Pain is a complex, emergent experience.
Tissue injuries are not.
Tissue injuries occur when the loading on the tissue exceeds its capacity.
This can be an acute issue – think of a sprinter suddenly straining their hamstring mid race – or a chronic issue – think of a builder developing elbow pain over time.
In both circumstances, the principle is the same.
The formula for managing an injury is fairly simple on a macro level:
- Decrease the volume, intensity and/or frequency of aggravating activities to manageable levels
- Improve biomechanical efficiency
- Increase capacity with progressive overload
What is challenging is how to achieve these objectives in living, breathing humans who have needs, wants and annoying things like emotions that make us behave irrationally.
This is where a clinician needs to have excellent listening and communication skills, be a master of persuasion and thoroughly understand the physiological and biomechanical aspects of movement, stress and adaptation.
This post is going to outline a few of the methods I use to achieve the above outcomes.
Decrease Volume/Intensity/Frequency of Load
The most obvious thing to do when we are injured is often the hardest.
- Necessity. We all need to continue working, caring for family or performing our activities of daily living (ADL). It can be hard to offload your injured body part when there is a baby crying or a load of laundry that needs doing. Let alone when you have a work deadline to meet.
- Desire. This is an emotional issue. Many of us desire to continue doing something as it brings us pleasure, status, or allays a negative emotion like guilt or fear. For example, it is common for people to want to continue to push themselves exercising whilst they are injured because of body image issues.
However, in most cases, an all or nothing approach is not required.
You don’t have to stop something completely to reduce the loading effect.
Here are two examples from a patient who has lateral hip pain that I’ve diagnosed as a gluteal tendinopathy. In these cases we are reducing the volume of the load primarily:
- Use the fitness tracker in her phone to estimate her daily activity level. Work out at what activity level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
- Track her walks accurately (pace/duration) and work out at what level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
Here is another example of how I reduced the intensity of the load in a builder with elbow pain. He couldn’t stop working, and a lot of what he did (using tools) aggravated his injury.
- Use tennis grip tape to wrap around the handle of his hammer. This increases the circumference of the handle, which reduces the mechanical leverage of the forearm muscles, taking the load off the tendons at the elbow.
In most cases, there are ways to continue doing what you need or want to do, with some modifications. And in most cases, this is actually better than complete rest.
Improve Movement Efficiency
Everybody knows Roger Federer. You don’t have to be a tennis fan to appreciate his skill and technique. He makes things look easy.
As we improve our skill at a task, we become more efficient as well. It takes less effort and as a result we tend to load our body less.
Roger Federer demonstrates this – his supreme technique has helped him accumulate very few injuries in his career, despite a demanding schedule and advancing age.
However, we don’t need to look to elite sport for examples of movement efficiency.
Think of your local pizza parlour. If it has been around for a while, watching the chefs put a pizza together is a picture of movement beauty (okay, I really love pizza). Every time I try and replicate this at home I just end up tired with a very messy kitchen bench.
Or let’s keep it closer to home. When I was younger, I didn’t know how to iron a shirt well. My mum could iron all of my dad’s and my brothers’ shirts in the time it took me to do one. All that effort, all that time under load. It’s easy to see how my inferior ironing skills could lead to more load on my body. Even though my mum was doing more total work, her body was adapted to it, and she did it in a way that was smooth and effortless. Contrast that to me, not adapted to ironing (still not) and very tense and inefficient.
When it comes to rehab for an injury, it’s not just the capacity of the tissue that we have to worry about, but the efficiency of movement, which affects the loading on that tissue for each movement/activity.
Improving movement efficiency is a topic in and of itself.
The input is related to sensory information from the nervous system. The better the quality of sensory information, the better the output. This is why rehab should begin on the sensory side. Sensory input can be improved with manual therapy, which is likely one of it’s biggest roles in modern practice.
Processing is based on cues and context. We can change both, but we have no idea how it will affect the processing. I’m not a big fan of the word processing, as it sounds to much like a computer, and we are not a computer or machine.
Remember at the start of this post when I said:
Tissue injuries occur when the loading on the tissue exceeds its capacity.
Well it makes sense that as well as reducing the load on the affected tissue(s), we increase the capacity as well. This has two benefits. No, actually, it has three benefits:
- Loading tissues helps with repair.
- Loading tissues that are painful helps (re)build confidence in the injured tissue.
- Increasing tissue capacity protects against future injury.
I like to use a two pronged approach here:
- A targeted exercise approach
- A graded return to activity approach
This isn’t revolutionary. It doesn’t have to be. It just has to be done well.
In the targeted exercise approach, I use a simple progression. I like someone to be able to (where possible) perceive the tissues properly (sensory awareness) before we work on the following:
- Isometric to dynamic
- More stable to less stable
- Simple to complex
- Less task specific to more task specific
There is some evidence to suggest local loading, particularly with isometrics has a pain relieving effect, which is why I start there.
More stable positions allow people to focus on the movement or activation required, without the extra motor and sensory demands of stabilising their body in space.
Starting simple allows more mental energy to be directed to recruitment patterns, while progressing to complex reinforces these patterns in different contexts.
Finally, starting less specific to the task allows for the load to gradually be progressed as tissue capacity increases.
Graded Return to Activity
This is an expansion of the first topic, reducing the load.
Put simply, we simply reverse the process, gradually increasing the load until the tasks can be performed normally again.
A good rule of thumb is to progress no more than 10% per week, to allow the person and the tissues to adapt. You cannot go too slowly, but you can absolutely go too quickly.
This is my current approach to treating tissue injuries.
You have to remember that not all tissue injuries present with pain, and not all painful presentations are related to tissue injuries.
When pain is the primary problem, we can use a similar approach if localised tissue sensitivity is deemed to be the main contributing factor.
Finally, we know that past injury is a big predictor of future injury. So while the pain from an injury subsides as the tissue heals (the tissue will heal if you give it a chance, regardless if you rehabilitate function or not), if you want to minimise your chance of re-injury in the future, it pays to be thorough.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.