Pain Scale and Its Importance

     For over 15 years, and probably longer, the pain scale of 0 to 10 has been both a valuable and mis-leading part of medicine. For those who read my blog regularly, you know that I relie on patients keeping the pain scale between 0-2 in my rehabilitation programs. It is in the 0-2 range out of 10 that I am insured that the patient is most likely not hurting themselves further, and most of the time allowing the injured tissue to heal. I try to get the pain down to 0-2 as quickly as possible, and hold pain level until they are back to complete function. 

The illustration above shows many of the ways to show this sliding scale with the green area pretty much where I need to advise patients to be functioning within. As the pain gets into the next real level of 3-4, the situation goes from tolerable to distressing. 

     Yet to ask a patient what their pain level is, is really asking them to do the impossible at times. Pain levels vary during to the day due to many factors, so I think we need minimum of 5 points during the average day to adequately assess. These points may be: first thing in the morning, during the morning, as the day goes on, with exercise, and after exercise. So, you can see that 5 points may really be 10, and it can get very complicated for an office visit. 

     In our physical therapy department, the patients are always asked how they feel before, during and afterwards. The goal of course is to have the patient feel better, in other words, have their pain go from 5 to 3 during the session. What has this to do with anything? I just think if you are really trying to rehabilitate a patient you should know more than just the average amount of pain they experienced that day. 

Plantar Fasciitis Post Cortisone Shot Advice

Love your info! I received a celestone 5mg. injection into the spot that hurts me the most(from plantar fasciitis) in the center of my left heel on Tues.May 17th (Dr Blake is reading this on 5/21). I have had pain since Sept. 2015 (over8mos.)! I am an avid speed walker, zumba dancer, and tennis player at the ripe old age of 76 years old! Guess I wore my thin narrow feet out walking 5 miles a day on the beach along the waters edge for the past 35 years (plus all my other activities)! I had an MRI done in Dec. 2015 that showed "mild Plantar Fa sciitis". I then went to PT for several weeks and do many stretching exercises AM and PM every day icing  for 15 to 20 minutes after each session.

                               I had no  pain after shot for about 3 hrs (Dr Blake's comment: This tells you that the shot was in the right place). Then bad pain till late AM next day. No pain Wed. PM until Fri. Pm. Then slight tinge lasting into this afternoon(Sat.= 4th day. I am icing it as you said! My Dr. never told me to ice it! I am doing this 3 times a day for 15 to 20 minutes after reading your info.

Dr Blake's comment: This bad pain is unfortunate, but can happen and typically lasts for 4 days, so you were lucky. Celestone is a long acting cortisone that can take up to 2 weeks to completely start working. 

                               Questions: 

Can I start the PT stretching now 2 times a day (icing after)??? Dr Blake's comment: I would do no weight bearing stretching for 2 weeks. You can do active range of motion stretch by pulling your toes towards your nose non weight bearing. You can massage your calf. You can do the frozen sports bottle roll for 5 minutes from the heel into the arch with progressively more pressure over that period.

When shall I try walking and tennis??? Dr Blake's comment: You can walk, but no impact activities for 2 weeks like running, tennis, basketball. 

When shall I contact my Doc again???He said shot should last 2 to 4 mos.? I'm to get appt. after that time if no problem. I am seeing a Sports Medicine Ortho Doc. who has helped me with ankle tendinitis and sole problems with PT in the past!! I really trust him but am getting frustrated over my PF. Dr Blake's comment: The goal of cortisone therapy is to get the pain down to level 2, and then ice and physical therapy can take it from there. Typically you rest for 2 weeks, then spend a week or two testing it, and if you are not consistently between pain levels 0-2, get a booster shot. I do not like to give more than 3, and again, never get the shot where the plantar fascia attaches into the heel bone, just under the heel bone in the relatively fatty area. 

What else can I try before another shot or any drastic treatment? ( extracorporeal pulse activation treatment or ultra sound therapy)??? Dr Blake's comment: There are so many treatments that should be used before injections with plantar fasciitis: orthotic devices, taping, icing, sleeping splints, physical therapy, acupuncture, calf stretches, deep calf massage, topical creams, various shoes, no barefoot walking, boots, etc. So, without knowing anything else you have tried or are using, it is hard to advise you. Hope this helps. Rich

                                               Thanks so much for your time,

The patient's response:

Thank you so much for responding so quickly! Just some clarification. 1.  Does it sound like my shot was in the heel bone? I believe it was where my worst pain was and where the facials come together in the heel? Dr Blake's comment: Typically the shot is under the heel bone in the fatty area that can form a bursae. This is the safest spot to inject. See my video below. 

https://youtu.be/plbBvPASXwM

 Is 2-0 pain very little pain on 0-10 scale?Dr Blake's comment: Yes, you are still smiling. 

 3.When should I go back to my full 11 stretch Pt program 2 times a day? Dr Blake's comment: You can do intense plantar fascial stretches starting at 2 weeks. 

 4.Can I use a towel and sit up on floor to do the toes to nose stretch you said? Dr Blake's comment: As long as it is gentle. 3 times daily for 30 seconds only---1 rep.

How many sets and how many times shall I do these? And how many times a day? I believe I should do this for 9 more days?

                                              Wish you were in Phila. area! I would certainly be one of your patients!!!

                                                           Thanks again,

Patient's comments:

Dr Blake,

Thank you SO much!  I feel a lot more confident about the future after reading your response.

I've been using your taping method on and off for months.  I've been doing a lot of resistance band exercises but after watching your video, I think I was letting the tendon on the front of the ankle do all the work.  I'm also doing a lot of arch exercises, picking up marbles, bands, doming my arch, etc.

How often should I use the tape?  I was a little nervous that I may have been weakening the PTT by wearing it too regularly.  Will the exercises offset that?

Dr Blake's comment: As long as you are doing the exercises, the taping is fine. Every 4th or 5th day go without the tape and see how you feel. Do it intentionally on days you will be alittle less active. 

Would you be able to recommend a podiatrist in New York City who has experience with PTTD?  As you can see, I haven't had the best luck here.

Dr Blake's comment: I would travel to Long Island to see my buddy Dr Karen Langone. She is wonderful. 

Again, thank you so much!  

Email Activity Followup: An Excellent Method in Helping to Treat Some Injuries

Joe had severely injured both feet several years ago. For 2 years he hardly walked, and this is when I first met him. He had injured his big toe joints and walked on the heels only of MBT shoes. It was a fantastic adaptation of this shoe. First thing I needed to do was to see if he could begin to walk on his full foot. This took many months to accomplish. It was also hard to wrap my fingers around his problem with our monthly followup visits. The monthly ups and downs of his pain levels based on what he did was hard to follow. So, March of this year, I had Joe email me a activity report based on the standard pain level . I will have a post just on the pain scale. It is based on a scale of pain from 0 to 10. As Joe began to walk, stand, bike, etc I wanted to follow his pain to understand it better. I told him we want to keep him in the 0-2 good pain area, but occasionally drifting to 3 or 4 is okay. Joe had kept his pain level between 0 and 1 for 2 years by not walking, but his muscles and bones were atrophing terribly. The golden rule of foot is if it takes 2 years to heal something, it will take 2 more years to rebuild the strength. I knew Joe and I had a long haul together. We had to do it right. This daily activity log with pain level during really keeps us honest and on the right course. EOD stands for End of Day. PL stands for Pain Level.

This is what Joe sends me and I respond only when I think necessary.


July 1 Walking 45 min Standing 40 min PL1-2 Biking 50 min PL1-2 EOD PL: 2-3

July 2 Walking 40 min Standing 25 min PL 1-2 Biking 25 min PL1-2 EOD PL: 3

July 3 Walking 15 min Standing 30 min PL: 1-2 EOD PL: 1-2

July 4 Walking 1 hr Standing 3.5 hrs PL: 2 Biking 45 min PL: 0-1 EOD PL: 3-4

Here I sent Joe an email to increase his icing and decrease his activity.
July 5 Walking 30 min Standing 1 hr PL: 2 Biking 45 min PL: 0-1 EOD PL: 3

July 6 Walking 25 min Standing 40 min PL: 1-2 Biking 35 min PL:0-1 EOD PL: 1-2

July 7 Birks Walk: 25 Standing: 35 PL: 1-2 Keens Walk: 5 Stand: 5 PL: 1 Biking 45 min PL: 0-1 EOD PL: 1-2

Joe has been walking in Birkenstock sandals without bending his foot to push off the ground. We are introducing Keen enclosed shoes as a step forward towards normalcy. Joe awaits some new tests to see how he is doing. I am ordering a new MRI (last one 6 months ago) and a bone scan. Yet, I think the activity and pain scale log may be giving us a great picture of how well he his doing.