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Saturday, November 29, 2014

Developing a Treatment Plan with 3 Sources of Pain in Mind

Developing a Treatment Plan with the 3 Sources of Pain in Mind
                                             By Richard L Blake, DPM
                                                  Past President of the AAPSM
   


     Dealing with pain in a Sports Medicine Practice can be a very difficult, challenging, and frustrating process. The patients want to get better as soon as possible. Some have high pain thresholds and some low. Let us take a look at approaching the 3 types of pain, dealing with Good versus Bad pain, and getting the athlete moving forward towards a complete recovery.


     What are the 3 general types of pain that come into play in podiatry practice? These are mechanically induced pain, inflammatory pain, and neuropathic pain. Of course, there is much overlap in all 3 areas. When a patient presents to your office, you will need to decide what is the primary pain to deal with at that time, with it possibly changing over the next few days. So often, the problem may have started with mechanically induced pain syndrome (for example, over pronation causing plantar fasciitis syndrome), but by the time you see the patient, the inflammatory aspect has spun out of control, and the neuropathic pain from limping and tweaking the low back is causing level 10 pain. Simply making orthotic devices and/or taping the foot to address the mechanics may be in the long run helpful, but it should not be the initial focus.  So, be mindful at each visit with the patient what type of pain you are primarily dealing with right then.

     The true uniqueness of podiatry in this world is our understanding of mechanically induced pain syndromes and their treatments. It is not the goal of this short article to stress these, but I would like to summarize the most common ones seen. Our expertise has taught us many treatments for each area below, so we can explore many avenues if the pain remains stubborn (for example, variations in stretching routines or OTC versus custom orthotic devices or even surgeries for metatarsal misalignments). The 6 areas of mechanically induced pain syndromes commonly evaluated are:

1.   Over Pronation (linked to 30 plus symptoms)
2.   Over Supination (linked to 20 plus symptoms)
3.   Short Leg Syndrome (linked to 10 plus symptoms)
4.   Poor Shock Absorption (linked to 10 plus symptoms)
5.   Tight and Weak Musculature (like weak VMO or weak posterior tibial or tight achilles and hamstrings)
6.   Miscellaneous (like fat pad atrophy, hip degeneration, metatarsal malalignment, etc)

     Key to our treatment of patients is our ability to create a pain free environment for that patient (typically 0-2 pain levels sustained). We must develop skills on protected weight bearing techniques. When the patients
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typically first present to your office with pain, you must get them to understand the concept of Good versus Bad Pain. Good Pain is pain at the start of an activity that disappears during that activity. Good Pain has little to no aftermath pain from an activity. Good Pain does not cause you to limp, and the pain can be kept in that 0-2 level. Good Pain can have an occasional sharp twinge that disappears in seconds with repeated activity. 

     As the patient and I try to team up to produce this pain free environment, all 3 types of pain are initially reviewed for their relativeness in the presentation. How much of the present pain can be helped by mechanically changes only (if a mechanical correlation has been made)? How much of the present pain can be helped by anti-inflammatory measures (patients are typically started on icing 2 times daily and contrast bathing each evening)? And how much of the present pain is neuropathic (it is always good to review the concept of "double crush syndrome")? 


     I think it is best to work through these problems 2 weeks at a time. At the first visit decide how the treatment should be started based on how you weigh the various types of pain as it presents. Let us take a patient presenting with severe achilles pain (level 7-9) in 3 scenarios to work through this. 

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1.   Achilles pain, acute in nature, associated with long history of back pain and no clinical signs of swelling are noted.
2.   Achilles pain associated with long history of long distance running,  that has come on gradually and is getting worse and worse, with thickening of the tendon on examination.
3.   Achilles pain, acute in nature, after stepping off a curve, with swelling, ecchymosis, and errythema.


     With all 3 of these presentations, you have to decide:
1.   Does any test need to be ordered?
2.   Is there any mechanical factors that caused or can help reduce the stress on the area? Even though heel lifts/clogs/boots typically help mechanically reduce stress on the achilles, and all need them, what presentation seems to be the most mechanical? (Answer 2)
3.   Is there any inflammation that can be treated? Even though all 3 presentations can be helped by anti-inflammatory measures, which presentation needs it the most? (Answer 3).
4.   Is there any nerve pain which may not respond to anti-inflammatory or mechanical treatments? What is the cause of this nerve pain? Which presentation seems neuropathic? (Answer 1)

I love an oral prednisone burst in situations where the pain is high and I am not sure it inflammatory or neuropathic. The neuropathic patients typically get very little relief from this 8 day course, and the treatment can be directed towards Lyrica, etc.

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     In summary, the practitioner will be daily surrounded by pain syndromes from mechanical, inflammatory, and neuropathic causes. It is the health care provider, with the patient practicing good vs bad pain recognition, that must create a healing pain free environment while slowing learning if there are mechanical causes to be treated, and anti-inflammatory and anti-neuropathic measures to be undertaken. A bi-weekly approach is commonly done as the symptoms change with the treatments recommended. Add to good treatments, remove treatments that seem useless, but overall, learn what is at the root of the pain syndrome. 
     

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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.