Pain is a complex multidimensional experience that involves biological, psychological and sociological factors that vary to different degrees in terms of how much they each contribute to a person’s unique pain scenario.
Some people may experience musculoskeletal pain that is heavily driven by messaging from their tissues (sensory input or nociception-often called ‘mechanical’ pain), while others may experience pain that is modulated heavily by stress, emotions, or beliefs. In fact, some sources report that up to 1/3 of individuals with depression experience musculoskeletal pain only and do not feel sad.
It is important that we remember each person’s pain is real and unique and that we take the time to listen to their story. Many times the drivers of the pain come out in their story rather than a bunch of complicated orthopedic tests. I can’t tell you how many times I have been working with a patient and on their third or fourth visit they say something like, ‘I just remembered my pain began about the time my kids left for college’ or ‘when I lost my job’. If we are too focused on muscles, fascia or whatever other tissue, we often miss what is happening to the whole person.
Health should always be examined through a biopsychosocial lens. Let’s not forget this.
Everything in the body is 🔗 connected. Achilles tendinopathy is a great example of this. The Achilles tendon and calves are connected to the plantar fascia on one end and the hamstrings on the other.
Weakness in the hamstrings is a known risk factor for Achilles tendinopathy. This weakness causes movement compensations that lead to extra loading on the Achilles.
If you can’t 🏃 propel yourself forward via hip extension, you may resort to pushing off more at the ankle and foot. This movement compensation ⤴ increases the stress on the Achilles and can overload the tendon.
So when you want to fix an injury, you have to look beyond the site of pain. Attacking locally is a great place to start but you may need to move up or down the chain for long term resolution. You know what hurts, but you need to figure out WHY. Find the patterns. 🔎 Find the compensations. And often you’ll find the solution.
The talocrural joint is sometimes referred to as ‘the ankle joint proper’, and it is usually what comes to mind when discussing ankle mobility. It is formed by the tibia and fibula, the bones of the lower leg, and the talus. The ends of these bones form the mortise into which the talus bone fits, creating a hinge joint. The joint produces the plantarflexion and dorsiflexion movement on which we are focusing in this series
The subtalar joint is located directly underneath the talocrural joint and it is where the talus meets the calcaneus (heel bone). The motion that occurs at the subtalar joint is inversion and eversion of the foot. This movement is extremely important to allow the foot and ankle to adapt to changes in terrain or uneven ground, as well as absorbing shock and impact as the foot hits the ground
Language matters a great deal when interacting with people in pain. Words that are either misunderstood or not understood well can delay recovery and, potentially, worsen one’s symptoms.
Here are a few examples of words or phrases that rehabilitation practitioners frequently use and how they are interpreted by individuals receiving care:
1️⃣ Instability – lay individuals often interpret this word as meaning that their back could ‘go out’ at any time.
2️⃣Wear and Tear – often interpreted as something is ‘rotting away’, there are no treatment options and the condition will not get better.
3️⃣Non-Specific – often interpreted as the health professional thinks my problem does not exist or doesn’t know what my problem is.
4️⃣Chronic – interpreted as ‘a few steps from a wheelchair’, will not improve or absolute.
So, choose your words wisely when speaking with someone in pain. Sometimes, the best thing can be to listen, provide reassurance and stay positive. At the end of the day, the fact is that most musculoskeletal problems get better with time and no intervention at all.
Neurodynamics is an area of active research that aims to explore mechanical and physiological properties of nerves and how these properties might contribute to common pain conditions when compromised. You might be surprised at how many orthopedic conditions respond to nerve specific treatments (i.e. plantar fasciitis, tennis elbow, sciatica, carpal tunnel syndrome, etc).
Many times the answer to pain may be strategies that enhance neural health. Did you know your nerves have their own intraneural network of nerves and blood vessels? When a nerve is stressed to a certain threshold, it can loose all blood supply and oxygen, which can trigger nociceptive or ‘danger’ signaling to the brain. Keeping nerves healthy can be as simple as learning to move in new and unique ways and doing this often throughout the day.
We often hear people say that stretching can help prevent injuries, but before diving into a stretching program, we might want to consider why someone is stretching in the first place. If an individual is stretching to increase mobility, so that they can better carry out functional tasks, then I am fully onboard. In this case, a lack of necessary mobility to complete a functional task surely could predispose someone to injury.
But, what about situations where extra mobility is not needed? Does stretching really aid in injury prevention? If we take a step back and reference the literature, science tells us that stretching often does not reduce the risk of injury and, in many cases, that we do not have enough evidence to say if it does or not. As always, we need to appreciate the complexity of human movement, injury and pain before making blanket statements.
What do you think? Do you believe stretching can help prevent injuries?
Is this movement bad for your back?
Can this damage your discs?
No‼️ However, many physiotherapists, doctors, orthopaedic surgeons, and the general public believe this to be true and need to change their beliefs 🤔 about the spine.
People with degenerative discs have been told that they cannot bend their backs, lift anything heavy or do manual work. However, there are many examples where people have gone back to doing the very things they were told they cannot do. Being told you cannot use your back in certain ways and should protect it, creates much fear about the integrity of the spine. Research tells us that fear can be a major driver of abnormal pain behaviour, so we must be careful with what and how we explain things to people in pain.
A shift in beliefs has to happen within the medical and physiotherapy professions, and in the general public.
We can trust our back as It is a robust, strong structure!
Biomechanics is all about tension and compression. You are either pushing or pulling, or bracing or hanging. Your feet brace onto the floor and your shoulders hang off the rib cage. Shearing, bending and torsion are all combinations of tension and compression forces. Biomechanics is the sum total of how your body handles tension and compression.
The dowels float in a 🏊🏾 pool of soft tissues and change when stress is applied to the tensional forces (elastics) causing a change in shape. 🔺🔻♦️When the tension is increased, called strain, the structure becomes less mobile and stronger💪🏼. The mobility of the structure is called adaptability. When the tension increases⬆️, adaptability decreases⬇️. Tensegrity structures, when stressed, tend to distribute🔄 rather than concentrate strain. Which means the body is designed to take the strain as a system. It is the adaptability of the system that determines the integrity of the whole. The body distributes the strain; it does not localize the strain and the result of local injuries soon become global 🌎 strain patterns. If an injury, shortened ➡️⬅️muscle or postural➿ imbalances occurs to the soft tissue and shortens one of the continuous lines of tension in the body, the whole structure is impacted. The body is designed to distribute the strain but an injury occurs when a strain is localized. The pain isn’t the problem, it’s the symptom. 😲
Of the four rotator cuff muscles, supraspinatus is the most commonly torn and/or involved when shoulder pain is present. Pain that is thought to be associated with irritation of supraspinatus is often called ‘shoulder impingement’ or, more appropriately, ‘subacromial pain syndrome’.
There are many theories as to why pain develops in the subacromial space and many believe it may have to do with compromise of supraspinatus and it’s tendon. These hypotheses include: limited blood flow/nutrient delivery and increased mechanical stress associated with factors such as postural alignment, scapular bony morphology and motor control (particularly scapular dyskinesis).
Individuals with subacromial pain syndrome often report that their symptoms are located at the top of the shoulder and may radiate into the lateral arm. Aggravating activities include: sleeping on the affected side, reaching overhead or behind the back and quick shoulder movements.
Fortunately, a graded resistance training program, that loads the shoulder complex, often helps eliminate these symptoms.
These exercises are all being performed through full concentric and eccentric motion. If your pain is severe, it is often best to start with isometric and eccentric only contractions. If you have questions about this, I can explain how to modify these exercises.
1️⃣Full Can (make sure thumb is pointing up)
2️⃣ Sidelying External Rotation
3️⃣Push-up with Plus
A network of trabecular fibers run through the head and neck of the femur and are extremely important during function, especially during single-limb stance. These fibers allow the proximal femur to withstand both compression forces (blue regions) and tension (red regions) and undergo more deformation (change in shape) than the hard cortical bone found in the shaft of the femur.
Although this region is designed well from an architectural standpoint, it does demonstrate a zone of weakness where trabecular fibers cross at suboptimal angles leaving the bone vulnerable to injury in certain instances such as falls. When this type of fracture does occur it is usually in cases of high force collisions (motor vehicle accidents, sports, etc) or in situations where bone health has been compromised such as seen with osteoporosis.
This is yet another example that illustrates the importance of a resistance training program and a sound nutritional plan in order to optimize bone health and reduce the risk of fracture. Populations that are most at risk of suffering this injury include older adults, especially females, athletes who spend large amounts of time exercising in environments that reduce bone stress (cycling and swimming) and females who fall in the ‘female athlete triad’ category (osteoporosis, absence of a menstrual cycle and disordered eating).