Got a knee problem that just won’t knuckle under? A groin pull that just won’t go? A rotator cuff tear you can’t relinquish? This short article will help you troubleshoot by introducing an underappreciated perspective on injury rehabilitation.
“The importance of injury prevention” is one of those concepts we can all get behind without any fuss, like the importance of regular physical activity, or saving for retirement. But this article is not just about preventing injuries that happen again or injuries that happen because of another injury. Those are underestimated hazards, but they are related to an even lesser known concept in injury rehabilitation: minor re-injury can stop healing in its tracks, or at least slow it down.
This is the really important injury rehabilitation concept I want to get across in this article. We’re not just talking about the risk of a second “oh @#$!&” moment, dramatically re-injuring your injury, although that can certainly happen: re-injury routinely occurs in small, sneakier ways. And every minor re-injury retards recovery. Minor re-injuries can be so subtle that you aren’t even really aware that it’s happening — all you know is, you aren’t getting better fast enough. (Although it’s awfully hard to tell how fast is fast enough.1)Every minor re-injury prevents recovery.
Good health care professionals are always considering the “aggravating factors” of their patients’ pain problems. What factors in patients’ lives are making the problem worse? What keeps people from healing? What adds insult to injury? In a sense, almost every “aggravating factor” is a kind a re-injury. You could call them “micro” re-injuries. Here’s a great example:
I had a client with an exasperatingly tricky knee problem, a case of patellofemoral syndrome, a notoriously vague diagnosis that basically mean “hurtin’ kneecap.” It was an overuse injury originally. Over the course of a long walk, her kneecap just started to hurt … and months later it was still hurting. What was keeping it going? I got nowhere with this client for several appointments, until one day when I was digging deeper into her story and learned that she had a habit of sitting at work with her knees bent sharply, her feet tucked well underneath her, a position that puts enormous pressure on the underside of the patella. Bingo — there was our “aggravating factor”! She was re-injuring herself all day long, every day!
When you are trying to figure out why your injury isn’t healing, do not neglect this important perspective: could you be slightly re-injuring yourself regularly? Have you actually removed from the equation any forces that might be, even just slightly, hurting you again … and again … and again …?
Obviously, injured parts are vulnerable. A classic example of re-injury is the ankle sprain. The anterior talofibular ligament in the ankle is the most commonly injured structure in the body — and undoubtedly the most commonly re-injured structure in the body. Once it is damaged, it is never the same again. The chances of having a second ankle sprain are way higher than the chances of having the first.
People also often continue doing the very same activity that injured them in the first place. Like me, for instance: for years, I had almost annual compression sprains of my thumb joint — a “thumb jam,” well known to rugby players — from playing ultimate.2 I was at great risk for re-injury because I kept exposing myself to the same dangers, and the thumb was so damaged that virtually any impact constituted a real hazard, flaring it up again for weeks.
The need to avoid re-injury might seem too obvious to even bother writing about. But the failure to do so isn’t just an amateur mistake made by people too eager to get back to normal after an injury. For decades, patients have often been encouraged to do so by professionals, to the point of serious risk. It’s been in vogue in physical therapy for a long time now to “mobilize” injuries as quickly as possible — probably too much in vogue. In the zeal to get people on their feet again ASAP, serious sprains — which are worse than fractures in some ways — are almost never put in a cast. Turns out that’s a mistake. A 2009 experiment published in the Lancet presents clear evidence that a full cast for a severe ankle sprain is superior to the almost universal practice of using braces and tubular compression bandages. The editors write, “This elegant study highlights the need for trials to address common problems.”3 In other words, it has not been common sense to make re-injury avoidance a top priority.
In many contexts, getting active makes complete sense — but doing it prematurely can be a disaster. You definitely have to consider the risk of re-injury when you are trying to heal.
Consider another story:
One of my clients, before we met, had a shoulder injury — an ordinary thing, no big deal, just a little rotator cuff lesion, a tear in the muscles around the shoulder socket. Unfortunately, it impaired her ability to catch herself when she tripped and fell. It is amazing — shocking, really — just how hard you fall when you aren’t able to catch yourself. She fell face first onto a curb, and fractured her jaw and facial bones severely … a much more grievous injury than the original shoulder injury.
This kind of thing is surprisingly common. Patients with injuries need to be wide-awake alert to the fact that you are more vulnerable when you’ve been injured!It is amazing — shocking, really — just how hard you fall when you aren’t able to catch yourself.
Being injured is an unfamiliar state, and it’s the “weirdness” of that state — the new sensations, and limitations — that gets people into trouble. Just like a child needs to be warned to look both ways before crossing the street, injured people — especially if they’ve never been injured seriously before — need to be warned to be much more alert to potential dangers.
A major mechanism for reinjury is the overconfidence given by masking symptoms with medication. Pain killers and anti-inflammatories, when they are effective, can make you feel less vulnerable than you actually are.4 And that’s when you’re going to go too far and hurt yourself … again. And you may not even realize it, both because of the masking and because it doesn’t have to be serious re-injury to really slow down recovery.
“Masking symptoms,” especially with medications, is often maligned because it doesn’t “treat the root cause.” But masking symptoms can be a good idea, and it should not be eschewed just because it doesn’t have a real healing effect … because there are very few real healing effects! “Healing” is mainly about removing impediments to natural recovery, like stress on tissues. It’s not dictated by some mythical power to speed healing, but by a strong understanding of the nature of the problem and what pisses it off and impedes recovery. Focus on facilitating natural recovery, and don’t knock a little “symptom relief” along the way.
But, if you decide you need some symptom relief, you must exercise more cautiously.
The risk of re-injury and collateral injury is not just underestimated, but a significant factor in many cases of chronic pain. “Prevention” is therefore not just a way of keeping yourself from getting injured in the first place, but directly relevant to recovery from injury. Double or triple your alertness and caution when limited by an injury, and bear in the mind the risk of minor re-injury turning an injury into a chronic pain problem.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.