What is pain? What happens when pain does not go away?
Pain is one of many responses from the brain when it has received enough danger messages from one part of the body.
Let’s take a common injury:
You just cut your finger. So what’s happening?
1. Danger receptors in your finger send danger (or ‘fire’) messages up towards your spinal cord and then onto your brain. These messages travel through your nerves.
2. The brain (aka the big boss/computer) analyses, processes all the information received from the finger area as well as going through your memory of similar past events (that happened to you or to someone you know).
3. At the same time, it analyses information from outside your body, receiving messages from your vision and hearing, to know whether you are in a safe environment.
Why does it do that? Because in the unlikely event a tiger just happened to be behind you when you cut your finger, you would obviously need to escape first, and only once you’re safe would it make sense to start worrying about the finger. So the brain would release some adrenaline to help decrease the danger messages or even stop them for long enough for you to get to a safe place.
4. If your life is not in any immediate danger and there are enough danger (‘fire’) messages going to the brain, one of the response will be that you feel pain in your finger.
There will also be other responses, such as your immune system kicking in to start the healing process, muscles reactions, etc..
5. As the wound heals with time, there will be less and less danger (‘fire’) messages going to the brain. Therefore the pain decreases until it’s fully gone.
*However, sometimes pain levels are not proportional to the tissue damage (think about a paper cut, ouch!) but also it does not always equal damage*
How is that possible?
That’s because pain is there as a PROTECTOR, it can be a response to BOTH ACTUAL threat and PERCEIVED threat. It will feel the same either way, pain is pain. It is there so you can get out of a situation your brain perceives as dangerous or threatening to its wellbeing, whether it really is or not.
So, this is what happens with what we call “Acute Pain” or pain that has been present for less than 3 months.
The medical body considers that most injuries will be healed to their best ability within 3 to 6 months. For example, it ‘only’ takes about 6 weeks for a fractured bone to heal.
But what happens when my pain persists beyond this timeframe?
We don’t always know why some people’s pain persists once all the tissues have been healed, but we do know that it happens in around 20% of cases.
Going back to our finger analogy, the danger (‘fire’) messages from the finger always travel up the same road (the nerves).
Before the injury, you could say that the road wasn’t used a lot, it was a single lane
dirt road, with danger messages travelling through from time to time. For example when the finger was slightly touching a hot surface.
However, when pain stays for a while, there are sustained danger (‘fire’) messages travelling through that same road, meaning the road gets busier and busier.
So the old single lane dirt road has to be upgraded to a 2 lanes dirt road, then later on to a 2 lanes sealed road to then upgrade to a fancy 4 lanes sealed road and so on it goes.
The more danger messages travel to the brain, the more road upgrades have to be made by the brain. That is called central sensitisation.
Your brain is so smart, it learns to be more aware of that finger, more protective of it and more sensitised to any messages.
Your nervous system becomes wound up.
So what can I do to help the road go back to a good old single lane dirt road (and reduce the sensitisation)?
There are many things that can help reduce the danger/fire but be aware that there also are things that can increase it.
Danger/fire reducers (aka buckets of water):
They help secrete endorphins, which helps decrease the danger messages
ANY meaningful activites to YOU. That is things that you LIKE doing, things that bring you JOY, that make you PROUD, give you a sense of ACHIEVEMENT. Be it calling a friend or family member, playing with or petting your pet (or any pet, really), looking at photo albums of good memories, helping others, gardening, volunteering, working, etc..
Pain education. Because it reduces fear of the pain, improves your understanding of what is happening in your body, gives you some power back over your it.
Relaxation/Mindfulness techniques. Because it helps soothe your nervous system.
Sleep management. If you have issues with insomnia or pain at night, get help from a professional to work out how to improve it.
Medication. See your GP or a pain specialist to review your pain medication. What to take, when to take it, how many pills, for how long. Be aware that strong analgesics including opioids can get addictive with regular use and a tolerance can develop, meaning you will need higher doses as time goes by for the same effectiveness on pain. On the long term, opioids use can even create MORE pain. The evidence does not really support their use for chronic pain. There are other alternatives, discuss it with your GP.
Goal setting and Pacing plan to achieve these goals. Think about what you used to do before the pain started and that you would like to go back to or do more of without having a flare up. It can be about work/vocational related activities, social/family related activities, leisure/sport related activities or even domestic/personal activities. Find a practitioner with chronic pain specific knowledge/education to help you work out a pacing plan to achieve your goals and get you the tools to get there.
Danger/fire increasers (aka buckets of petrol):
These are stressors that induce the release of cortisol, which increases the danger messages
Negative thoughts, concerns, fears about the pain
Pain/recovery expectations (for example, my friend had low back pain 3 years ago and never got better, is this going to happen to me too?)
Grief, anger, depression, anxiety, etc .. Belief that pain always equals damage Fear avoidance behaviours of certain movements/activities
These can be worked on with the help of your healthcare practitioners, psychologists or ACT/CBT trained professionals. They will give you reassurance about what is happening regarding your pain, but also tools to use during difficult situations and day to day stresses.
It may look overwhelming. Know that you don’t have to do all of these steps in one go. Choose one, do some research about it, note your questions down and start your journey back to recovery. The other steps will slowly follow, at your own pace.
Here are some great resources to dig deeper into pain, chronic pain, mindfulness:
Have you recently found a passion for either tennis or golf? If you have, it is likely you have played it as often as possible to improve your skill set and potentially get the bragging rights over your friends. I mean who doesn’t want a win over a mate? Unfortunately however, your ability to keep playing is probably derailed due to the development of elbow pain. If this is you then you need to visit your osteopath for a thorough examination and diagnosis.
The elbow joint is formed by three bones: the humerus (upper arm), the ulna and radius (two bones in the forearm). The humerus has two raised bumps known as epicondyles on its end closest to the elbow joint itself (distal end). The lateral epicondyle is located on the outside of the distal humerus, while the medial epicondyle is located on the inside of the distal humerus. After explaining to your osteopath that your elbow pain developed after regular golf or tennis, they would complete their examination and likely diagnose you with tennis or golfer’s elbow.
What is Golfer’s and Tennis Elbow?
Tennis Elbow is medically known as lateral epicondylalgia and it is a tendinopathytype of injury. As the name suggests the pain and injury is located on the lateral epicondyle of the humerus. The tendinopathy occurs in the extensor muscles of the forearm, which originate on the lateral epicondyle of the humerus. Although frequent in tennis players who repeatedly forcibly extend their wrist on the backhand shot, it is more common in manual workers who perform tasks which constantly stress the extensor tendons. Manual tasks such as computer typing, carpenters and hair dressing can frequently result in ‘tennis elbow’.
Golfer’s elbow is 7 times less common than tennis elbow and is medically known as medial epicondylalgia. It is also a tendinopathy type injury and the location of the injury is on the medial epicondyle of the humerus. The muscles affected in the tendinopathy are the forearm flexor and pronator muscles, which attach to the medial epicondyle of the humerus. Although frequent in golfers, it is also commonly seen in throwing based athletes (baseball, cricket) and weightlifting. However over 90% of cases are not due to sport and are due to occupations suchas construction and plumbing. What causes the tendinopathy?As can be seen, it is the repetitive forceful action of the forearm muscles being frequently utilized that ultimately results in both forms of tendinopathies. Repetitive forceful extension of the wrist (a common action in tennis) can result in tennis elbow. While repetitive forceful flexion of the wrist and gripping (common action in the golf swing) can result in golfer’s elbow.
Your osteopath will use a variety of techniques such as soft tissue massage, mobilisation, manipulation and dry needling in a treatment consultation. The most important part of the recovery process is to complete rehabilitation exercises. Numerous studies have shown the benefits of exercise for tendinopathy injuries, including tennis and golfer’s elbow. Your osteopath will write up an appropriate rehabilitation program that will lead to full recovery and you getting the win over your mate in your sport.
Written by: Dr Jackson Redfern – Associate Osteopath – MOVE Osteopathy Alexandra Hills
Dr Jed Pullen – Senior Osteopath & Marathon Runner
What is it?
The achilles’ tendon is the lower attachment of the calf muscle onto the ankle. Achilles’ tendon issues often occur due to an increase in load through the lower limb and calf muscle. Overloading the tendon can result in tendon related problems. Increasing age, being male, and obesity can also increase your likelihood of injury.
Why do Achilles Tendon Problems occur?
2 theories exists:
1) Chronic degeneration: Chronic degeneration of the tendon may lead to a rupture without the need for excessive loads to be applied. It is also thought that impaired blood flow to the tendon with resultant lack of oxygen and altered metabolism could play a major role in injury.
2) Mechanicaltheory: Movement and force applied to the tendon may lead to tendon failure. Push off activities where the muscle and tendon has to go from a shortened position to near maximal contraction are likely culprits..The risk of injury increases when the body is unable to reduce excessive and uncoordinated muscle contractions. This is often seeing in those who train less such as the weekend warrior.
Types of Achilles Tendon Problems:
1) Chronic Achilles Tendinopathy
2) Achilles’ Tendon Rupture
1)Chronic Achilles Tendinopathy
Typically found in middle aged, male runners and is also associated with overuse/excessive load. It has been found that there is a 10 x increase in injuries in those that run compared to non-runners at the same age. 31% of those injured did not do vigorous activity which points to the fact the cause may be related to other influences. Metabolic or circulatory imbalances may be culprits. When we look at the tendon under a microscope we often find a change in structure without inflammation. This changes in collagen structure shows us that this is primarily degenerative yet non-inflammatory problem.
We find this in 2 places. 55-65% of the time it is located in the middle of the tendon and 20-25% it will also lie at the insertion of the achilles.
1a) Non – Insertional Achilles Tendinopathy
Pain: Beginning and shortly after finishing exercise.
Location: Most of the time it is located 2-6 cm above the attachment onto the heel.
Modifying activities, eccentric exercises, anti-inflammatories, injection and Shockwave therapy.
Eccentric heel drops: At 12 weeks 36/41 had no further tendon pain and the structure of the tendon had normalised.
Injections: These may be used to provide pain relief but must be completed under ultrasound. It is important to note thought there is a possible risk of future rupture due to the effect of corticosteroids. Platelet-rich Plasma is another option also a possible injection and has shown inconsistent results.
Surgery: This can also be an option if conservative treatment fails.
1b) Insertional Achilles Tendinopathy
Degeneration of Achilles’ tendon fibres at the insertion of the Achilles. This is normally associate with older age, steroid use, obesity, diabetes, and inflammatory conditions.
Pain: Mid point of the Achilles, worse in the morning and also very sore day post exercise. These individuals may also have prominent boney prominence near the top of the heel.
Activity modification is key: Reduce walking up hill, shoe lifts will help avoid pressure.
Eccentrics strengthening : Typically make this worse due to compression of the tendon.
RUNNERS + ATHLETES: How can we keep on moving and exercising whilst managing an Achilles’ tendon problem?
The last thing a runner wants to hear is to stop running all together. We need to manage the load going through the tendon to allow healing and reduce aggravation. One of the first questions we should ask ourselves is, “What has changed?”. Something has changed a sudden increase in load, a sudden increase in speed, a sudden increase in hills, a sudden increase in kilometres, a sudden change in gym work out, shoes, surface etc. A sudden change normally precipitates an injury.
We can massage the area to desensitise it, we can use rock tape which may provide the body with additional feedback and we can strengthen it. If we don’t take some load off the area then we won’t allow healing. How do we do this?
Reduce Intensity: Slow down your runs to a pace where your body is able to absorb the load.
Avoid running up hills: This stresses the back of the leg. It is great when you are healthy to strengthen the calf but can put undue stress on the achilles.
Running technique: Improving your running technique can be very helpful to avoid undue pressure going through your body. You may need to revert back to your old technique because you suddenly changed your style.
How do you know if you have done to much and overloaded the tendon?
There are 3 parameters that I look at for: .
1.Pain during your work out
2. Pain for more than an hour after your workout
3. Pain the next morning/day
The most overlooked parameter is pain the next day. People often don’t know what has flared them up as they felt great during their workout. Keep a look out for this key sign.
2) Achilles Tendon Rupture
It is common for ruptures to occur in healthy, active, young to middle age people approx 37 -43.5 years of age, with a ratio of M/F 5:1.
The tendon most commonly ruptures through the mid section 3- 6 cm from the achilles attachment often where there had been no prior pain. A sharp forceful push off or abrupt activity often causes it to rupture.
Alternatively you can get a tendon rupture where it attaches onto the bone. Normally this happens after ongoing pain for a period of time.
Should i get a scan on a rupture?
Scans aren’t completely necessary as this can often be diagnosed clinically by assessing the area. If we think surgery may be an option a scan is usually ordered to asses the severity of the tear. Surgery may be indicated if a gap of more than 5mm is found. Surgery can reduce the risk of tearing it again by 8.8% but comes with other complications.
Take Home Message!
Overall Achilles Tendon Problems can be a frustrating. The journey to full recovery is often a marathon not a sprint. Exercise and load management is the key to proper recovery of these particular injuries. Maintaining some form of load is also important, with the exception of tendon ruptures, to ensure the muscle is maintaining strength. 12 months of an evidence based loading program must be included for full recovery. It has been found to better than surgery to reduce pain and function. Seeking help from your qualified health professional as to the proper management regime is very important.
Load management, load management, load management is the a key to prevention and recovery of this often cranky ongoing tissue injury.
Dr Jed Pullen – Senior Osteopath. Move Osteopathy. Marathon Runner
Have you ever felt a big ‘click’ or ‘pop’ as you have opened your jaw? and wondered why does my jaw click?Or maybe when you have been chewing on some food it constantly makes clicking noises? Don’t stress! This is a common occurrence as up to 60-70% of the population will experience a dysfunction of the jaw at some point in their life. Good news is that it’s also very treatable by a health care practitioner
The jaw is made up of the temporal bone (part of the cranium) as well as the mandible. Together they make up the temporo-mandibular joint (TMJ). There is a small articular disc which divides the two bones up and provides a smooth fluid movement at the joint. There are lots of ligaments around the jaw which provide stability. The discomalleolar ligament arises from the smallest bones in your body (within the middle ear). If these ligaments get damaged, this will often lead to tinnitus or other inner ear conditions. That’s why there is a HUGE LINK between the ear dysfunction and jaw pain.
Muscles of the Jaw
There are many different muscles that attach to the jaw and allow movement in many directions. Closing – Masseter, medial pterygoid, anterior and middle temporalis, superior head of lateral pterygoid Opening – Inferior head of the lateral pterygoid, mylohyoid and digastric muscle, eccentric contraction of closing muscles against gravity
Retrusion (gliding jaw back) – Middle and posterior temporalis
Why does my jaw ‘click’? Exactly what is happening?
When you hear your jaw clicking, it is often a result from the articular disc being displaced. This can be due to a variety of reasons such as lax ligaments, muscle imbalances, arthritis, clenching/grinding teeth, trauma or sleep apnea. Treating these underlying issues can help get your jaw moving well with no pops or clicks!
How can an Osteopath help?
Using a variety of soft tissue techniques, we can release the tight muscles around the jaw and create more space within the joint capsule of the TMJ to allow greater ease for the articular disc to move when opening and closing your mouth. An Osteopath may also treat the cervical spine, as many muscles attach to both the jaw and neck. This is often why people who suffer from headaches are more likely to experience jaw pain. Don’t let jaw pain or constant clicking and popping sounds disrupt you in your daily life and come see one of our amazing osteopaths. You will be jaw-dropping amazed by the results!
Written by: Dr Ellie Sweeney – Associate Osteopath – MOVE Osteopathy New Farm and City
Dr Ellie Sweeney (Osteopath) graduated graduated from RMIT University with a Bachelor of Health Science/Bachelor of Applied Science (Osteopathy) and has also completed post-graduate qualifications in Dry Needling and Myofascial Cupping.
Do you experience a feeling of tightness at the front of your hip? If so, you probably try to relieve that tightness by stretching the problematic area. Did stretching only result in a brief period of relief? If this is the case and you want longer lasting relief, then strengthening the area is ideal for you. The culprit of this muscular tightness is due to weakness in the hip flexors!
The hip flexors are a group of muscles that function to bring the hip into flexion (bring the thigh towards the abdominals/chest). The primary hip flexor in the body is the iliopsoas muscle. This muscle actually consists of two muscles that converge to function as one strong muscle. One part of the muscle the psoas, originates by attaching to the vertebral bones of the lower back. It converges with the other part of the muscle the iliacus, which is located in the pelvis to attach to the big thigh bone (femur). Other muscles that contribute to hip flexion include rectus femoris, sartorius, tensor fascia lata and a few of the hip adductors.
How do hip flexors get tight?
The feeling of stiff and tight hip flexors is extremely common in the general population due to large amounts of time we spend sitting down. Those who it is likely to affect include desk workers, truck drivers, video gamers and the common Homer Simpson (couch potato). When we sit for long periods of time, the hip flexors (primarily iliopsoas) contract in a shortened/weakened stationary state. It is this mechanism that leads to the feeling of tight/weak hip flexors. Even though the hip flexors are already in a contracted shortened position, they need to be contracted over their complete range of motion for the body to best adapt and restore normal function. Our bodies were made to move, which is why it is important to stay active and avoid long periods of sitting.
Not only are tight and weak hip flexors annoying they can be quite painful. They can also lead to a range of other injuries. As the iliopsoas muscle attaches to the lower back, individuals with low back pain commonly also have tight hip flexors. Hamstring and gluteal weakness is extremely common as a result of weakened hip flexors. tIt can also increase the risk of hamstring strains. Furthermore groin and quadriceps muscle strains are at an increased risk due to contracting at higher loads to compensate for the function of the weakened hip flexors.
What can i do for tight hip flexors?
Stretching as-well as strengthening exercises are often useful for the hip flexors. Some strengthening exercises include, psoas march (standing or supine), dead bug variations, seated hip flexion with torso perpendicular to outstretched legs and reverse lunges with sliders.
The video below goes through some of these very basic exercises
This is only a select few of the potential exercises available. Each case is individual and unique. You should see an Osteopath or Physiotherapist if you have tight hip flexors. Your osteopath or Physiotherapist will be able to coach and prescribe these exercises and many more.
This isn’t to say that stretching has no benefits, however strengthening the hip flexors will provide longer term results and your overall body will thank you for it. Stretches are a great addition post strengthening.
Written by: Dr Jackson Redfern – Associate Osteopath – MOVE Osteopathy Alexandra Hills
Are you familiar with videos that circulate social media showing someone ‘cracking” joints or the spine? But what makes that satisfying sound and what does it achieve? Seeing an Osteopath will often combine various techniques tailored to you and your pain, one of which may include a spinal manipulation. The technique has been around for over 2000 years. It involves a quick thrust to a joint over a very short amplitude, thus the name high velocity thrust (HVT). Manipulation is also another name for an ‘adjustment’,
What is the crack?
Osteopaths, Physiotherapists and also Chiropractors can use this technique for treating neck and back pain. Manipulation is often also associated with an audible ‘crack’ or ‘click’ (which often feels very satisfying) and can be applied to various joints in the body. Contrary to the old wives’ tale, there is no evidence to suggest that this technique can cause arthritis, which I’m sure many parents have told their children, probably to stop them clicking their fingers at the dinner table. In fact, Dr Donald Unger spent 60 years cracking only the knuckles of his left hand. At the end of which, there was no degenerative differences or ailments. For this research he was awarded an Ig Nobel Prize in 2009.
Another outdated belief is that the click is produced by bone rubbing on bone. Again, this is not correct. The sound happens within the synovial fluid of a joint (a lubricant within the joint capsule which reduces friction). There is no contact between adjacent bones. This click happens when the joint slightly separates, creating gas filled cavities or air bubbles which then rapidly dissipate.
Does this technique realign your bones or put them back in place?
This is the oldest theory of spinal manipulation and not very accurate. Osteopaths use manipulations every day with various patients, the myth that spinal manipulations crack your bones back in place is only a myth. Practitioners did once believe they were ‘putting the bone back in place’, which is believable with the relief that often follows. In my clinical experience, patients who think their bones need popping back in are often suffering from acute back pain with associated muscle spasm or a restricted joint of the spine, of which manual therapy can help. Don’t worry, your bones won’t pop out!
(Evans, 2002)Evans, D. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), pp.251-262