Understanding Pain

Understanding the Pain :

Pain is a protection mechanism to preserve the body. If a stimulus is damaging to the body, your neurological system will relay information to the brain which will evoke a response. This is the common response to a painful stimulus, for example, place your hand on a hot plate, you will withdraw your hand quickly without consciously thinking about it. This makes sense, we understand it, there are very few problems associated with this.

Problems arise when we don't understand pain. Accepting it, gaining help to manage it and finally knowing why we are getting pain in the first place are the most important stage's in the recovery process.

Below are some examples where and why you may be getting pain and what may be needed to be done to resolve the issue:

The Muscle

Acute muscle tear or strain will cause a sharp "knife like" pain if you try to stretch or activate that area. Additionally there maybe a dull ache when you are at rest, this may imply a significant tear or strain. RICE (Rest Ice Compression Elevation) and gentle pain free stretches are important at this stage. 

Chronic muscle pain usually involves muscle cramping, tightness and an associated dull ache. Correcting any biomechanical issues, breaking down scar tissue and strengthening the region is important at this stage. Usually a complete tear will be visible, as the muscle will roll back on itself. If this is apparent we and/or your doctor will recommend surgery at this stage. 

The Bone

Acute fractures will cause a sharp "knife like" pain if any load is placed through the fracture site. Often night pain and a dull to severe ache is associated with this injury. In this instance surgery and or immobilisation will be key.

Post fracture pain will be dull in quality, it is important to gradually load the bone in this phase without any sharp "knife like" pain and mobilise joints above and below. Stress fractures are usually sharp in quality but can eleviate with exercise, however post exercise a dull ache or throb will be evident. A severe stress fracture will intensify with exercise. Reduction in training load and correcting biomechanics is key at the stage. 

The Ligament 

A partial tear will result in sharp "knife life" pain when the ligament is stretched. There will be no pain associated when the joint is compressed as the ligament is not being stressed. Stabilisation of the joint at this stage is important to prevent further injury and surgery.

A ligament that has completely torn will not result in a sharp pain when the joint is stretched as the fibres are not attached and therefore can't be stretched. A severe dull ache, joint instability and extensive odema is associated with this condition. The type of ligament torn will determine whether surgery or conservative treatment is needed.

The Tendon

A micro tear (Tendonopathy) will result in a sharp pain whilst loading the tendon, such as stretching or activating its associated muscle. As the tendon is used and the muscle warms up the pain will subside, however upon rest the area of aggravation will result in a dull stiff ache and an increased sharp pain with movement. At this stage muscle relaxation is essential to reduce tendon stress and aid recovery. Gradually loading the tendon once pain free is ideal to prevent scar tissue from forming and return to pre injury status. 

Complete tendon rupture will result in extreme sharp pain initially followed by an intense dull ache. In addition to this there will be an inability to move the joint that tendon is designed to move or extreme weakness if multiple joints are responsible for moving that joint.

The Nerve

Without nerves it is impossible to detect and experience pain. Nerves like to glide freely through their interface. A nerve gets irritated when a muscle or joint restricts the nerves available movement. This is extremely uncomfortable and is usually sharp or burning in quality. To differentiate nerve pain from other injuries you have to stretch the nerve at a remote place and reproduce the same specific pain without stressing the injured site. Mobilising tight muscles and joints, correcting biomechanics and moving the nerve pain free through its interface is important at this stage.

When a Nerve gets so irritated one will experience numbness, pins and needles, muscle weakness and  loss of sensation. If the symptoms persist or get worse and conservative physiotherapy treatment doesn't work, consult with your GP or neurosurgeon. Surgery might be indicated to release the trapped nerve. 

Severed or a complete nerve block will result in the inability to activate its supplied muscle or sensory area depending on whether it is a motor or sensory nerve.

The Brain

Without the brain is it impossible to interpret or perceive pain. Centrally dominant pain occurs when the brain misinterprets a non painful stimulus as painful or becomes hypersensitive. This pain is very real and is extremely difficult to treat, as there is nothing structurally wrong. There is a high risk of this pain turning chronic, as the mechanism and nature of the injury doesn't reflect the pain. Most people find this hard to comprehend. 

The best way to treat this pain is through education, identifying painful stimulus, gradual introduction of more challenging or painful stimulus and exercise. Every body part represented in the sensory and motor cortex of the brain, is constantly changing based on supply and demand. For example over the last 20 years the area in the brain that represents the thumb has tripled in size due to an increase in demand of activities such as phone texting. This is relevant to centrally driven pain as the area in the brain that has constant painful stimulus associated with it will increase in size and become more sensitive.    

The Blood Vessel

Certain blood vessel diseases such as peripheral vascular disease will cause claudication (intermittent pain with an increase in the demand of blood vessels such as during exercise). This pain will usually be associated with cramping, feelings of heaviness, pins and needles, numbness. Pain eases as soon as exercise stops. Building up tolerance to exercise is important with these conditions.

It is uncommon for blood vessels to be the cause of pain in young healthy individuals besides rare blood diseases. However during trauma blood vessels can tear causing odema. This swelling can compress nerves causing a intense sharp irritation with movement. Best treatment at this stage is RICE. During the repair of blood vessels excessive load placed on them prior to healing can lead to a dull aching throb.

The Joint (articular cartilage)

Excessive load of joints without adequate recovery leads to degradation of the joint surface. Loss of articular cartilage will cause pain as cartilage is somewhat smoother than bone. Increase in friction leads to irritation inflammation and swelling. This will cause a dull ache with associated stiffness when loading the joint. Increase in load will result in an increase in pain. Treatment at this stage involves assessing biomechanics to unload the damaged joint and preventing further damage.

If too much load is placed through the joint at a particular point in time a tear may result. This is usually very painful initially (sharp stabbing pain) and involves locking or restricted movement of the joint, as the cannot bend past the torn cartilage. Treatment at this stage usually requires surgical intervention or extensive physiotherapy involving muscle relation techniques, joint mobilisations and strengthening exercises surrounding the joint.

In conclusion

Pain is very complex and can come from a number of structures. To make it even more complex pain can be referred from another structure entirely. It is vital to understand the cause of the problem and have a clear resolution pathway. Everyone is different and therefore two people with the same cause of pain will respond differently to the same treatment. Find something that works for you.

Due to the complex nature of the pain a number of pathways can be taken to get someone pain free. The best pathway will depend on the person in pain. For most people it is the quickest and most cost effective pathway. To ensure this happens it is vital you find an objective measure that reproduces your specific pain. This is important to show effectiveness of someones treatment. For example if you can reproduce your shoulder pain (8/10) when you lift your arm up to 80 degrees, then by the end of the session you want either the pain to be less (<8/10) or the same pain but more movement (>80 degrees). CAUSE AND EFFECT.