Video from Dr Richard Blake on Injury Rehabilitation General Rules

https://prezi.com/v/view/wyPiHlcIQ9LKeHoi88I2/

Good vs Bad Pain: Very Important Lesson to Learn when You Are Injured

Dilemma of Good vs Bad Pain

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 through, or to feel afterwards. Bad pain is discomfort that must be stopped; it is 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!” and probably in several languages. They can participate at very high levels with pain, hoping they can work through it. Sometimes they can, but many times they cannot, 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 cannot be tolerated. This group may actually learn to accept some pain as okay. 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 the injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt, especially with deep swelling that cannot escape the joints, bones, ligaments, or tendons. 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 of this?

Four Golden Foot Rules that 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., and even icing.

• 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 2 pain level (scale 0 to 10).

Let us focus on these four 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 (as you have hit the threshold of tissue strength) and it is best to stop. Participating in 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, taking medication six hours before an event is permitted. Many of the anti-inflammatory drugs (NSAIDs) 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 step 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 may still exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, and 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 then hurt for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 2 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, although a temporary sharp twinge lasting seconds is typically okay. Dealing with good pain is not the perfect scenario for my patients, but it is 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. It can be your training guide and friend.

But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more de-conditioned 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 and sometimes unnecessary fix. If you still believe “No pain, no gain,” I cannot wait to see you at our sports medicine clinic as a regular customer, but I will try to convince you otherwise in the long run. Learn about your body through this process. It has prevented three surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletic injuries. Good Luck!!

This is an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

The 1 Day and 2 Day Pain Level Increase Rules of Rehabilitation

     When I am rehabilitating a patient, we always talk about good and bad pain. It is so important for the patient to know the difference. And, it is very important for me to know where their pain is in my rehabilitative process. 

https://www.drblakeshealingsole.com/2020/12/good-vs-bad-pain-how-can-any-pain-be.html

     When you are rehabilitating a sore area, and you are progressing the patient through the 3 Phases of Rehabilitation, increased stress to the area is applied routinely every other day in activity progressions. This is typically Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. You have kept the pain between 0-2 successfully, but this increased stress (important for healing and return to activities) will elevate the pain for a period of time following. The goal during rehabilitation to keep the increased tissue soreness within 2 days or the 2 Day Pain Level Increase Rule. Therefore, if I am starting a more strenuous activity, like progressing to the Walk Run Program, or allowing small jumps in ballet, the increased pain needs to be contained within 2 days and not linger more. If you exercise on Monday, by Wednesday's start you should be back to square one even if Tuesday showed increased pain. 

     The One Day Pain Level Increase Rule is for the maintenance program. You are back at your normal level. You are exercising at a good level 3-4 times per week. Any increased pain after an activity is normal as long it is not during activity, not increasing in severity week to week, and contained with one day. 

   It takes alot of understanding to excellently rehab a patient, or yourself, of these 2 rules to avoid serious setbacks. Good luck 

It is Just the Wrong Timing of Events: Athletic and Other Injury Rehabilitation

     I am saddened when patients prolong their injuries with the Wrong Timing of their Treatments. Many times it is only because the definitive diagnosis has yet to be made. Many times it is because the health provider has too short of range of options to offer (as I do sometimes). Many times it is because the patient is impatient for a cure, or the subtleties of any treatment regimen is not followed or fully explained (and thus the patient keeps irritating things). And thus there are so many variables, so many different provider that will practice their treatment protocols, that I have found following the 0-2 pain level in all treatment phases must be followed. I know only some good physical therapists that can make you hurt and still get you better. I know that when surgery is required (1-2% of all athletic injuries) you will have more pain for awhile. But, in general, after you get the proper diagnosis, you should get better and better on a month basis (so September should be better than August, and October better than September, etc). 

     So, you develop pain with or without an injury. If the pain is between 0-2, and you can do full activities, you can probably wait a month before you see someone (and maybe the pain will go away by then). Of course, when you do see someone, you expect their diagnosis to be correct (which it normally is by the way), and month by month you get better and better (I assume 3 months on average to greatly improve if the injury requires a doctor visit). It is important in my mind to drive the pain down to 0-2 as quickly as possible (a week for sure), and then keep it there. This could initially be done by stopping an activity, put in a cast, and/or up on crutches. This is how you know you have the right diagnosis and treatment plan. You should be able to increase function, with no increase in pain, month by month. Of course, if your diagnosis requires a cast or boot or surgery, you may not be able to start that progression to full function for several months. In these cases, the diagnosis is definitive from the start (verified by xray or MRI or ultrasound).

     So, that is the Right Timing of Events: Injury or Pain Development, Proper Diagnosis and Treatment, Pain Quickly Down to 0-2, and Pain Kept There as Full Function Returns. Sounds simple, but it gets messed up all the time due to the limitations on medicine listed above. And, we can add insurance issues that block both diagnosis (say inability to get MRI) and treatment (do not cover the expensive bone stimulator you need). The patient is carefully moved through the phases of rehabilitation (immobilization, re-strengthening, and return to activity) and all goes well. 

     I will give you 2 recent examples of the Wrong Timing of Events. The first was a patient that partially tore her achilles, pain level 6-7, limping. She went to the local hospital clinic, and received 3 stem cell injections one month apart as her only treatment. No cast. No driving the pain to 0-2. And, no better, so 5 months later comes to me for a second opinion. This is one of the top hospitals in the country, or so they advertise.  The second was a patient whose plantar fasciitis was improving with orthotics, taping, icing and stretching, but when she had a flare from running too much on the weekend, when the pain got to 5-6 from the 0-2, all the doctor did was put some more padding on her orthotic devices and give her a Rx for PT. This does not sound bad, but she had never had this much pain, and it took 3 weeks to see the PT for the first session (which is typically just information gathering). So, one month went by, the heel padding had made her worse, the PT really not started, and her pain from limping had increased to 6-7 levels. The doctor had a second chance to right the ship, but again the orthotics were adjusted, and taping was applied which did not help. She clearly had a severe flare of her plantar fasciitis or a new injury. After seeking a second opinion, due to the level of pain, an MRI revealed a calcaneal stress fracture, and definitive treatment started. So, when the pain you are treating gets worse, ask yourself if you still believe in your working diagnosis first, and ask how can I reduce this patients pain to 0-2. 

Injured or Treating Someone Injured: Fight Inertia and Get Going

Golden Rule of Foot: When injured in one sport, find another one or two to keep healthy. 

     These Golden Rules which are all over this blog are rules never to be broken. However, this article speaks of how we become so addicted to one method of exercise, that when we can not do that exercise, we also have the inability to do something else. Inertia wins (and in this case it is psychological inertia). As health care providers, it is a good reminder as we talk to our athletes, that we help them understand the significance of cross training. Do not say "I think you should do something else for awhile". Say "we really need you to spend 30 minutes every other day on a bike and 30 minutes on the elliptical. Also, on your off days start hitting the weight room for your core, upper extremity and stretching." Be more proactice!! Your athletes will rehab better.

Golden Rule of Foot: When injured in one sport, start cross training the next day. 

https://journals.lww.com/acsm-msse/Abstract/publishahead/Injured_Runners_Do_Not_Replace_Lost_Running_Time.96421.aspx

Rehabilitation Concept: Floor and Ceiling Concepts

Tim Gabbett (@TimGabbett) Tweeted:
NEW PAPER: How Much? How Fast? How Soon? Three Simple Concepts for Progressing Training Loads to Minimize Injury Risk and Enhance Performance

@jospt 

https://t.co/ialFUhJMeW https://t.co/Ob2nHtN6L4
https://twitter.com/TimGabbett/status/1196189182105804800?s=20

Principles of Athletic Rehabilitation: PowerPoint Presentation

https://www.slideshare.net/RichardBlake39/principles-of-athletic-rehabilitation

Principles of athletic rehabilitation from Richard Blake