Dealing With Injury, Part 2 (Chronic)

Now that we've looked at acute injury, as well as the cellular mechanisms and management progressions associated with damaged tissue. We recognized acute injuries as instantaneous, event-related episodes and gave some examples of how our bodies, and minds, deal with those situations.

 

Now we are going to examine chronic injuries. This will benefit from some defining and also relating to the framework we discussed with acute injuries. Specifically, a chronic injury is one that simply won’t get completely better. It may stay present at a low grade or go up and down in levels of exacerbation, but it never completely goes away. It can be a nagging, frustrating situation to say the least. A chronic injury is one that has not progressed completely through the phases of bleeding-scabbing-scarring we discussed last week (refer to that article if you would like more information on this process). It’s essentially stuck somewhere along that continuum, most likely in a never-ending state of scab formation. A chronic injury will often reach the stage of scarring and remodelling, then we irritate it with some aggravating microdamage (bleeding), and it moves back into scab phase again. Most of us have probably had this experience.

 

Beyond the basic definition that a chronic injury is one that just won’t go away, there are several terms that can describe the stubborn, unresolving injury state. “Itis,” “osis,” and “opathy” are common suffixes applied to these injuries, such as plantar fasciitis or achilles tendinosis. I don’t think it is necessary to go into all the diagnostic terms available, but I just wanted to give you that vision. Overuse injury is also a popular phraseology, and this indicates perpetual loading of tissue that exceeds its tolerance. We’ll keep this discussion centered around muscle, tendon, and ligament...saving arthritis and other joint pathologies for another time.

 

It is also good to keep in mind that any acute injury has the potential to become chronic if management is suboptimal and full recovery is impeded. Failures with nutrition, sleep, posture, work positions, and stress management can put our bodies in a situation where they may be incapable of complete healing. Improperly applied or incomplete management, such as inappropriate strategies in rehab and training, can also put an injury into chronic status. This is often the classic “trying to come back too soon” phenomenon when motivation levels exceed tissue readiness, and an athlete pushes a not-quite-ready body a bit too early or hard. In most cases, the conditions just described are related to inadvertent judgement errors, and we usually learn from such experiences and avoid repeating these cycles indefinitely. Fixing sleep, or nutrition, or rehab progression usually solves the problem.

 

But the real issue, and root cause, of any chronic injury, is movement dysfunction. Sometimes this is due to a compensatory or substitution pattern that our bodies develop around a painful area. Our bodies are innately brilliant and they will always try to “get the job done.” Our brains will be sending messages like “get from Point A to Point B,” and our bodies obey the command, coming up with any movement pattern available to accomplish the task. This is the case even if the natural, preferred motor program is unusable due to pain or injured tissue. We readily invent an alternative movement strategy that works...just not as well, in almost all cases, as the original program. 

 

Compensatory movement patterns are wired into our neuromuscular systems as emergency tools to use only in dire circumstances, and they are far less than ideal for long-term function. Relying upon such a substitution pattern (which is usually present initially to offload and protect injured and healing tissues) is inefficient at best and is potentially quite damaging at its worst. The resultant condition is known as movement dysfunction and it is the major underlying obstacle to recovering from any chronic injury.

 

Movement dysfunction causes our bodies to generate, transfer, and dissipate forces in inefficient manners. This ultimately alters loads borne through the body and makes the movement system suboptimal. Just like in any machine, if movement mechanics aren’t flowing along in the body in a properly-functioning manner, breakdown is imminent. Picture any number of components in your vehicle where something could be “out of whack.” It won’t run as well and will lack power, economy, or handling. If the underlying issue is not identified and addressed in a timely fashion, the vehicle will break down and usually require expensive repairs. 

 

That is what movement dysfunction does to our bodies. Somewhere in the system, or in multiple places, dysfunctional movement can create loads that exceed tissue tolerance. In most chronic cases, the resulting damage is increased wear and tear, and unresolved inflammatory states. A chronic injury can even progress to catastrophic tissue failure (rupture, tearing, etc.) but unlike an acute injury that comes on as a total surprise, a chronic injury that goes to failure is like the “final straw that broke the camel’s back.” There were warning signals overridden or ignored long before the disaster finally occurred.

 

So how do we end up with dysfunctional movement patterns? Sometimes this is due to the ingraining of a compensatory pattern we developed around an acute injury. An example might be a barely perceptible, but perpetual limp following an ankle sprain. The neuromuscular system learned the new, limping pattern in order to protect the original injury, but it never “un-learned” that pattern and “re-learned” the original, proper sequence of gait mechanics. The body adopted the substitution pattern (limping) as a “go-to” and just kept using it. In this case, such a dysfunctional pattern will usually cause a chronic problem somewhere in the body’s movement, or kinetic, chain -- not necessarily at the site of the original injury. Often the breakdown occurs at the point or tissue in the system that is most vulnerable (the weakest link). With the gait pattern we are using as an example, that breakdown can be further up the chain at the knee, hip, or back, and often on the opposite side of the body.

 

However, beyond complications related to acute injuries, the majority of movement dysfunctions leading to chronic injury are caused by force management that is less than ideal. Deficits in mobility and stability are usually at fault. A mobility deficit can be caused by tissue stiffness, joint restrictions, and poor coordination. Stability deficits are usually related to joint integrity (looseness or laxity) and strength insufficiencies (weakness or lack of supportive muscle contractions). Either way, the body does not move “quite right” and ultimately something (a tendon, muscle, fascial connection, etc.) becomes sore and angry as it is being chronically overloaded and inflamed. This is where the term overuse is exemplified. You probably are not overusing your body (they are made to be used) but your poor movement patterns related to the imbalanced mechanical and neuromotor system are overusing, or overloading, a player in your movement orchestra. And just like an orchestra with a sour note, your performance is below potential, and at risk of many negative issues, not just poor reviews from the audience.

 

As in life, biology, and most things human -- movement dysfunction is not always so simple. In many cases, there can be several factors at play, and each will need to be addressed in order for ideal performance to be restored and maintained. This is where a human performance professional can be of great value. Coaches, athletic trainers, physical therapists, and other providers and specialists can help in this regard. In many cases it matters less what a practitioner’s specific background is...as long as he/she knows how to analyze movement, identify and prioritize problems, and apply the appropriate interventions to get results. That stated, this is the core training of physical therapists and they are usually a good place to start when dealing with chronic injuries. 

 

So if movement dysfunction is the underlying problem with chronic injuries, and correcting that dysfunction is the ultimate solution...how does one embark upon such a project? First, we need to identify the major dysfunction that is present. Next we determine the deficits or imbalances that are affecting the situation. This is followed by establishing a priority of interventions and an appropriate time-frame. Finally, we treat, tweak, and, evaluate until we have a successful outcome that is represented by optimal performance in a pain-free state. I’ll provide a brief example of each of those 4 items.

 

• Major Dysfunction(s): Let’s say we are dealing with a runner who complains of chronic upper hamstring pain, and his physician has given him the medical diagnosis of “recurrent bilateral proximal hamstring tendinosis.” When we examine his gait, we determine that he runs with a very anteriorly-tilted pelvis, lacks optimal hip extension, and exhibits an overstriding, heel-striking locomotive pattern. Since I’m assuming not everyone is a thera-geek like me, this looks like a guy with a very arched lower back, who doesn’t push off the ground very much with each stride, who then throws his leg out in front of him to move forward, slams the ground hard on his heel, and then sort of “pulls” his body back up to that forward foot. Over and over, thousands of times per day. [This is exactly the kind of movement analysis an expert should be able to quickly make from a rapid assessment.]

• Deficits: Let’s list out the examination findings:

  • Hyperlordotic (arched-back) standing posture

  • Inflexible (tight) hip flexor musculature

  • Weak, underdeveloped gluteal muscles

  • Painful, tense upper hamstring muscle bellies and tendons

  • The use of thickly cushioned, heel-elevated running shoes

• Interventions: The deficits we listed above are quite common, and are often associated with a few more issues but I wanted to keep this example fairly straightforward. I will focus this section on treating causes, not symptoms, but I’ll come back to that topic a bit further in our discussion. 

  • Postural Re-education: For the pelvic tilt, lower-back issue, we need to teach this runner about hovering near neutral (neither excessively arched nor flexed) positions with his back. This pelvic tilt problem is usually due to a combination of habit (not so much laziness but energy conservation as standing with your back arched loads the skeleton and requires less muscular effort -- we sometimes do this obliviously). This typically results in weakened abdominal muscles so in addition to some cueing and training on alignment we’ll also utilize dynamic stability training for the trunk.

  • Hip Flexor Stretching: That chronically forward-tilted pelvis shortens the primary hip flexor muscle (the psoas major and minor) as it adapts to never being properly lengthened. This is exacerbated with chronic sitting as well -- let’s just assume our runner has a desk job also. The tight hip flexors keep the pelvis anteriorly tilted and block its ability to return to neutral. This contributes to the back issue mentioned above but is also very detrimental to hamstring muscle function. Tilting the pelvis forward moves the rear/bottom section of the pelvis where the hamstrings originate (ischial tuberosities) upward and away from their attachment at the knee, thus pre-loading, or pre-straining them, in this athlete’s case.

  • Glute Strengthening: A flat buttock is not a good thing. The buttock is home to the most powerful muscle group in the body, and even skinny runners need some of its force production. This atrophy is partially set up by the pelvic position problem, but we need to help this runner recruit, activate, and develop his backside for more propulsive force in his stance/stride mechanics. A program of resisted hip thrusts, extension (backward) and abduction (outward) movements, and functional anti-gravity work (step-ups, squats, deadlifts -- with proper instruction and coaching being critical here) will be an important part of training.

  • Hamstring De-activation/De-sensitization: This may surprise some of you, but we don’t really need to get into much hamstring stretching here. In fact, many folks find that, in a case like the one we are describing, hamstring stretching makes the problem worse, not better. This is true for several reasons. First, The hamstrings are actually being chronically overstretched by the anteriorly-tilted pelvis and overstriding leg. More of the same won’t help the situation. Next, any muscle that is inflamed from being overstretched will naturally (via CNS activation) maintain a contracted state to protect itself from being further insulted by lengthening forces. This is actually called protective guarding in the literature, and for good reason. What we really want to do here is calm down the angry muscles and turn off this response, which isn’t helping the situation by impairing circulation and worsening gait mechanics. The muscle isn’t firing at the proper time and for the appropriate duration in the gait cycle and it’s throwing things out of sync to its own demise. We’ll use some gentle and brief inhibition techniques that include the foam roller and therapeutic balls of various sizes as research supports these practices to reduce the contractile state of muscle via their pressure and manipulation. We could possibly consider using instrument-augmented tissue mobilization techniques if we feel we need to re-stimulate the inflammation process (if the tissue appears stubborn to complete the healing process), but in this specific case that may not be necessary.

  • Temporary Reduction in Training Volume and Intensity: No runner ever wants to run less, but he’s going to have to swallow this pill. We’ll utilize cross-training to maintain conditioning (cycling, pool running, etc.) and experiment with a very small amount of easy, controlled running (below the threshold for irritation) that we’ll go over in the gait training information below.

  • Switching to Minimalist Shoes and Soft Surfaces: Running shoes with thick, overly-cushioned, and stability-oriented midsoles have actually been shown to encourage overstriding, heel-striking, and in most cases do not actually enhance stability despite their marketing claims. We’ll put this runner into a minimalist shoe with a 0-4mm drop (heel to forefoot differential) and have him do all of his running on grass fields and soft tracks for now. We’ll even have him do some of his training in the barefoot condition. This naturally increases knee flexion angles, brings footstrike to the midfoot/forefoot, and places the contact point under the hip, not in front of it. He’ll fight me hard on these points but I’ll encourage him to embrace science and his ancestral biology, and to progress very gradually. I’ll fire him in an instant if he can’t stay with the program. Let’s not waste each other’s time.

  • Gait Training and Neuromuscular Re-education: This is re-training in proper movement patterns and function, with an emphasis on swing, footstrike, and stance phase mechanics. Basically, we’ll repetitively review a few basic components of ideal running form, and then we’ll have that minimal amount of training our runner is doing barefoot (or minimally shod) on grass be in the form of a series of drills and strides. Gone are the days of endless schlepp-jogging. No mas. Nada.

• Evaluation: Treatment for this condition should be dynamic in that we assess progress at regular intervals (function and symptoms), make necessary adjustments, and then reach a positive outcome in a reasonable time frame. With a motivated and compliant individual -- and let’s assume our runner is both of those things -- it will probably require 4-6 weeks for him to achieve pain-free running status and have the knowledge and tools to continue forward independently. He’ll need to work on building further supportive conditioning, maintain his good drill and gait habits, and progress mileage very cautiously. With the deficits addressed and the movement dysfunction corrected, this runner can finally break free of his chronic problems and embrace a more functional, higher-performing future. 

 

Now we can return to the subject of treating symptoms versus causal factors. There is nothing wrong with treating symptoms to alleviate discomfort and provide temporary relief...as long as we realize that’s all we’ll get. Palliative therapies or interventions like heat, ice, medication, and other applications can be adjunctive to our work on root causes. But we have to remember that mechanical and neurological factors are the real problem, and the injury will never go away until we find, focus upon, and fix that problem. 

 

Massage is worth mentioning here. There can be soothing benefits to manual tissue work in the specific case we are discussing, but deep therapeutic massage may not be indicated, as the hamstrings themselves are more inflamed than restricted. There might be a small amount of scar tissue to break up (if you like that term) but that won’t be appropriate to do until we get this injury progressed firmly into the scar phase of recovery. Massage could also be used to target the lower back and hip flexors, and to facilitate the awakening of other tissues or muscles in the kinetic chain. My point is that no modality or technique is necessarily bad, or medically contraindicated in this particular case, but real results will only come when our runner becomes a better, more natural, locomotor. 

 

Recovery from chronic injury is most often a true teamwork situation. Expert clinicians and engaged athletes work together to get results. Each case is unique and is an opportunity for learning and experimentation. If you are a regular reader of these diatribes, or a listener to the podcast, I must first thank you wholeheartedly for your support. I’m really trying to get valuable information about health and performance to as many folks as possible. You have also probably ascertained that I’m a relatively concerned and caring person. I’m not an insensitive bastard. However, I am a bit of a joker (but not a smoker or a midnight toker), and this whole movement dysfunction thing has perplexed me for decades. Why wait until you are f****d up to fix the problem? Don’t let pain drive your performance! Solve your movement problems before they cause breakdown and improve your outcomes, enjoyment, and in all probability...your orthopedic longevity. This is the story of UMS and the “Ahhhh” factor. Allow me to explain.

 

UMS stands for “Ugly Movement Syndrome.” It’s a term I first developed decades ago to describe what I observed when I viewed myself in the mirror struggling with certain movement patterns, as well as in some videos of me performing various sports movements. I was aghast! It was nauseating. In fact, my ugly movement made me actually want to hurl (thanks Wayne’s World) and utter the guttural, wrenching sound of “Bllleeeaaaauuuuwwwwgggaawwddd!!!” It was actually that bad. So I practiced what I preached and fixed my issues, for the most part. That is an ongoing process and forever will be. Then I began to notice this in so many people. They just were not moving in ways that were artistic, poetic, graceful, and beautiful. Trying not to be labeled “a-hole of the decade,” I explored ways to break the news to them. “Hey, you are moving downright ugly. Not only is that s**t inefficient as hell, it is probably going to cause you breakdown, eventually leave you unable to do what you love, and is actually pretty painful for me to watch. In fact, it is disrespectful to your body and is an insult to every onlooker in the universe. You owe it to yourself, and everyone else, to learn how to move optimally, respect and maximize your body’s potential, and give the onlooker the sensation of Ahhhhh...that’s beautiful!” I won some and I lost some. But that’s the way it is. Move ugly and eventually it is YOU who suffers the most. Move beautifully and everybody wins. JZ out!

 

[author’s note: This information pertains to correcting movement deficiencies in able-bodied individuals. It is in no way condemning or condescending to anyone with physical disabilities or incapacities that are congenital or uncorrectable.]