The Pain Game: Pain Perception


“Stop being a woos” , “I’ve done that, they don’t hurt that much”, “hard up princess”…all common sentences which enter the Australian vocabulary on a regular basis in order to tell someone that the pain they are feeling wouldn’t affect you in such a way. How a person perceives pain is completely individualized and personal to that person at that particular time.
What impacts our perceived pain can be as simple as reduced sleeping hours to anxiety about a memory associated with the same interaction from when were a child, and even more complicated than that.
In this article we look at what pain is to people, how culture and history effect pain and the complications associated with pain perception.

The amount of pain which is felt by an individual is not necessarily equivocal to the amount of tissue damage which has occurred at the time of trauma or thereafter.  Pain is the body’s best alarm system in the face of danger, if tissue damage has occurred to some extent and pain is not felt then there is a high chance the brain has not interpreted this change in tissue structure or chemical structure to be a threat. The brain is our interpreter of all messages; it is the deciding factor if we as individuals feel pain. Age and gender have shown to not influence how we feel pain, however; life experiences and cultural identity have an influence on how we express pain.
A female is more likely to be honest about her pain before she endures child birth, after this time it is a social influence which tells her that nothing will ever be as painful and therefore a true pain expression is suppressed.
Similarly, a male is seen to hide his pain in many cases due to being seen as a protector and provider in a social text which should not show weakness.

The unfortunate downside to the suppression of pain acknowledgement or expression is that trauma of significant nature can go untreated and result in further issues down the track such as re-injury, poor mobility, loss of use and mis or undiagnosed issues of severity.
Missing your optimal repair time can lead to the formation of scar tissues, misalignments and below optimum activation.

Pain has been identified to feel different within different tissues, once again, the descriptions which are provided by many patients are those which best makes sense to them. Bone and joint injuries are commonly described as a grinding, gnawing or aching feeling, much of the time these descriptions are made as it makes sense to use from a mechanical point of view. As mentioned in our previous pain article https://footnotesblogging.com/2015/05/21/the-pain-game-a-very-basic-anatomical-and-physiological-process-review/ as pain hangs around for longer and longer time periods the type of pain which is described, regardless of body region changes.
Severe muscle injury is something which is not too common; many times the muscle fibers which have undergone trauma are superficial and heal quickly. The reason for this is due to the muscle flexibility and adaptation. When we develop or receive trauma associated with muscles our innate survival mechanisms kick in and the once long stretchy muscles shorten to prime ourselves for escape or battle. If this continued over a long period of time due to ongoing pain or for that matter fear of pain then there can be negative consequences associated with that behavior. This is important to note for practitioners who are wondering, why, if they believe everything they are doing is correct, why my patient is not getting better. The quick response which many forget over the years is to treat the person not the problem.

Central sensitization of the nervous system in the very simplest terms is brain and spinal over activity after the healing process has completed. It is at this time when addressing a chronic injury that it is important to understand the reasons behind the pain and not just the diagnosis itself. Of course the first component most practitioners are comfortable with is nociception contribution as this is focused on so intently at educational institutions. However, this is only one part of the puzzle. What attitudes and beliefs does this patient have in regards to pain? Are they blaming themselves, do they feel as if they are being punished by a higher being or trying to push on through a something they should be resting?
This can also lead to a state of suffering, a time where a non-vocalization of a feeling is eating the patient inside which may increase fear or bitterness towards others “all the quacks can’t seem to get it right!”
Pain escape behaviors may manifest within these suffering thoughts; there may be a leading toward unconventional self treatment with drugs and alcohol. Retail therapy may begin to occur as a distraction from the pain they feel, this however can also develop into gambling and adult gaming which can have further affect on the patient and their family. This then leads us to the social environment and the impact it can have upon a patient; locking themselves away from others, reading blogs on their particular issue with an obsessive demeanor.
All these issues need to be addressed when treating a person and not just the condition presented to you, this is why developing a good referral system with those of different abilities is essential for best patient care.

And this is where things can become messy for a patient, all these practitioners of different backgrounds, beliefs and theories about what is best for a patient can be confusing and lead to increased anxiety. It is highly suggested that a team be developed together, in the best interest of the patient with a General Practitioner or Specialist over-looking all treatments and educational processes which are being taught.
The patient should be fully understanding of any prescription supplied or medical practitioner which they are referred to and the role they will have in treating them.
Any and all questions asked by the patient should be answered in a manner which the patient will be understand – any information which is considered to be too in-depth or an overload of information is given then it should be given in writing for consideration at a later time.
It is important that the patient avoid health practitioner dependence and be aware of the part they play in bettering their own health. As well as how they aim to reach short and long term goals with the aid of their health practitioner team.

This summary has really just been the tip of the iceberg that is pain perception. If you have found it as interesting as I did when learning about it, I highly suggest you look up some of the references labeled below and view more of Lorimere Moseley’s videos on youtube or TedX.
As we have seen, a person’s pain perception and then how they display that perception of pain is highly variable and subject to change due to life experiences. Pain is the primary reason most allied health practitioners are sought out for consultation and without understanding pain itself or what pain is to that individual we cannot possibly provide optimum care.
Until next time

Jackson McCosker
Director /Chief Editor

References

Butler, D. S., & Moseley, G. L. (2014). Explain Pain. Adelaide: Noigroup Publications.

Butler, D. S., Beames, T. B., Giles, T. J., & Moseley, G. L. (2012). The Graded Motor Imagery Handbook. Adelaide: NoiGroup Publications.

Garland, E. L. (2012). Pain Processing in the Human Nervous System. Primary Care Clinic and Practical .

Shin Splints: An Overview of an Umbrella Term


Shin Splints: An Overview of an Umbrella Term
The word shin splints has been used by patients and practitioners alike for  years to quite commonly cover a number of conditions which is probably not so appropriate for that ailment. From compartment syndromes to Tibialis Posterior injury to Medial Tibial Stress Syndrome and Stress Fractures, the term shin splints has been touted as the key term to use when patients describe a dull ache with the occasional sharp stabbing at or around the tibia bone.
The primary focus of the this article will be that of the both medial and anterior stress syndromes, how they come to be, the preventions which can be put in place and the how as a practitioner diagnosing and providing intervention early can be easily achieved.

Medial/ Anterior Tibial Stress Syndromes are simply defined as overuse injuries of the tibia or surrounding musculature due to repetitive contractions or tibial strain associated with overloading.
Patients will commonly describe the pain as diffuse ache running along the medial or anterior aspect of the tibia with occasional bouts of sharp pain during activity. Shin splints has an incidence of 4-35% and is seen to be most prevalent in runners, dancers and military recruits.

A conclusive etiology for medial /anterior tibial stress syndrome has not been decided upon by the research community. Periostitis of the tibia bone while under repetitive load has been floated regularly amongst the literature; however, more recent studies suggest that the conditions can be placed within a spectrum. The idea of a spectrum for issues associated with excessive or over indulged load almost seems too convenient. Put simply – what chronic condition cannot be put on a spectrum?
The use of a spectrum places MTSS/ATSS into its own umbrella term with a less laymen descriptive name for the condition.  This has potential to open up a whole other issue associated with how specific we should be when labeling a condition and the treatment options, legal ramifications and perception of incompetence it can have upon a practitioner; so to limit the rant let’s stick to the issue at hand.
Other authors have put forward the theory that fascia plays a significant role in the physiology of shin splints. Bouche and Johnson have described the contraction of deep leg flexor tension being placed on the tibial crest, however, although sound in theory this has only been backed by the use of nonspecific soft tissue interventions.

The development of shin splints has a high correlation with rotation forces upon the lower limb. This can be contributed to a number of defining factors however, poor proximal strength of the glutes and core muscles as well as excessive pronation at the rearfoot are most likely when assessing a patient.
The importance of proximal strength and lower limb injury can be revisited here: https://footnotesblogging.com/2015/02/26/proximal-muscle-strength-and-foot-injury/
Excessive pronation beginning at the rearfoot and therefore increasing rotation upon the tibia can be addressed both individually and as a multiple approach prevention tactic; strengthening of both extrinsic and intrinsic muscles are required for slowing of pronatory forces however to what extent you can limit pronation through strengthening alone in an individual is yet to be seen, the aim is to develop the body to be able to handle the stressors placed upon it rather than limit pronation itself.
The use of offloading devices can also be useful in the prevention of shin splint development or re-occurrence. Highly dependent on the individual and their identified biomechanical contributors, this can be as simple as a 4mm medial wedge to the use of a custom orthotics. Of course using the in-shoe devices to offload or limit the pronation at the area of concern while strengthening over a period of time would be expected to yield the best results.
Additionally, increasing lower leg flexibility and reducing soft tissue tension will also have a positive impact on the prevention of shin splints.

To ensure that a correct diagnosis can be made a full medical history, activity log, biomechanical and footwear assessment should be obtained. The observation of tell-tale training errors should be noted as well as any surfaces the patient may be training on which are considered inappropriate. Female patients have a greater risk of progression through to stress fracture and should be considered for more in-depth medical imaging earlier in their presentation.
The most common misdiagnosed or potential differential diagnosis are those which would fall on the previous discussed spectrum but are as follows; acute or chronic exertional compartment syndrome, muscle tears, stress fractures and syndesmosis injury. Other conditions are more aligned with cardiovascular issues such as; peripheral vascular disease, venous thrombosis, popliteal artery entrapment and infection.
Imaging is not generally required when diagnosing shin splints, however, MRI has begun to be the more sort after technique due to the ample information it is able to provide for both soft and hard tissues of the body.

Conservative treatment for shin splints is best done through a multiple intervention approach. In the acute stages it is highly advised that the use of rest/offloading, icing and NSAID use is put in place however, this should not exceed any more than the first 48hours. In the sub-acute phase training modification should be look at; in most cases decreasing activity levels by 50% will be enough to improve symptoms without complete cessation of activity. Additionally, in replacement for the reduce high impact activity a regime of lower leg stretching and eccentric strengthening may be used to reduce fatiguing factors associated with contributing biomechanical abnormalities.
Footwear can be used as a modality by reducing the amount of shock distribution through the lower leg with the correct cushioning. In-shoe devices such as medial wedging, D-fillers and custom orthotics can be also used if deemed appropriate with the shoe which is best suited for the individual.
Soft tissue therapies such as; massage, mobilization, dry needling and assisted stretching all have a place in improving muscle tensions however there has been very little in the way of RCTs published specific to shin splints.
Finally, proprioceptive training is necessary for neuromuscular education and adaption. This modality is has been one which has been overlooked for time and time again but is beginning to hit mainstream clinical implementation with recent publications related to ankle instability and the impact of proprioception tasks on tendon rehabilitation.

More invasive treatment options are available for shin splints although are only used in very rare cases. Posterior Fasciotomy is reserved for those with recurrent shin splint pain which has not been successfully reduced via conservative approaches. The surgical option has shown relatively positive result with 69%- 92% having significantly reduced symptoms.

In closing the use of multiple interventions which focus on soft tissue therapies, flexibility improvements, reducing rotational forces and when appropriate referring for surgical opinion will lead to faster recovery and return to sport for the athlete. Being able to educate the patient about the condition they have and how each intervention put in place will move them a step closer to recovery is an important factor in increasing compliance. Keeping a patient in the dark about what their condition is and why treatments are put in place only leads to mistrust, skepticism and following that, self discharge or delayed heeling.
Get the patient on board from the start and allow the patient – practitioner relationship to blossom!

In our next article we take a look at Part Two of our pain series with a step away from the anatomy and physiology of pain and the delving into the psychology (this is the interesting stuff!)

Jackson McCosker
Director /Chief Editor

References

American College of Sports Medicine. (2015). Exercise-Induced Leg Pain. 1-4.

Angoules, A. G. (2015). Medial Tibial Stress Syndrome in Athletes: Diagnostic and Therapeutic Approach. Journal of Novel Physiotherapies , 1-2.

Aweid, O., Gallie, R., Morrissey, D., Crisp, T., Maffuli, N., Malliaras, P., et al. (2014). Medial Tibial Pain Pressure Threshold Algometry in Runners. Knee Surgery Sports Traumatology Athroscopy , 1549 – 2558.

Galbraith, R. M., & Lavalee, M. E. (2009). Medial Tibial Stress Syndrome: Conservative Treatment Options. Current Review of Musculoskeletal Medicine , 127-133.

Moen, M. H., Holtslag, L., Bakker, E., Barten, C., Weir, A., Tol, J. L., et al. (2012). The Treatment of Medial Tibial Stress Syndrome in Athletes; A Randomized Clinical Trial. Sports Medicine, Arthroscopy, Rehabilitation Therapy and Technology , 4-12.

Schulze, C., Finze, S., Bader, R., & Lison, A. (2014). Treatment of Medial Tibial Stress Syndrome according to the Fascial Distortion Model: A Prospective Case Control Study. The Scientific World Journal , 1-6.

Carlton’s Cameron Giles Navicular Nightmare


Cameron Giles (Jumper 19)
Carlton Football Club
DOB 05/05/95
195cm
93kg
Second round of the 2013 National Draft, Cameron Giles played the 2014 season in the VFL before succumbing to a season-ending fracture to the navicular bone in his foot.

FN: Hi Cameron,
Thanks for having a chat to us today. I have been looking forward to hearing how you have been getting along since succumbing to your injury in 2014. I think the best way to do this is to start from the start.
In your own words are you able to tell us what exactly happened and if you were feeling any pain in the lead up to the diagnosis of the injury?

CG:
I got drafted as an 18 years old, came over from SA, I had no previous injuries or foot trouble. I played 6-7 games in the VFL and began to get some pain in my metatarsal, which was diagnosed as a hot spot and saw me sitting out for 3 weeks at which point we re-scanned and at that point they actually found a crack in my navicular. Because the hot spot was so large in the first scan they actually could not see the navicular issue in the first instance. When they found the crack in the navicular, they CT scanned me and found I had fractures in both naviculars which were a bit of a shock.
The decided not to operate on the left foot, but they did on the right which involved; 4 screws, a metal plate, a bone graft and a bit of an ankle clean out as well. At this point I hadn’t had any trouble with my left foot. Then 6 months after the surgery I underwent a re-scan on my right foot at which point they found a bone cyst which required another surgery and sequential bone graph.
I’ve only just started full body weight running, 12 months on from my initial surgery. The running has primarily been completed on grass, so about four sessions on grass and previous to that I have been running on the Alt-G machine which allows you to run at different bone weights. So I started at 40% body weight and worked my way up to 90% before getting back onto the park for some straight line running.

FN: From a medical perspective who were the practitioners that took care of your case from start to finish?

CG: So the footy club has been really good in helping me with my recovery. I had 3 physios and I guess Mark Homewood has been the main physio looking after my recovery stuff. The surgeon was Otis Wang, he operates mostly out of the northern Melbourne and the club doctors work pretty close with that stuff as well. Otis is pretty confident that the injury is fixed now and has been consulting about the injury from the beginning.

FN: Have you had a podiatrist look after you at all?

CG: yeah, so there’s a podiatrist at the club, I’m currently wearing some heel lifts with an off the shelf orthotics which has been heat moulded to my feet. His name is Dan, he just works with a couple of the boys and looks at how you walk and how you run – he’s pretty happy with how I’m going, I just catch up with him once a week.

FN: A navicular fracture is a pretty scary injury to deal with for both player and practitioner given how dangerous it can be with reduced blood supply and response to treatment, how have you managed to cope both physically and mentally with this injury?

CG: In the beginning they were a bit skeptical on whether they should do the surgery or not, but once they found the crack in the navicular they decided it would be best to just get it done. They said that my age worked in my favour and had a bit of time to recover and still have the chance to play AFL. Obviously, navicular is a bit of a scary word, and I guess I was probably a little ignorant to the seriousness of the injury. But I have had a bit of support from Jack Trengrove, him and myself are pretty much on exactly the same timeline for recovery. I am probably a little ahead of schedule, but I catch up with the physios once a day to try and increase my range in the right foot. At the moment it is probably only 50% of what I can achieve on my left. At the moment the most annoying thing is pulling up really sore after a run and having to have three days off.

FN: Since the injury have you spent much time back in South Australia or have you tried to spend as much time around the club as possible?

CG: It’s been pretty tough; I was pretty a bit immature in not knowing what was going to happen after the navicular surgery. I have tried to keep myself pretty busy, outside of footy I’m studying psychology at Melbourne Uni, I had Matty Kreuzer out with me at the same time which gave me someone to catch up with, and just tried to have fun around the club as much as possible.
About 2 weeks after the surgery I went back to SA to see the family, but I have tried to stay around the club as much as possible to stay on top of my rehab.

FN: What has your exercise regime looked like over the time since completing your injury?

CG: It’s been a pretty good chance for me to improve my upper body, I have been completing about 3-4 sessions a week in the weights room, doing a bit of boxing and plenty of cycling to get some condition back in the legs. Every now and then I have been doing some cross fit type stuff for the upper body and that’s done at another gym – so once again a change in environment helps with the motivation side of things. I have done a lot of swimming also!

FN: It’s coming up to July which was meant to be your time to test out a return to full senior training, do you believe you’re on track to see yourself removed from the injury list or even step into the backline for senior squad?

CG: I’m still on track, in fact as I said earlier I am probably a little ahead of schedule. If I get back to full training in July, I will probably start playing in July as well. In a few weeks Ill start joining in and doing a couple of drills for a month or so but my main goal is to return to full running. Its a bit of a waiting game at the moment but it seems to be all on track.
The AFL is probably a little too far away at the moment, I’m coming off a very limited pre-season in my first year and zero pre-season this year, so just looking to play some good footy in the VFL and see how I go in that regard. If I do get back into the team we will probably looking at the last 7-8 games, but it’s all about just playing some consistent footy for me right now.

FN: What kind of shoes are you wearing most of the time? Do you have a range of them or do you stick to the most comfy pair? What football boots do you wear and is it associated with a sponsorship deal?

CG: So Carlton is sponsored by Nike, so I have been wearing Nike for the last 2 years just with the orthotics and the heel lifts inserted into them. I have always worn ASICS before but it doesn’t really matter what shoes you wear as long as you have the support from the orthotics.
I might wear a different range of boots when I get back to training, so wearing the more supportive ASICS boots because they are more like a runner and work back into wearing Nike.

FN: Well thanks for talking to us mate and all the best for the future.

Cameron’s Progress can be followed at:
https://www.incogo.com/member/journeybox/1211?home=true

Jackson McCosker
Director /Chief Editor