Injuries

9 THINGS YOU SHOULD KNOW ABOUT PAIN

1. Pain is output from the brain. While we used to believe that pain originated within the tissues of our body, we now understand that pain does not exist until the brain determines it does. The brain uses a virtual “road map” to direct an output of pain to tissues that it suspects may be in danger. This process acts as a means of communication between the brain and the tissues of the body, to serve as a defense against possible injury or disease.

2. The degree of injury does not always equal the degree of pain. Research has demonstrated that we all experience pain in individual ways. While some of us experience major injuries with little pain, others experience minor injuries with a lot of pain (think of a paper cut).

3. Despite what diagnostic imaging (MRIs, x-rays, CT scans) shows us, the finding may not be the cause of your pain. A study performed on individuals 60 years or older who had no symptoms of low back pain found that 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc, upon diagnostic imaging.

4. Psychological factors, such as depression and anxiety, can make your pain worse. Pain can be influenced by many different factors, such as psychological conditions. A recent study in the Journal of Pain showed that psychological variables that existed prior to a total knee replacement were related to a patient's experience of long-term pain following the operation.

5. Your social environment may influence your perception of pain. Many patients state their pain increases when they are at work or in a stressful situation. Pain messages can be generated when an individual is in an environment or situation that the brain interprets as unsafe. It is a fundamental form of self-protection.

6. Understanding pain through education may reduce your need for care. A large study conducted with military personnel demonstrated that those who were given a 45-minute educational session about pain sought care for low back pain less than their counterparts.

7. Our brains can be tricked into developing pain in prosthetic limbs. Studies have shown that our brains can be tricked into developing a "referred" sensation in a limb that has been amputated, causing a feeling of pain that seems to come from the prosthetic limb – or from the "phantom" limb. The sensation is generated by the association of the brain's perception of what the body is from birth (whole and complete) and what it currently is (post-amputation).

8. The ability to determine left from right may be altered when you experience pain. Networks within the brain that assist you in determining left from right can be affected when you experience severe pain. If you have been experiencing pain, and have noticed your sense of direction is a bit off, it may be because a "roadmap" within the brain that details a path to each part of the body may be a bit "smudged." (This is a term we use to describe a part of the brain's virtual roadmap that isn’t clear. Imagine spilling ink onto part of a roadmap and then trying to use that map to get to your destination.)

9. There is no way of knowing whether you have a high tolerance for pain or not. Science has yet to determine whether we all experience pain in the same way. While some people claim to have a "high tolerance" for pain, there is no accurate way to measure or compare pain tolerance among individuals. While some tools exist to measure how much force you can resist before experiencing pain, it can’t be determined what your pain "feels like."

PT's Guide to Lower Extremity Stress Fractures

Lower extremity stress fractures are a relatively common injury seen most often in athletes playing sports that require repetitive impacts (running and jumping). Stress fractures make up about 8% of all activity-related injuries of the lower extremities. Female athletes are about one-third more likely to develop stress fractures in the legs and feet. While athletes may be more susceptible to these types of injuries, individuals who walk, march, or spend much of their workday on hard floors are also at risk. A physical therapist can help with recovery after a stress fracture as well as identify potential risk factors for prevention of future stress fractures.

What is Lower Extremity Stress Fractures?

Stress fractures are tiny cracks that occur in bone, usually related to repetitive activities that impact the bone in a similar way over time. These stresses lead to change in the normal process of bone breakdown and reformation. Stress fractures are most common in the feet and legs as these structures bear weight during walking, running, and jumping.

How Does it Feel?

Stress fractures are characterized by a sharp pain in a very specific point over the top of a bone. Lower extremity stress fractures generally hurt when you are up walking, running, or jumping. You may also experience aching pain in the area after activity.

Signs and Symptoms

With activity-related lower extremity stress fractures, you may experience:

  • Pain during activity (walking, running, or jumping)
  • Sharp pain over a specific point on the bone (point tenderness)
  • Swelling without bruising at the site of pain
  • Aching pain after activity

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist may ask whether you:

  • Have increased your activity significantly over the past weeks or months
  • Noticed an increase in pain with activity that slowly subsides after activity
  • Can touch a specific area on the bone that hurts
  • Experienced any specific event that caused your pain (fall, twist, collision)

Your physical therapist also will perform special tests to help determine the likelihood that you have an activity-related lower extremity stress fracture. For instance, the therapist may repeatedly bump on the bottom of your foot (called the "bump" test or the "percussion" test), MFPT.com Editorial Board Webinar or  gently push directly over the site of the injury or squeeze the bone. (You might feel some discomfort during these tests, which is normal.) Your physical therapist may use additional tests to assess possible damage to other parts of your legs.

To provide a definitive diagnosis, your physical therapist will collaborate with an orthopedic physician or other health care provider. The physician may order further tests, such as magnetic resonance imaging (MRI) or bone scan to confirm the diagnosis.

How Can a Physical Therapist Help?

Initial Treatment

Stress fractures are treated by resting the leg as much as possible. Whatever activities you are participating in that increase force in the legs (running, jumping or "cutting" in sports) must be stopped for at least 3 weeks in order for the bone to begin the healing process. Your physical therapist can decide whether you should use a compressive brace, crutches, or a walking boot to protect your bone while it is healing. Your therapist can design a specific treatment program for you to follow at home to help speed your recovery. Initial treatment will focus on muscle-strengthening exercises using bands rather than heavy weights.

As You Start to Recover

Your physical therapist's overall goal is to return you to your normal daily tasks at home, at work, and in the community. Without proper rehabilitation serious problems, such as chronic pain, swelling, weakness and more severe fracture, could arise further limiting your ability to perform your usual activities.

Your physical therapist will select from treatments including:

Range-of-motion exercises. Because you have been less mobile over the past few weeks, your range of motion may have decreased. A physical therapist teaches you how to perform safe and effective exercises to restore full movement in the joints of your legs.

Muscle-strengthening exercises. Even short-term inactivity weakens the muscles of the legs, increasing the potential for new injuries. Additionally, your stress fracture may have been related to some underlying weakness in the legs. Your physical therapist can determine which strengthening exercises are right for you based on the severity of your injury and where you are in your recovery.

Body awareness and balance training. Specialized training exercises help your muscles "learn" to respond to changes in your environment, such as uneven or unstable surfaces. When you are able to put full weight on your foot without pain, your physical therapist may prescribe these exercises to help you return to your normal activities. For instance, you might learn how to stand on 1 leg or stand on a wobble board, with or without your eyes closed, to challenge the muscles in your legs.

Functional training. When you can walk freely without pain, your physical therapist may begin "progressing" your treatment program to include activities that you were doing before your injury. This program will begin with slow, progressive weight-bearing activities, such as hopping and light jogging. Your physical therapist will create your own unique training program, based on the therapist’s examination of your legs, your goals, and your activity level and general health.

Activity-specific training. Depending on the requirements of your job or the type of sports you play, you might need additional rehabilitation tailored for your job or sport. Your physical therapist can develop a program that takes all of these demands as well as your specific injury into account.

Can this Injury or Condition be Prevented?

While there are no guaranteed ways of preventing lower extremity stress fractures, there are a number of factors known to be associated with their occurrence. These include:

  • Excessive impact physical activity (running, jumping, cutting) with inadequate rest
  • Running more than 25 miles per week
  • A sudden increase in physical activity
  • Consumption of more than 10 alcoholic beverages per week
  • Smoking
  • Inadequate nutrition, including low calorie and Vitamin D intake

Real Life Experiences

Joan is a 27-year-old runner with no history of previous bone or joint disease. She has been training for her first marathon, and recently ran her longest distance of 15 miles last Saturday. About 9 miles into her run, Joan noticed some pain on the lower inside portion of her right shin. It increased over the next 6 miles, and by the end it was sharp and throbbing, and the area appeared slightly swollen. The site continued to be painful to touch; Joan had difficulty walking even short distances without pain. She decided to contact her physical therapist.

On her first visit, her physical therapist took measurements of her hip, knee, and ankle strength and range of motion. He gently pushed on her lower shin and bumped the bottom of her foot. Joan stated that both of these tests recreated her pain. Joan consulted with her physician, who agreed to order a bone scan of her lower leg. Joan was diagnosed with a lower extremity stress fracture.

Joan's physical therapist provided her with a walker boot and placed a compressive brace over her shin, which she wore for 4 weeks. During this time, her physical therapist taught her how to gently exercise on a stationary bike and complete specific leg strengthening exercises with elastic bands. She also swam periodically for exercise. Joan was instructed not to run or walk without the boot. After 4 weeks, the boot was discontinued and gradual weight-bearing activities were started (weight shifting, stair climbing, small hops). Over the next few weeks, Joan's physical therapist taught her additional specific lower-leg strengthening exercises and helped her slowly return to jogging—and eventually running. He monitored her running form and suggested any changes she should make in her training. Now, 2 months after her injury, Joan has resumed her training with more care and attention to preventing injury for her next marathon.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat activity-related lower extremity stress fractures. However, you may want to consider the following:

  • Choose a physical therapist who is experienced in treating people with activity-related lower extremity stress fractures. Some physical therapists have a practice with a sports or running focus.
  • Choose a physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have stress fractures.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

For more information, visit www.apta.org/ 

TWO-A-DAY SEASON

As our "boys of fall" begin practices again before those friday night lights turn back on, it's crucial that their bodies be as prepared as possible for the affects associated with such a strenuous routine.

1. Eat 

Carbs and proteins are going to be essential to rebuild the tissues that inevitably break down from exercise. Two-a-days are meant to maximize the time spent prior to the start of the season, meaning coaches are trying to improve your strength, speed, and confidence as much as possible to start off the season on a good note. The only way to build tissue is to break it down, first - meaning workouts will be difficult. It's crucial that you increase the calorie count when the workout routine increases, as well - by as many as an extra 1,500 calories (on average) per day, depending upon the workout and the athlete's body type. Make sure to get proteins and carbs in your system within 2 hours of finishing a workout, but your body is most efficient at allowing proteins and carbs into your cells within the first 45 minutes. Not only will your body recover faster when you're well-fed, but keeping the energy stores in your body plentiful helps to improve the duration you can withstand a workout at such a high level. 

2. Drink - and don't drink

Athletes of all ages: staying hydrated is so important. Keeping electrolytes in your system by means of gatorade or pedialyte (for quick replenishment), and drinking plenty of water throughout the day will help you to stay hydrated during those long days out on the practice field and in the weight room. It's hard to hold a practice and manage thirst in full padding in 100+ degree heat for coaches; to keep athletes properly hydrated, they'd need to allow water breaks every 10 minutes or less. This turns into an extremely inefficient practice, which is why it helps to seriously manage hydration when not in practice.

Collegiate athletes, on the other hand, also need to limit their alcohol consumption during, and leading up to the start of two-a-day practices to help keep them hydrated and firing on all cylinders. One episode of binge drinking just about wipes out all progress made in 2 weeks worth of workouts, physically, and the aftermath of a binge drinking makes maintaining mental focus very difficult. 

3. Rest

Get plenty of rest. Adjusting to such an extreme amount of high level physical activity will wipe you out - and it's crucial that athletes accommodate their sleep schedule to help reduce fatigue in the days following. Sleep is when your body does most of it's healing - and you will need time to heal and recover to be able to make it through the next day, let alone the next couple of weeks. 

4. Take Advantage of Breaks

Any breaks you're given during a workout - take them. Instead of having to run to drink out of a fountain, keep a large water bottle with you to help you minimize time spent running to get to and from the drinking fountain. 

5. Know Your Body

When you realize you're beginning to severely overheat, back off of a workout. It's imperative that you listen to your body. We understand that most coaches are tough on their players, and therefore, expect them to finish the workouts and only take breaks when allotted with the entire team. The best thing you can do in these situations is back off whatever you're doing; whether it be running, burpees, lifting, etc. by slowing down your pace, lifting a little bit less weight, or taking more time to recover between sets. 

6.  Talk to the Coach

Need an excuse for a break? Go talk to your athletic trainer about a stretch for an "old injury" or a "cramp" or go talk to a coach about something he may want you to do. This will give you some time to recover while still being productive.