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Tuesday, December 24, 2013

Foot Pain: Dilemma of Good vs Bad Pain

This is the Post all my athletes need to read.




For the athlete dealing with a painful situation, coming to a useful understanding of what is good and bad pain becomes crucial to speedy rehabilitation. Good pain is discomfort that is appropriate to work out through, or to feel afterwards. Bad pain is discomfort that must be stopped, the breeding ground for setbacks and flare-ups.

Varying pain thresholds in athletes can greatly complicate matters. Some athletes with a high pain threshold can train through a more serious injury believing that they are doing no harm, only to find that the injury has greatly worsened. In this case, their body’s own feedback mechanisms have let them down. Something in their head is yelling “No Pain, No Gain,” in probably several languages. They can participate at very high levels with pain, hoping that they can work through it. Sometimes they can, but many times they can not and the injury gets worse. Most of these athletes need the outside help of coaches and personal trainers, doctors and physical therapists, to help set some limits. Their own “self-preservation” mechanism is not working properly. Evolution to better body awareness can occur with good coaching. There is hope for this group.

For other athletes, including myself, with low pain thresholds, all pain is bad and can not be tolerated. This group may actually learn to accept some pain as okay, or good pain. They can also evolve.

Besides varying pain thresholds, there are many physiological reasons that the exact same injury can hurt a lot more for one athlete than another. The closer an injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt. If the injury is on the outside of your foot, and you walk/run on the outside of your foot, you will hurt more than another patient who walks/runs on the inside or the middle of their foot. The weaker the area is before you are injured, the more you will hurt after the injury since it will take longer to get the area strong. These factors are just a few.

Remember, injuries first heal and then double heal. Some bones like your metatarsals may get approximately twice as thick during the total healing process. This is why tendon and ligament injuries can heal with scar tissue that leaves the tissue twice as thick. So, even when an injury is completely healed, more healing may occur for several more months possibly producing noticeable symptoms to the athlete. Healing always produces some level of pain with swelling, muscle tightness for protection, scar tissue breakdown, etc. This can be good pain. So, how do we make some sense with this?

4 Golden Foot Rules may give us some focus.

Golden Rule of Foot: Never push through pain that is sharp and produces limping.

Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen, aspirin, etc.

Golden Rule of Foot: 80% of healing occurs in 20% of the overall time, with the remaining 20% taking 80% of the total time.

Golden Rule of Foot: Good pain normally dwells in the 0 to 3 pain level (scale 0 to 10).


Let us focus on these 4 rules.
When an athlete asks if they can participate in their activity, there is no breaking of the rule of sharp pain and limping. Good pain may be at the start of a workout, then eases up. If the pain comes back in the middle of a workout, this is bad pain and it is best to stop. Participating with a team activity that is semi-dependent on you is tough as you ease yourself back into activity. But you must be clear from the start of the activity that you may need to stop if pain develops. Ask your co-participants to tell you if you are limping. Sometimes they see it before you feel it. Limping throws the entire body off, risking other injuries. Sharp pain normally produces limping, but limping can also occur as you transfer weight to avoid pain or if a body part is too stiff to bend properly.

Drugs, as simple as aspirin, ibuprofen, etc, can mask little to significant pain. Never take these drugs before participation, only after if allowed. In general, 6 hours before an event is permitted. Many of the anti-inflammatory drugs also inhibit bone healing, so are contra-indicated in bone injuries entirely.

Healing can take a long time to completely occur with any injury. The job of the doctor, therapist, and patient is to try not to repeatedly get in the way of the healing process. But even with our best efforts, we tend to take two steps forward, one back, then two forward, then three back, and so on. I am happy to say in following injuries for more years than most of my readers have existed on this earth, injuries do heal. People do forget what ankle they sprained in 2004, and what heel got plantar fasciitis in 2007. Yet, most healing occurs in 20% of the time, with the remaining 10-20% healing occurring in 80% of the time. When you are 80% better, level 1 or 2 pain still may exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, occasional flare-ups, to get rid of the last 20% of symptoms. It is considered the realm of good pain, but it can wear thin on our nerves and patience.

Good pain is pain/discomfort/soreness/tenderness/dolor that does not have to interfere with activity. Listen to your body. Does the pain cause limping? Is the pain sharp in intensity? Does the pain come on in the middle of an activity? Does the pain come on after an activity and hurt then for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 3 range, no matter what your pain threshold is. Good pain is normally gone the next day, so there are no residuals. Good pain does not cause limping, and is not sharp. Good pain, is not perfect, but your daily reminder to keep icing, stretching, strengthening, and listening to your body. Good pain can be a good guide to allow you to work an injury to complete healing.

But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more deconditioned you become, and the longer the return to activity process will actually take. So, it is better to try to discover the difference between good and bad pain. The better you become, the better decisions you will make in your athletic life, and the longer you will be an athlete. The better you become, the better prepared you will be for the next injury. An important medical decision may be made based on your knowledge of good and bad pain. If all pain is bad, you will have a less active life and may seek surgical intervention as a quick fix. If you still believe "No Pain, No Gain", I can not wait to see you at our sports medicine clinic as a regular customer. Learn about your body through this process. It has prevented 3 surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletics. Good Luck!!

8 comments:

  1. This an excellent post Rich, and shares an extremely valuable clinical perspective on what we non medical folks typically are just doing guess work on. It takea a long time to learn to listen well to your body, but many more serious injuries are prevented when we do. Thanks for the insights. I am hot on the tracks to get you more followers this is such an excellent blog more people need to know about it!

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  2. There are many factors for foot pain, the most common one is bad footwear and a combination of specific foot bio-mechanics which are faulty, like flat feet or over pronation.
    http://www.footcentersofnc.com/common-foot-problems.html

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  3. We need to select comfortable shoes for running or for other sport. Comfortable shoes can prevent many sport injuries.

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  4. Great article! I have had plantar fasciitis for 1.5 years, and have not been running because of it. The pain is not bad at all, but I assumed that I should avoid running in order to let my foot heal. My lack of exercise has really been bothering me. Is it ok for me to do short runs? I do wear Sole orthotics in my shoes. Thanks.

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    Replies
    1. Ben, Thanks for the comment. Complete rest is fine when the pain is unmanageable, but as long as you can keep the pain between 0-2, I would begin a Walk Run Program. See my blog post on that. Ice after each run, and one more time that day. Continue to do the Plantar Fascial Wall Stretch 3-5 times daily. Listen to your body. If the pain inches up past 2, learn to do one of the arch tapings for running. I hope this helps. Rich

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    2. Thanks so much for your reply!

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  5. My aunt used to Tap Dance and I remember she was one of the best but due to excessive practice she broke her ankle and the doctors advised her to stop dancing but she did not quit and went to Physiotherapy North Ryde to regain her energy back and now she is able to practice for half an hour twice a week as the therapist has advised her a plan for dancing and she is happy with her life now.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.