Pain Does Not Equal Damage
Pain plagues us all, but when should we be worried about it and when can we work through it? To answer that, we have to have a better understanding of what pain is.
Pain is an alarm bell. It draws attention to a part of the body in anticipation of damage. That is the key, anticipation. You can hold your finger to a flame and feel pain before the skin actually burns. Past experiences inform the nervous system how to respond to stimuli. The nervous system is like a software program that constantly learns from new inputs. If you burnt yourself over a candle flame as a kid, you will be more responsive to this stimulus compared to someone who hasn’t.
However, damage and pain are independent of each other. You can step on your son’s lego with bare feet and a string of expletives will come flying out of your mouth, yet you can be bitten by a black widow spider while sleeping and not even wake from pain despite that it can cause serious tissue death.
This is not to say that tissue damage can’t be accompanied by pain, however all too often it is inaccurate. Once as a teenager, I fell on some wet leaves while playing street hockey. It wasn’t until I stood up and looked at the faces of my friends that I realized I had fallen on a broken glass bottle and the fat pad in my knee was hanging out. The fat pad is known to be a highly sensitive structure, yet I felt nothing. Until I looked at it.
Imaging is another good example. In a study of 1211 subjects ranging from ages 20-70, 87% displayed disc bulges on MRI yet had no pain (Nakashima et al., 2015). If you ever get a sense of hesitance from your physical therapist when you ask, should I get an MRI, it’s because of examples like this. We worry that we’ll find “pathology” that is benign, but can easily, and wrongly, be attributed to the pain you are experiencing. This can wrongly inform decision making as to the best course of action. There is an expression, “if you want to have surgery, get an MRI”.
The problem with the “pain equals damage” paradigm is that it can send you into a nasty feedback loop. It goes something like this: I have pain, so I should not move (and you’ve probably been told the dogmatic advice to rest it). The pain doesn’t go away, and you get weaker and stiffer, then the pain worsens. The cycle continues and now you are developing chronic pain.
There are situations where you have to immobilize something, like a fractured femur. We aren’t talking about these types of cases. We are talking about the back pain you get from an intense workout, the pain in your knee from running, elbow pain from tennis, etc. You want to stop the provocative movement, but you still want to move in a pain free manner. In the same way that the nervous system turns on alarms and sensitizes a tissue, it can also desensitize the tissue with pain free movement.
The process we use is called D2R2 and it looks like this:
D1: Desensitize
D2: Decongest
R1: Reperfuse
R2: Restore
These steps overlap, but the gist of it is to desensitize the area and maybe use some techniques like massage or foam rollers. This allows for pain free movement. Now use these muscles to “get the garbage out and groceries in”. I.e. get blood flow to the area. Then the last, and most important step is to restore. Restore what is missing. If you have pain, chances are something is missing in the neighboring joint. That is the true culprit. This is the problem with chasing the symptoms, they’ll just return unless you get to the root cause. When I see a golfer with elbow pain, the first thing I do is check their shoulder and wrist range of motion. Once we’ve reduced the symptoms, we restore the missing range of motion, and then the pain doesn’t return.
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References:
Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 40(6), 392–398. https://doi.org/10.1097/brs.0000000000000775