NSW Sea Kayak Club – Pain Alternatives [62]

By Sally Jacobs – Sport and Remedial Therapist

Many people struggle to understand their injuries or know who to turn to for help. The purpose of this article is to help you differentiate between various types of injuries and the different types of treatments available.

Chronic verses Acute Injuries

Chronic Injuries can be defined as persistent injuries with an insidious onset. The injury develops over time and is a result of a range of factors which include our postural habits, the physical stresses we place on our bodies, nutrition, hydration and stress. The human body is not designed to remain in the same posture for several hours a day. Doing so will create imbalances in muscle function and altered posture, which in turn increase stress on joints and other tissues, leading to pain and dysfunction. Examples include chronic musculo skeletal pain, tendonitis, bursitis and Repetitive Strain Injuries (RSI). We often fail to seek treatment until the odd twinge or recurring injury become regular fixtures in our lives. The longer the injury exists, the longer it will take to resolve, so taking action early can save a lot of pain, frustration and money.

Acute Injuries arise out physical trauma, they include fractures, dislocations, open wounds etc. The coverage of these injuries in this article will be limited as they all require the same treatment protocol, being first aid and, depending on the injury, may require medical attention followed by physiotherapy.

Symptoms indicate which tissue is involved, it can be one or all of those listed below, in varying degrees of severity, and more than one tissue may be involved.

Nerve impingement:

Nerve impingement refers to pressure placed on a nerve or nerve root by surrounding tissue which may be bone, disc, muscle or fascia. Hernias and tumours can also increase pressure on nerves. Symptoms include numbness, tingling, pins and needles, weakness and sometimes a degree of loss of control of an affected limb. It is for example, impingement of the sciatic nerve that leads to a temporary numbness in the buttocks, legs and feet when you are paddling, caused by muscles tightening around the nerve. This may be due to poor technique, poor posture or poor boat fit, for example, due to direct pressure from the seat or having the foot rests too far back. You might ask an instructor to check your form and boat. Stretching the gluteal muscles and sports/remedial massage can help prevent and relieve these symptoms. However, if the symptoms persist after the activity which caused them has ceased, or they recur frequently, then medical advice should be sought. Your doctor may then recommend that you see an osteopath, chiropractor or physiotherapist.

Numbness in peripheral areas such as fingers or toes, or around the mouth can also be indicative of a viral inflammation or a metabolic disorder and should be discussed with your doctor.

Nerve impingement is often neglected as the symptoms are not severe enough to prompt action, yet it can be a precursor to nerve inflammation, a very painful and serious condition.

Nerve inflammation

An impinged nerve can become inflamed. The inflammation further increases pressure on the effected nerve and causes its dysfunction. This is symptomised by sudden sharp shooting or stabbing pain, which follows the nerve pathway, therefore it tends to radiate from an epicentre to another part of the body, for example, along a limb. It can cause muscle spasms and reduced function in the affected limb. In both nerve impingement and inflammation, the symptoms can occur with or without movement but are often worsened by specific positions. Sciatica, for example, is inflammation of the sciatic nerve and causes pain down the side and back of the leg, the inner thigh and into the foot. Viral infections such as Shingles also cause nerve inflammation.

Nerve inflammation can be excruciating. You should seek medical advice as soon as possible as permanent nerve damage can result if the cause is untreated.

Muscle spasms and strains

In the absence of an impact or accident, very few musculo skeletal injuries are “sudden”. They occur as a result of long term muscle tension, often brought about by remaining in one position for several hours a day, that is, sitting at a computer. A wry neck (torticollis) is an excellent example, where a normal neck movement can result in agonising pain and restricted movement.

When muscles remain in a state of prolonged contraction, blood flow through the tissue is restricted, thus reducing the delivery of oxygen and nutrients to the muscle and impeding the removal of metabolic wastes. Surrounding connective tissues and the nerves which run through the muscle are also affected; adhesions form in the myofascia – the slippery gel like connective tissue that is integral to the muscle tissue. The fascia not only provides the tensile strength of the muscle but also acts as a lubricating surface to facilitate the smooth glide of muscles and other tissues over each other. Adhesions in the fascia account for many of the postural changes which occur in our bodies and a significant amount of pain in musculo skeletal injury. Pain can refer through the fascia, resulting in a variety of symptoms from sharp jabbing pain on movement to burning and tingling. The latter is a result of nerve sensitisation caused by the fascia and or muscle impinging on the nerve endings and a build up of metabolic wastes in the tissue. Trig points form in the muscle, areas of hyper reflexivity in which dysfunctional nerve function will cause muscles to spasm, and shorten, thus reducing the normal range of motion. Any attempt to lengthen the muscle or achieve normal range of motion will evoke a “stretch reflex” which leads to increased spasm and pain. In this state the muscle is highly susceptible to injury through sudden movements or loads, and stretching should be avoided.

Before you get to the stage where you are experiencing the symptoms above, you will receive plenty of clues that all is not well. Over a period of time you will experience dull muscular aches, stiffness and muscle fatigue that is likely to be worse in the morning due to the build up of toxins overnight. Pain tends to dissipate as activity increases. These are signs that you need to take action! At this stage applying heat to the area and remedial massage can restore normal function and prevent injury. If you choose to leave it until you are unable to move without significant pain then you will need a longer course of intensive treatment. Regular massage and preventative exercises such as Yoga and Pilates can increase your performance and prevent injury.

Care should be taken if you have an injury – don’t forget most muscle injuries are overstretch injuries so seek advise from a sports massage therapist or physio before taking up new activities.

Acute muscle injury

If redness, swelling, turgidity or bruising are present as well as loss of or reduced function, massage and heat are contra indicated and can cause further damage. It is unlikely these will occur without some form of trauma, so the principles of acute injury management apply: first aid and see either a doctor or physiotherapist.

Tendon injuries (strains)

Tendons are the inelastic ends of the muscle which attach muscle to bone. A torn tendon will usually result in spasm of the muscle with corresponding pain and reduced function of the muscle and joint. The symptoms usually occur at the time of the trauma and, as with any acute injury, will worsen as the inflammation sets in. The tendon may be tender to touch, and there may be some swelling. It is important to see a doctor or physiotherapist for early treatment as you risk a permanent reduction or loss of function without judicial treatment.

Important! Do not stretch the muscle if any of the above symptoms are present. Seek treatment.

One of the problems arising out of tendon injuries long after the pain has gone is a perceived weakness. You may have badly sprained an ankle and found thereafter, that you roll the ankle for no good reason, that is, on perfectly flat ground. The likely cause of this is damage to the proprioceptors in the tendon which relay spatial information pertaining to the limb to the brain. When these receptors are damaged, the brain doesn’t know where your foot is in space, so that you may be putting your foot down on its side rather than the sole, hence you keep rolling your ankle. Special exercises are required to re-program the proprioceptor cells to prevent the injury recurring over and over again. A physiotherapist will be able to provide this information.

Tendonitis is inflammation of the tendon which usually arises out of excess friction of the tendon due to poor biomechanical function. This in turn may cause impingement of the tendon as is common in rotator cuff injuries of the shoulder. Pain and stiffness occurs on movement and there is usually restricted range of motion due to the pain. The tendon can feel tender or bruised to touch and, as with most inflammatory conditions, pain is worse after rest. This injury requires immediate attention. It will not self resolve. Stop any activity which exacerbates the pain and see a physiotherapist. They may refer you to a sports massage therapist for adjunctive treatment. Acupuncture can also be effective in treating tendonitis, but you should have the problem diagnosed by a doctor or physiotherapist.

Tenosynovitis is inflammation of the tendon sheath, occurring with or without tendonitis. The symptoms are similar to those of tendonitis, though the pain can be over a greater area. Again, seek immediate treatment from a physiotherapist. Massage is not usually appropriate. Acupuncture may be of benefit.

Bursitis

Bursa are fluid filled sacs which lie between tendons and bone and protect the tendon from excess friction between the tendon and bone. They are found around most joints. Bursitis is inflammation of the bursa due either to an impact or excess friction from a tendon. Pain occurs when pressure is placed on the bursa from lying or leaning on it or on movement as the tendon rubs on it. If the tendon and muscle are tight enough to result in bursitis, then the underlying cause is almost certainly a significant biomechanical discrepancy and it is likely that you are experiencing muscular and joint pain in other areas. The treatment may well require a multi disciplinary approach involving a combination of physiotherapy or osteopathy, massage and possibly a podiatrist, if the lower limb is affected. Rehabilitation is usually a lengthy process as the body has to go through a number of biomechanical changes for healing to occur. This problem will not self resolve.

Ligament and Joint Injury (sprain)

Ligaments attach bone to bone and provide stability of the joints. If the joint is overstretched ligament and cartilage may be damaged and the joint may be misaligned. Sprains are painful on movement or weight bearing on the joint and, because of inflammation, are likely to cause discomfort at rest. Often it is difficult to find a comfortable position. The pain is sharp and usually localised to the joint and corresponding muscles. The joint will feel weak and unstable. See a physiotherapist as you will need specific exercises to restrengthen the area as part of the treatment protocol. Ligament injuries are slow to heal and the resultant joint instability can give rise to other compensatory problems, for example, a weak knee can lead to hip, back and neck problems. Massage as an adjunct to physiotherapy or any of the above modalities will hasten your recovery and help in preventing the development of secondary problems. If the joint can not be realigned through soft tissue therapy, then manipulation may be suggested. This should only be attempted by a fully qualified osteopath, chiropractor or physiotherapist. Do not let anyone else manipulate your joints, ever! It could lead to a stroke or permanent disability!

To sum up, if pain persists or continues to worsen beyond 3 days, if you have an injury that recurs every few weeks or months, if you experience any symptoms mentioned above on a regular basis and they move around your body, seek advice.

If in doubt, see your doctor for advice on whom to go to for treatment. They will normally recommend physiotherapy or massage. Other options include chiropractic and osteopathic therapy.

The physiotherapist approach is generally focussed on treating the immediate problem area. If you have a neck problem, they focus on treating your neck. Physiotherapists are vital for treating acute injuries and providing rehabilitation programs after injury or surgery. Other modalities provide additional options for the treatment of chronic injuries:

The chiropractic and osteopathic perspective on health and disease emphasizes two fundamental concepts:

  1. the structure and condition of the body influences how the body functions and its ability to heal itself; and
  2. the mind-body relationship is instrumental in maintaining health and in the healing processes.

If there is a neck problem, then both chiropractors and osteopaths will look for other areas in the body and look at a person’s lifestyle.

Central to chiropractic philosophy is the importance of neurological function and its effect on the body’s ability to heal. Chiropractors work on the basis that by restoring structural integrity through chiropractic manipulation of the spine, neurological function and, therefore, the overall health status can be improved. Chiropractic treatment therefore is focussed more on manipulation of bone than facilitation of soft tissue and this is where they differ from osteopaths.

The osteopathic perspective is equally global but the difference between the two philosophies is that osteopathic principles are based in restoring and optimising circulation throughout the body without which cells cannot receive the nutrients and oxygen required to survive or remove metabolic wastes. Therefore an osteopathic treatment is more focussed on soft tissue therapy and facilitation rather than manipulation of bone structure.

Massage therapists are trained from osteopathic principles and focus on restoring muscle integrity. Often in the case of chronic injuries, several treatments are required, in order to condition the muscles to be able to accept change. That is, the removal of spasms, adhesions, trig points and correction of abnormal reflexes are critical for correct function to be regained. Massage is often used alone or as an adjunct to other therapies and is a powerful tool in the prevention and rehabilitation of injury.

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