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
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.
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.
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.
sad3r23r
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