Severity first, then acute or chronic
The things we would be most concerned about when informing a patient what they should do moving forward in regards to their training when they have an injury is understanding the severity of the injury, and then understanding whether that injury is more of an acute onset or a chronic onset.
Generally speaking, if an injury is more acute and the significance of the severity of the pain is higher, that’s going to give us a more conservative approach on how we address that patient in regards to their training. If the pain is more chronic and the severity of the pain is more mild, we’re more apt to be a little bit more aggressive or lenient with how we’d inform a patient to move forward in regards to their training.
An armbar, no pop, and two weeks off the mat
We had an MMA fighter and jiu-jitsu athlete recently who had a competition. During the competition, they suffered an injury to their left elbow because they got placed into an armbar submission. During the match, there was no popping or snapping noises associated with the injury, and the patient did have pretty sufficient range of motion within their elbow immediately after.
But the day after the onset of injury, the patient lost significant range of motion in their elbow and they were unable to move their elbow sufficiently through full range of extension. There was no bruising or swelling around the elbow, but range of motion was significantly reduced and their pain was reported to be over a seven out of ten on the pain scale.
With this patient, our advice was to have a much more conservative approach to their training. Obviously as an athlete, they want to try to get to regular training as quickly as possible, but we advised them to essentially rest from any sort of sports-specific training for at least a couple of weeks and to perform more isolated or rehab-specific exercises to expedite the healing process of their elbow.
Rehab that stays under a five out of ten
The two primary objectives with this patient’s symptoms were reducing the pain, increasing the range of motion, and reducing potential inflammation from the acute injury. We did very light weighted exercises helping to eccentrically load the elbow back into establishing normal amounts of extension range of motion, as well as pronation and supination range of motion.
With any sort of acute injury, there’s more likely to be pain associated with even performing rehab. So we advised them not to go over a five out of ten on the pain scale, and only to move their elbow through ranges of motion that they could tolerate up to that five out of ten pain. For managing inflammation, we advised switching between heating the muscles around the elbow to help relax the musculature and icing to help reduce inflammation within the local region, plus topical diclofenac cream to get some nonsteroidal anti-inflammatory activity in the area, and regular oral anti-inflammatories as needed.
80% range of motion, 75% less pain
Before someone goes back to sport-specific training, we’d be most concerned with establishing at least around 80% range of motion within the injured area. And with loaded movement, having at least around a 75% reduction in the amount of pain they had felt when they first came in.
When managing an athlete or anyone who takes their training very seriously, it’s very unlikely that you’re going to be able to rein them in to be 100% recovered and have 0% pain within an area before they can get back to training. Quite frankly, sometimes waiting until someone feels 100% before returning to their sport can actually impede the healing process a little bit. Complete rest has its own detriment: it might increase stiffness, it might increase deconditioning in the athlete.
So you want to get the injury healed enough that they can likely perform most of the activities associated with their training without a significant risk of re-injuring the area or making it worse, but also not waiting too long, where the deconditioning or the sedation of not training actually backlashes and can potentially make things worse or make them more susceptible to injury because of those factors.
Returning to sport doesn’t mean returning to 100% intensity
One of our clinicians, Zach Cullen, is a jiu-jitsu athlete himself, and has firsthand experience having sport-related injuries and coming back from those successfully. In his own experience, there’s a certain degree of wisdom that is needed, but he’s had success with not waiting until things are 100% to get back to training.
Returning to sport doesn’t mean returning to 100% intensity and 100% volume and 100% effort. It means a slow increase in ramping back up to regular sport: interacting with the sport that you’re trying to get back to, but maybe having a modified version where you’re doing a little bit less intensity, maybe a little bit less time. And then using that same pain scale that we’d use for evaluating rehab exercises or range of motion for what you’re feeling during the sports-specific activities as well.
If we put it on a handout, it would read like this: wait until it feels almost healed to get back to the sport. It doesn’t need to be perfect, and if you have a red flag, that’s a hard stop. If you have yellow flags, that’s a sign to move forward with caution.
What counts as a red flag
Generally, if pain with any sort of given exercise, movement, or activity goes over a five out of ten on the pain scale, that’s a hard stop.
The other one is a significant slide back in range of motion or function in the area of injury. If we’ve presumably established around 80% improvement in range of motion from the initial injury, then we’d want to maintain the majority of that. If they did an activity where maybe they didn’t feel that five out of ten, but then later that day, or within a time frame close in proximity to that activity, they had a significant slide back in range of motion or function, that would also be a red flag.
Chronic pain isn’t acute pain that lasted longer
With chronic pain, the underlying mechanism that is generating the pain is likely to be very much so fundamentally different than when you have an acute injury. The neurology, the biopsychosocial model of pain, and how the body is perceiving nociceptive signaling in a chronic case is much different than in an acute case.
The assumption that can be made most of the time is that pain when an injury is acute is much more accurately representing the structural damage associated with the area that’s hurting. With chronic pain, a lot of the time the pain signaling or the individual’s perception of pain or dysfunction in an area is very heightened, and so we don’t have to respect it or appreciate it quite as significantly as when someone has an acute injury. The framework we’re working in with chronic pain is more to help give the patient a direction to interact with that part of their body in a way that doesn’t hurt, while being a little bit less concerned with the pain, assuming the orthopedic testing, any imaging reports, and the conclusions of the evaluation suggest the underlying structural generator isn’t super serious.
With chronic pain, the bigger risk is avoidance
What we observe more likely to be the case in chronic pain patients is that because the pain has been around for so long, they’re more likely to have fear or avoidant behavior associated with movement and exercise. Go back to the acute case and how being sedentary or resting for too long becomes a problem: that concept is very much so heightened in a chronic pain patient.
They might feel pain during exercise or movement, and so their internal reaction is to avoid things that hurt. But because the pain has been around for so long, and because the structural generator of the pain is likely to be less serious, that fear avoidance is actually creating a lot more problems. Now, in a long-term perspective, they’re deconditioning themselves, reducing their strength, reducing their capacity, all in an attempt to avoid pain. It can become a real serious problem. So with these patients, we’re more focused on informing them and supporting them through the emotional struggles they might be having with their pain, and giving them the confidence to move forward and interact with some sort of movement or stimulation or stress upon the area that is bothering them.
The moment that builds the confidence back
What we want to do is find movements that maybe they’re having a little bit of fear or even a little bit of pain with, and then coach them through how to stabilize or interact with that area where they don’t feel pain.
If we can create an opportunity where they do something, they feel pain, they’re interacting with that movement, and they no longer feel pain, we will really fixate and get the patient to focus on that moment. That’s the opportunity for them to start building confidence and start building a belief within themselves that they can have control over the pain that they’re feeling, and control over moving forward in a way that is successful in getting them back to regular function in their day-to-day life.
If you’re sitting out of something you love because you’re not sure whether training through it is making it better or worse, that’s exactly the conversation to have in the room. Book a visit with our team and we’ll figure out which category you’re actually in.