain, all of which lead to improved ambulation and a more stable gait.

Techniques

I use six basic techniques that I modify and/or combine based on patient history and complaint, along with my observations, assessments and diagnoses. These massage maneuvers are distraction, percussion, cradling, drainage, light touch and myofascial release. These are based on anatomy, physiology and biomechanic principals. Distractive techniques are used in almost every patient I see because the foot in under constant stress secondary to imbalanced retrograde forces. Combine this with the extraordinary pressures of gravity, motion, shock and body weight and you have a prescription for burden, micro trauma and the need for constant maintenance. Massage is maintenance and rehabilitation, for both foot use and misuse.

Distractive massage is the technique of choice for arthritics, but patients with contractures and peripheral neuropathy report benefit as well. The method involves traction of the joint to resistance with the addition of slow movement within the planes of motion. This is done repetitively and slowly to let the soft tissues relax and elongate much like runners are encouraged to stretch before activity. Given that two bones in space would have no reason to interact but for the sack that contains them (the foot) and the soft tissues that attach and cause them to function interactively. This imperfectly architechtured “bag of bones” is a three dimensional appendage whose job it is to function on and adapt to uneven and unyielding surfaces. This leads to muscular imbalance, asymmetric joint spaces, scar tissue and ligamentous contraction. By making use of the elastic nature of ligaments, capsules, muscles and tendons that hold joints in contraction and perhaps subluxation, distractive massage can increase range of motion while decreasing inflammation and pain during mobility.

Percussive maneuvers are quick and repetitive physical interactions with the foot. Open handed perpendicular techniques are meant to create an increase in circulation while “Spider Drumming” (alternating horizontal motions), are used on the long tendons of the foot to break up scar tissue and increase flexibility to promote neutral joint spacing and increases in range of motion. This is almost always included with Pes Cavus foot types and patients with compromised arterial systems.

Cradling is a two handed technique that is a favorite among patients. By marrying the three dimensionality of your hands to the architecture of the patients foot, they are bathed with a sense of security, relaxation, and warmth. This is most often used on the medial longitudinal arch with plantar fasciitis, the lateral longitudinal arch with cuboid subluxations or peroneal dyfuction and on a contracted Tendo-Achilles secondary to surgery, Short Limb Syndrome, Polymyalgia, trauma or equinus.

Of all the methods used, drainage is probably the most dramatic visually. With the patient reclined comfortably and the foot higher than their heart, the edematous limb secondary to venous or lymphatic system insufficiency is manually drained with appropriate compression and very slow proximal motions. This is another two handed position where the foot is often lifted higher than the patients heart. The fluid and bloods cells move from the interstitial tissue back into vessels to eventually release its toxins and reoxygenate. In addition to edema, I find this technique to be quite useful when a patient is observed with venous distention or anterior lower limb staining as often occurs in Diabetics.

For the Podiatrist, myofascial release is, in part, deep tissue work, manipulation and cross fiber massage employed to stretch and ease the bonds between the integument, fascia, muscle and bones in the foot/ankle. The goal is to reorient and reorganize the connective tissue fibers to an elongated and more flexible and functional arrangement to benefit gait. This practice is particularly good for patients with old injuries, localized pain and imbalances.

Light touch is a finishing move that is perhaps more “eastern medicine” but it’s effective and patients tend to love it. It is a good way to signal the ending of a session while releasing stress and providing some exercise for the local sensory nerves. With the heel cradled in well lubricated hands and positioned above the patients’ heart (when appropriate), allow the foot to return slowly to the footrest below, cushioned between the practitioner’s hands and arms.

As aforementioned, ultrasound and electrical muscular stimulation are also used in this office and are very effective therapeutic tools, by themselves or in combination.

Topicals

All the above described massage types incorporate the use of topical medicines and remedies, both prescription and over the counter. Pore and vasodialators, stimulants, relaxants, toners, nourishing massage lubricants, anti-inflammatories, pain relievers, antispasmodics and carrying vehicles are used to bring about the desired goals as stated above. Without endorsing any specifics products, I use preparations with ingredients such as menthol, camphor, arnica, cortisone, DMSO, Emu Oil, lanolin, capsaicin, lavender, tea tree oil, grapeseed oil, eucalyptus, aloe vera, skullcap, urea, waters, amino acids, minerals and vitamins to name but a few. The basic philosophy is to open the pores with dilators, then use carrying mediums for penetration of the beneficial active components. After the selected topicals have been worked into the local tissues by appropriate massage technique, I degrease and constrict the pores to seal in the medicines with a toning water spray and blot dry under mild traction. I often suggest such topicals for home use. This keeps the patient focused and actively involved in their treatment plan.