Last month we explored different descriptors of pain which can be used to understand your situation. How you describe your pain or other sensation you wish to go away, guides your clinician towards a clinical diagnosis which may simply involve a specific anatomical structure or may be more complex. If the primary structure or issue that needs addressing was always where you feel pain then medical diagnosis and treatment would be tremendously easier! But we need to ask ourselves, is the problem where the pain is?
The human nervous system has a function to protect us from damage or further damage e.g., it hurts when you step on a sharp rock so you don’t do it again and cause more damage to your foot. You may remember what happened last time you did something, so you don’t do it again.
We quickly adapt movement patterns to reduce pain – I like to say “we don’t limp because it hurts, we limp so it hurts less.”
Often those protective patterns we subconsciously engage can linger and change the way we move. The fear of further pain will restrict or alter movement strategy and a chain reaction can occur resulting in stiffness, weakness, loss of muscle patterns and a change in tissue sensitivity which can all eventually cause further problems – and pain.
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Let’s explore a very common scenario experienced by thousands of people: Some time ago you hurt your shoulder lifting a heavy bag off the carousal at the airport. For the rest of your holiday, you change the way you use that arm so it doesn’t hurt as much. You quickly figure out “if I do this, then I can get on with my holiday”. You may use you other arm more, you may use your trunk muscles more to lift, you will probably shrug your shoulder more when lifting with that arm and your neck muscles can therefore get fatigued.
Six months later your shoulder is still weaker than it was and the way you use that arm has changed. Your shoulder may not hurt anymore but your neck does, as you never returned to the ‘normal’ shoulder function you had before. You seek treatment for your neck pain – but the solution includes regaining the shoulder strength and movement pattern you originally had before picking up that bag on holiday!
Part of a thorough assessment process should be extensive questioning about your history of pain and injury and a full movement and possibly manual examination of body parts beyond your area of described pain. Unless you underwent a complete and thorough rehabilitation process (which unfortunately many people do not) then we can almost assume there is some ‘hangover’ from the original injury.
One of my favourite patient stories was a gent who presented with back pain but 10 years prior had broken his big toe. He never regained full movement in the toe and the subsequent change in walking pattern had, we thought, gradually overloaded his back. We mobilized and strengthened his toe and foot muscles and… his back pain decreased a significant amount before we locally addressed his back movement patterns and strength. The problem was not where the pain was!
Another common scenario is ‘referred pain’, where the nervous system gets confused as to where the tissue damage, irritation or even disease.
Common visceral (internal organs) examples are shoulder pain referred from a gallbladder inflammation, back pain from a kidney problem and of course arm and jaw pain from a heart attack.
The most known referred pain Physios will see is commonly known as ‘Sciatica’ - leg pain due to tissue irritation or compression in the lower spine. Other common referred pains are shoulder pain from the neck, chest pain from the rib joints and headaches from the upper neck. If you have such pain and the local area of pain is treated without addressing the area irritated and causing the pain then it probably won’t go away – or get worse.
BUT WHY? It was not until we had our own children that I really understood the power of a 3 year old’s incessant ‘why?’ questioning. I use this as inspiration to ask why, when someone seeks my help with pain.
Sometime the answer is clear e.g., your knee hurts because you fell down the stairs and damaged a ligament - you sustained an acute injury. In sports, performing arts and general life injuries this is an easier scenario to diagnose and help manage. The damaged tissue will heal and we can help to regain full function as it does.
A very important factor in these cases is to be aware of the adaptive movements you might subconsciously engage to minimize the pain as you try to maintain day to day life. Often these adaptations are needed for a while, but we must recognise them and ensure they do not become your new way of moving – and then cause another problem in the future.
It's not just age!!
Of all the possible ‘whys’, it is easy for us to blame one in particular – age. “Is it just old age?” says the patient with one sore knee. Well to credit our esteemed colleague David Butler “How old is the other knee?’.
We have to explore why that knee is painful and that may lead to an exercise program - for example – aimed at improving your hip and back strength. It is very easy to blame age and aged or load related changes like osteoarthritis for having pain, but we must look at what can change throughout the whole body and help to reduce the pain and improve function.
So very often in physical medicine the underlying problem that needs mobilisation, movement training and strengthening is not where we feel the pain. If you have chronic or recurring pain, a ‘dodgy back’, a ‘bung shoulder’ or a “stuffed knee” and the local area is being treated without progress then maybe it’s time to ask “is the problem where the pain is?”.
Do you you need help recovering from an injury? Improving your performance? Or just getting back to doing the things that you love? Visit us at PhysioTec, and let one of our physios assess you and provide you with a personalised program to help you get on-top of your condition, and feel at your best.
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