Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden,or non weight bearing on crutches or Roll-A-Bout
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity.

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with reflares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation.

I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!

More On Pain: Lortimer Moseley

I have many patients in pain. It is a very disturbing, challenging, fascinating problem. This introductory lecture by Lortimer Moseley discusses how pain becomes it's own source of pain. The brain senses a danger that does not exist, or has existed in the past. It is a fascinating talk. Hopefully, for patients living in pain, it is the doorway to a better tomorrow. This is my prayer for you. It has great validity. 

Pain: Giving a Good Medical History

Giving Good Historical Information: Helping to Steer the Course of Treatment



More Inspiration from Portovenere, Italy

I have been watching ships and boats sail through the narrow channel between Portovenere and the Island of Palmaria (as seen in the photo above). They perform this task so effortlessly since they have done it so many times. In the medical arena, an important time to steer the ship/treatment plan in the right direction is by giving good historical information. Come prepared with the information typed (unless you have great handwriting; typing in the best). Point your doctor or therapist along the right path/channel and it help you get better faster. Think over each question carefully when answering. The process will clear your head and keep you focused on the most important aspects. While many of these questions can be the most helpful clues, it may also free the doctor/therapist to ask the key specific questions related to your specific injury (for example, does your painful knee lock where you can not bend it?)



I would like to introduce you to a mnemonic that I used in medical school for asking a great history. The basic questions over the years have remained the same and the hallmark of great history taking. I hope you can take these questions and make them paint an accurate picture of your problem for the doctor/therapist you see next. If they are not impressed by your organizational skills, I will be amazed.



The mnemonic goes like this---

F Family History of similar problem? Frequency of pain (how often)?


A What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?


I How Intense (use Pain Scale) is the pain? What Irritates (makes it

worse)?


L With one finger, point to the exact Location of the worse pain?


E What Eases the Pain? Does the pain have an Electric sensation with it

D What has been it’s Duration (how long has it been going on)?



O What were all the events surrounding the Onset of Pain? Are there

any Observable skin changes?


P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?


Q What is the Quality of Pain (burning, tingling, dull ache, sharp,

numbness, throbbing, pulsating, etc)?


R Is there Redness? Does the pain Radiate and where to?


S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?


T What have you done to Treat the problem? What Treatment has

helped? What Treatment has made it worse?


U Are there Underlying Health Issues (diabetes, osteoporosis,

arthritis, poor circulation, etc.)?


V Does the pain Vary (better at different times, worse at other times)?


W Can you Work? Were you injured at Work? Does this affect your Work

shoes?


Good Luck and I hope this is really helpful to you. I hope your boat ride is enjoyable.