Reflections: Understanding Pain

Pain, /pān/, noun

1. physical suffering or discomfort caused by illness or injury.

“she’s in great pain”

I spend much of my time working with people in pain. Injuries and illness are unprejudiced; making pain a universal that we all eventually have to deal with. In the end, the ways in which pain manifest, are not ubiquitous, and while I firmly believe that much of the pain people deal with can be quickly relieved, there are some limitations to what people can do. I think it is important to figure out where on the spectrum of injury one is, so as to determine what the best way to approach it is.

A) Aches and pains:

//Descriptors// – Achy, tight, sore while using or touching the tissue.

//Treatment// – sleep, proper nutrition, proper fasting, light movement, passive stretching, soft tissue work.

//Timeline// – recovery in 1-5 days. Berardi argues that full recovery takes 7-14 days.

On one end of the spectrum we have soreness. Usually this is an caused by increasing the load, range, or volume of work on any given part of the body. For the most part this is benign, whenever we increase loading beyond the capacity of the tissue itself we end up getting sore. Mind you, the question of why exactly we get sore is debatable, and the importance of becoming sore in our training is an item that I mull on a lot. Pavel made the great comment once that if your only measure of efficacy of training is soreness, that he should just beat athletes with a shovel, thus ensuring maximal soreness.

In that vein, Thomas Kurz made a comment in one of his earlier books that annoyed me when I read it a couple decade ago, and now I find myself starting to agree with more and more: physiological soreness is a sign that an athlete has trained too much. This comment makes some assumptions about general physical preparedness of any given athlete, but as is eluded to by Pavel, at a certain point, we have to start focusing our training on the CNS and not the physiological structure.

In short though, general soreness and fatigue are useful markers to let us know we have worked outside the bounds of what we are physiologically comfortable with. The best treatment for this, from my perspective is simple: sleep, proper nutrition, proper fasting, return tissue to length post training with a mix of soft tissue release and passive stretching, ensure it is moving well, then grease that with light movement/cardio.

B) Acute Injuries:

//Descriptor// – Sharp, hot, cold, continual pain, pain in movement or use of tissue

//Treatment// – Add to the list from A; hot/cold exposure, and really focus on blood flow

//Timeline// – 60-120 days for bone. 90 days for muscle. 180 days for tendons. Swelling hits a maximum in the 48-72hr mark.

If you rupture a muscle, break a bone, or smash your arm you have done some actual damage to the body. Injuries of this category seem to have some annoying limitations in terms of recovery that seem to be dictated by some physiological hard points. The difference in tissue recovery time seems to be dictated by blood flow. The issue of course being that if you injure your arm, and then rush about waving it around, trying to get blood flowing in it, you have a good chance of just causing more stress and strain to the tissue and slow down the healing process. So the goal is maximal blood flow without (sharp) pain. I think that we can massively change how we recover from acute injuries, and I think being coached in that recovery helps us from pushing things into the injured stage again by trying to return to regular activities too quickly.

If I have an athlete come in with a ruptured achilles, we are not going to be doing box jumps. However, this doesn’t limit us from getting as much blood flowing in the body as possible, and in trying to actively work the joints above/below the injury site. I am a fan of using heat to increase blood flow, and encourage pain free movement. Ice/cold come out when it comes to a specific need to decrease swelling so we can move the tissue again. I personally think these timelines can all be shortened if a person has the correct drive and is quick to work on maximizing blood flow.

The problem here comes down to the differences in tissue recovery time, and the fact that the CNS adapts almost immediately to the injury. The change in how we move often creates a far greater cascade of issues than the actual injury itself. Changes in movement patterns, and the fact that we can often feel we are recovered (perhaps muscle is recovered and tendons are not) when the tissue is partially recovered, results in another injury. This pushes us into the category of injury where things get really messy.

C) Reoccurring injuries. Movement related pain. Can become chronic pain.

//Descriptor// – Achy, pain in some movements.

//Treatment// – Hit athlete with brick. Trigger point release. Stretch tissue. Develop strength in greater range. Work on movement pattern changes.

//Timeline// – Minutes to decrease pain, usual timelines for tissue to recover from over-use.

I live here for the most part.

I have some athletes that have learned that attention to training post injury is the best way to avoid movement related issues, not to mention speed recovery, and minimize pain/boredom during an injury. However, most people who walk in the door are doing so because they have pain in some specific movement, or keep injuring something. I see far more people who have knee pain which won’t go away, than I see people who injured their knee the day before.

The nice thing here is that we can change this category extremely quickly. My aim is to find any tissue that isn’t moving well, and then prime the CNS to get it moving. Active release of tissue, passive stretching, movement under load at full range, and then more of the same.

This is the category of pain that can seem like voodoo in that pain can be dealt with almost immediately.

The longer standing issue here is that I still think most movement related injuries have resulted in a strain to tissue. Sure, I can show you how to change how your knee tracks and moves and decrease the pain in a squat almost immediately, but that doesn’t change the fact that A) you have learned a pattern that you are used to using that causes the pain, and B) the pain is just a great cue from the body that the tissue is stressed beyond its physiological capacity. This means that if we don’t put in some actual time to solve the underlying adaptations, your knee is still going to hurt when you snowboard.

Now the real value in this spectrum is understanding that at any moment we are likely occupying multiple spaces on that continuum, and using that information to inform how we train and approach our injuries.

So if we have had an acute injury to a pec (caught a hold on an extended arm while bouldering and got a sharp pain in the shoulder) that seems to have resulted in movement related pain that exists in certain angles (it hurts to lift my arm overhead and my pec hurts), the road to recovery is going to be a lot easier to navigate if we understand what is going on.

First off, a bunch of that pain might just be a locked up trigger point that resulted from you taking tissue outside of its normally adapted range. However, we really should aim to get the shoulder moving, work on changing the way you use your arm, and start developing strength at a further range. Yet, in all of this, you may very well have gotten an actual tear in your pec. The tissue itself may have some hard limits on the time it takes for actual recovery. Maybe it will take a full 180 days until you can load it fully again (assuming you don’t injure it again along the way).

The best athletes I have ever known adapt to injuries. They train other things. They work on weaknesses and try and figure out why they injured the tissue in the first place. Sure, they do daily work to speed the rate of recovery, but beyond that, they have grace. Rather than obsessing about the injury, and regularly making it worse, they do other things. They come back stronger, with fewer weaknesses. They treat injuries as opportunities to improve in areas they have neglected.

In the end, pain from injuries is a thing we will all deal with at some point. With effective training, patience, and some insights into how tissue moves, we can drastically change the timeline with which we can recover from these things. However, the far more interesting item is to ask the question about whether or not we can change our training so that we quit getting injured at all. That continues to be the item I am chasing. How do we train in a way that leaves us capable of our sports, regularly improving, but also free from injury?