Effectively Treating Soft Tissue Injuries
If it's just a strain, why does it hurt so much?
If it's just a "strain", how come it hurts so much? Why is it taking so long to heal? How can it heal faster? Can you make it heal more completely? If it's a more serious or chronic problem, and you've already tried medication, physical therapy, splints, exercise, chiropractic and maybe even surgery, and it still hurts, is there any way to get rid of the persistent pain?
You would think that care of musculoskeletal injury would be fairly straighforward, but even medical experts disagree on the diagnosis and management of such common conditions as back pain, tennis elbow, shoulder pain, whiplash, carpal tunnel syndrome, knee pain, TMJ, heel pain, etc. A sprained ankle might be treated by rest and crutches by one physician and by early weight bearing and mobilization by another. Some would prescribe an anti-inflammatory or cortisone, but some sports medicine experts recommend avoiding suppression of inflammation just after injury, because inflammation promotes healing. So how does the average person know what to do when injuries, aches and pains don't respond to self-care or treatment by doctors, chiropractors and other therapists?
Understanding the Causes of Pain
The majority of us incur some bodily damage on a regular basis. We bend and twist our backs when we should be flexing our legs and pivoting on our feet in the performance of life's daily tasks. Wealthy young girls were once sent to "finishing schools" to learn proper posture and graceful movement; but most of us have never truly been instructed on the importance or science of basic biomechanics. "Physical Education" in our schools mostly involves learning to play sports.
Then we have occupations and recreational activities that cause us to sit all day, perhaps in a bad chair or car seat, or repetitively perform a motion that strains certain muscles and joints, or require an unnatural posture for prolonged periods of time. A government program to reduce workers risks of job related pain syndromes was killed by congress in 2001 because of unaffordable costs to employers.
There are also all the minor and major stresses and injuries that result from: falls, stopping short in a car at 55 mph, or on the baseball field, shoveling snow, moving furniture, or performing such simple tasks as trying to open a jar that one actually doesn't have the "unassisted" strength to open. Cumulative wear and tear on our anatomical support structures causes painful degenerative changes at a slower pace than injuries, but does ultimately cause osteoarthritis.
A general disregard for our physical vulnerability is suggested by national cultural worship of those who engage in the most physically punishing sports from football, ice skating, auto-racing, hockey, and rodeo to the relatively fast-rising, low-budget "extreme" sports of flipping bikes, skates, snowboards and such.
Unfortunately, some people who never engage in high-risk physical activities are genetically predisposed to premature degeneration of their spine and joints or nerves. Others may have diseases such as rheumatoid arthritis or diabetes, which often cause painful inflammation and/or degeneration of joints and peripheral nerves. Pain of the musculoskeletal or nervous system may also develop because of such diseases as cancer, shingles or herpes, and various other infections, toxic exposures, metabolic conditions, etc.
Pain Itself Can Cause Inflammation
Healthy humans have a biological pain control system. Pain provokes chemical changes at sites of trauma or potential injury that stimulate a cascade of chemical changes through nerves, the spinal cord, and brain. A neural reflex arc is completed when the brain sends chemical messages back to the local tissue, which induce repair. The brain also releases natural painkillers, such as endorphins, which block the individual's perception of pain.
So if you just whacked your elbow on the edge of the table, it might make you stop other activities for a few seconds. You might howl a bit and rub the painful area. You might even hop around and speak unprintable words. But barring serious injury, you might also forget about the incident twenty minutes later. Perhaps it's still tender to lean on, but if your pain control system is in tact, the initial pain resolves quickly.
Unfortunately it doesn't always work that way. The pain control system may become dysfunctional in various ways. Sometimes a painful stimulus is so prolonged and or intense that it overpowers the neuro-chemical response. Sometimes the neuro-chemical response is inhibited because of physical trauma to its anatomical parts; sometimes chemical dysfunction disables an individual's ability to turn off the pain.
Pain often persists or spreads because of compensatory postural changes the individual makes to relieve his/her pain. The classic example is the individual with sciatic pain of the left leg, who instinctively learns to reduce symptoms by tilting his torso to the right. After doing this for a few weeks his right knee, hip and/or foot may start bothering him as they have born increased weight. The muscles on the left side of his back are being stretched while those on the right develop a tightened, shortened state that compresses local nerves and blood supply, and causes increased pain in the back. As his torso leans right, visual reflexes tilt the head back to the left to maintain a sense of being upright and balanced, causing further asymmetric muscle tension in the neck and probably eventually on the shoulder region as well.
The more pain this individual develops, the more stressed his pain control system becomes. In numerous cases he become reliant on pain medication that further suppress his biological output of natural endorphins, while his biomechanical complications are left untreated and at risk of worsening.
The individual described above can become so distressed and disabled by pain that he will often resort to a surgical procedure aimed at taking pressure off the sciatic nerve, usually the removal of disc material that has ruptured onto the nerve. Hopefully his pain will be resolved by the surgery. But for the unfortunate patient whose pain persists, it becomes critical to assess and treat for biomechanical dysfunctions that caused or resulted from the disk herniation.
In other words, that little strain you had of your thumb or foot or neck may be persistently painful because of the tendency for muscles to spasm around joints whose support structures (such as capsules, ligaments, tendons, menisci, disks) have been stretched, torn and weakened. The muscles spasm reflexively to protect the unstable joint from excessive motion and further stretching. But the muscle spasm itself is all too often painful and results in further unhealthy changes in other places.
So What Is The Most Effective Way to Treat Pain?
There is no single answer to this question, but the best response is that the least risky, most successful, best-tolerated methods should be used. The most effective treatment is also one that is aimed at realistic goals. To date, there is no way to stop the aging process or cure rheumatoid arthritis or peripheral neuropathy. But there are many painful conditions that can be corrected or mitigated.
Principles of Treatment
History of injuries and physical activities, past treatments, pain patterns, disability and associated problems is carefully reviewed. Patients are physically examined with special attention to musculoskeletal function. Physicians and therapists observe posture, gait and activities such as bending, reaching, turning, tying shoes, etc. Assessment of range of motion, joint stiffness or laxity, muscle asymmetry, spasm and/or shortening, and neurologic evaluation are conducted.
Physicians may also obtain and review labs, x-rays, CT scans, MRIs, operative reports and other studies pertinent to understanding the cause and course of the patient's problem. Treatments frequently employed are directed at correcting biomechanical dysfunction and may include nerve blocks, trigger point injections, manual medicine, physical therapy, prolotherapy, acupuncture, and pharmacologic interventions.
Research shows that nerve blocks (anesthetic injections) can immediately stop the intense pain of acute injury, and with repetition, can break the pain cycle of more chronic conditions. Nerve blocks can sometimes pinpoint the cause of a pain problem more accurately than can x-rays and MRIs. Anesthetics also have been demonstrated to reduce inflammation and irritability of irritated or damaged nerves. Another benefit of nerve blocks is their ability to make other procedures such as trigger point injections relatively painless.
"Trigger points" are areas in muscles where spasmed fibers develop into a taut band or tender knot that causes local pain, shortening of the muscle with loss of flexibility, and tension and pain in other areas of the muscle. One of the most effective ways of eliminating trigger points is to inject anesthetic into the "knot" and peck at the spasmed fibers with a small sterile needle. This procedure called "needling and infiltration" or "trigger point injections" can mechanically separate and relax the spasmed fibers, which releases tension in the rest of the muscle. When numb from anesthetic, the patient can also tolerate deep massage or other manual and physical therapies that can relax and re-educate muscles that have become dysfunctional.
Manual Therapies may include:
- Post-isometric Relaxation Exercises
- Joint mobilization
Physical Therapies may include:
- Electrical Muscle Stimulation
- Thermal Applications
- Physical Exercise
Prolotherapy is the technique of strengthening lax ligaments, joint capsules and similar connective tissues by injecting solutions that stimulate the production of new collagen.
Acupuncture is rapidly gaining research support as a safe, effective technique for reducing pain and improving range of motion for patients with both acute and chronic musculoskeletal problems. In a 1997 consensus statement by the United States National Institutes of Health, a list of fourteen specific conditions recognized as being effectively treatable by acupuncture included, headaches, fibromyalgia, myofascial pain, osteoarthritis, low back pain, tennis elbow, carpal tunnel syndrome and drug addiction.
Ergonomic factors may require intervention, but be prepared to maybe have to purchase the right chair for your workstation, if your employer won't do it for you. Many patients will also benefit from pharmacologic treatment; nutritional recommendations and some may require co-management by an internist, rheumatologist, counselor or other medical specialist.
Treatment approaches are individualized to meet specific patient needs. Patients and clinicians evaluate treatment results at all follow-up visits.
Successful treatment is expected to result in:
- Improved blood flow and nutrition to compromised tissues
- Reduced edema where swelling occurs
- Relaxation of spasmed, shortened muscles
- Reduction of pain
- Prevention of disuse muscle atrophy
- Re-education of damaged muscles and joints
- Restoration of lost or impaired function
- Prevention and reduction of secondary complications
For chronic problems, at least three treatment sessions may be required before benefits can be appreciated. Complex conditions or pain of many years duration tends to require more extensive treatment than recently developed problems. Some painful conditions resolve after just a visit or two.
If you've been told you'll just have to learn to live with your pain, but you haven't been treated with these techniques, you may be unnecessarily doomed to long term suffering and deterioration. Or you could be on your way to recovery with a program designed by a physician who has specialized training in the management of difficult pain problems.
For more detailed, referenced information about pain and our treatment methods, visit our website at: www.painmed.com or call the Avicenna Spine and Joint Institute at (435) 655-9800