What to do about injuries that keep coming back.

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Often when someone is injured, after the initial round of healing is over, the injury enters a chronic or recurring phase.  I’m thinking of the kind of injury where someone lands on their shoulder or their knee…or they “overdo it” one day and the areas is never quite the same.  This is the kind of injury where there was damage to either the soft tissues or to bone.  Long after the damaged tissues have healed the pain persists or returns during or after specific activities.

This is true of gradually occurring injuries as well.  Those are the kind that tend to go unnoticed until one day your foot swells up or your hip hurts in a new and disconcerting way.

When the injury keeps coming back it can be disheartening, because it can feel like the pain is going to be there forever, but it doesn’t need to be there forever and it probably doesn’t even need an aggressive intervention (like surgery).

You may just need to go through all the steps of the healing process in order, finishing one stage and moving on to the next.  A lot of people don’t do this and they end up getting stuck between stage 3 and stage 4 (see below), continuing in an endless loop until it looks like there is no way out.

The goal and end point of rehabilitation is smooth, strong movement; without pain and with reduced chance of future re-injury.  A common mistake is stopping just at the resolution of pain.

What are the stages of the healing process and how do we progress through them?

Stage 1: Become aware that injury has occurred.  

The importance of this shouldn’t be underestimated, without pain doing its job of getting our attention and providing the motivation for us to change we could continue on in a damaging situation…and we often do.  For gradually occurring injuries we sometimes continue for years until we notice that we are in pain and become motivated.  This is why I list it as the first stage of healing.  The moment we become aware is the moment when we begin to move away from injury and toward health.

Main pitfall: Not noticing you’ve become injured.

Stage 2: Reduce or eliminate exposure to further damage.

When people hear that they need to eliminate their exposure to damage they imagine it means a favorite or necessary activity has become forbidden to them.  This is where people often push back and say, “I have to do this activity!  It’s my calling, it’s my obligation.” or  “I can’t quit my job.”   If the solution to your pain were to just not do the things that you want to do … what kind of solution would that be?  Sometimes it is best to entirely refrain from an activity for a little while, but that’s just temporarily, until a solution can be arrived at.

Main pitfall:  Thinking that this is an either/or proposition:  Either I do the things that matter to me, or I live without pain.

Stage 3:  Normalize the tissue.

Normalizing tissue means doing things like stimulating collagen formation, removing nerve compression or tension, increasing circulation, decreasing hypertonicity and increasing range of motion.  What these things all have in common is that they are forms of movement; they are different ways to bring more movement to a specific area.  Pain is telling you your body wants you to change something; for instance to remove compression from a nerve, create mobile and functional scar tissue or reduce the pain from a tight muscle.  This is an application of very specific movement to a stuck area.

“Movement is essential for the health of all body systems and processes. It is the principal body function which is affected, altered and sometimes controlled by pain.”

~ David Butler from Explain Pain page 114

Main pitfall: “Catastrophizing” pain.  That’s a real word you can search on PubMed.  It means freaking out because something hurts…and picturing in your minds-eye your tissues being crushed or torn apart or whatnot each time the pain happens.  The problem is, when you do that it actually causes pain.  One of the ways this happens is that when you get scared and visualize damage you automatically hold the area more stiffly. The best solution to this pitfall is to reframe what pain is so you can react to it differently. (Because pain is not closely linked to tissue damage.)  That’s a big subject.  In short, curiosity is an antidote.  I’ll give you some resources for that…soon.

Stage 4:  Return to full activity.

You’ll start with a return to full range of motion.  You can do this through stretching (active stretching is most effective) and what is usually referred to as “strengthening”.  When people think of strengthening they usually think of building muscle. What I’m talking about is relearning that it’s safe to use the formerly injured area.  When your body was injured it instantly changed what you were allowed to do with the area.  After the tissue knits itself back together the body needs help relearning what’s safe to do.  For example; you may do some repetitions of a side lying leg raise, or a forward bend, but rather than thinking about building muscle you should be thinking about finesse.  How smoothly can you go through the motion? How completely can you contract and relax the muscle?

If your injury has been recurring for a long time you’ve built up a significant neural pathway for the compensating movement and it will require some tenacity to counter it with the new neural pathway (i.e. relearn the movement).  It’s like a path through the woods that you walk all the time. There’s a little groove there and the plants are beaten down, but there’s this other pathway you haven’t taken in awhile and it’s had sticks and leaves fall on it and the plants have grown up.  At first it’s going to be easy to slip into the well-beaten path.

In tandem with reeducating your body you are also learning how to do all the things you love to do with greater awareness of physics and function.  You can then perform the same activities that used to cause pain, but in different, more sustainable ways.

Main pitfall:  Lack of persistence.

There it is. I’ve listed each major stage and its associated pitfall.  If I had to pick one stage that seems the most problematic it’s probably stage 4, because at that point the pain is likely gone and when the pain goes away the motivation goes away.  But maybe you can see how not completing stage 4 will cause a tendency for future re-injury and the beginning of that very demoralizing cycle.

It’s not hopeless.  There are effective things you can do. 

Let me know if questions come up and if you liked this article and found it helpful.  I’d love to hear some suggestions for future articles.

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