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Pain Does Not Always Equal Tissue Damage

When in pain it is natural to seek an explanation for why we hurt. We make our way to the doctor’s office or the physical therapy clinic in search answers. We want to know the reason for our pain and advice on how to eliminate it. Often we end up with a trip to the radiologist in order to get a detailed view of the involved anatomy. MRI’s are taken looking for any sign of tissue/structural damage that we can blame for our symptoms. However, this can prove problematic. Recent research is demonstrating that there is not always a correlation between pain and tissue damage. That is, we can have pain without tissue damage and we can have tissue damage without ever experiencing pain.

Here is what the research has to say:

Exert from: From A Guide to Better Movement by Todd Hargrove

“Common examples of tissue damage without pain are provided by the numerous studies involving MRI examination of joints that are not painful.

Backs: 52% of people with pain free backs had at least one bulging disc or other MRI abnormality. In a similar study, one third of individuals who had never suffered back pain had a substantial spinal abnormality, and 20 percent under the age of sixty had a herniated disc.

Hips: Among pain free hockey players, 70% had abnormal pelvis or hip MRIs, and 54% had labral tears.

Knees: 60% of people with pain free knees, aged 20-68, showed abnormalities in at least 3 of the 4 regions of the knee.

Shoulders: In one study 23% of people with asymptomatic shoulders had a rotator cuff tear. The authors concluded this percentage to be “astonishingly high” and concluded that “rotator cuff tears must to a certain extent be regarded as “normal” degenerative attrition, not necessarily causing pain and functional impairment .” In pain free overhead athletes, 40% of dominate shoulders had findings consistent with partial or full thickness tears of the rotator cuff, as compared to 0% of the non-dominate shoulders. But neither shoulder hurt, and none of the athletes had any pain or problematic symptoms 5 years after the study. “

So if you are worried about the results of your MRI keep this information in mind. What appears damaged on MRI may be a coincidental finding and simply normal age related changes. There is likely another source of your pain, see our previous blog on chronic pain here and look forward to our next blog on the Nervous System and the role it plays in painful conditions.

Jimmy Picard PT, DPT

References:
Jensen et al. (1994) MRI of the lumbar spine in people without back pain. New England Journal of Medicine. 1994 July 14; 331(2): 69-73

Boden et al. (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. Journal of Bone and Joint Surgery of America. 1990 March; 72(3): 403-8

American Orthopedic Society for Sports Medicine (2010).

Beatie et al. (2005) Abnormalities identified in the knees of asymptomatic volunteers using peripheral MRI. Osteoarthritis Cartilage. 2005 March; 13(3): 181-6

Templehof et al. (1999) Age related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery Vol. 8, Issue 4, July 1999, 296-9.

Conner, Banks et al. (2003) MRI of the Asymptomatic Shoulder of Overhead Athletes. A 5-year Follow-up Study. American Journal of Sports Medicine September 2003, Vol 31, No. 5, 724-7.

I you are experiencing pain, take action to eliminate it! We can help. Let us help you get back to the activities you enjoy. Call 804 320-2220 and setup an appointment today.

Understanding Chronic Pain and How to Eliminate It

Recent research into chronic pain states has revealed a variety of interesting facts. Pain is our body’s protective mechanism to prevent injury. For example, when you place your hand on a hot stove, you feel immediate pain, which prompts you to quickly pull your hand away, hopefully in time to prevent a burn! Likewise, when a person has continued to irritate a condition by repeated injury or continued repetitive stress, his or her nervous system can become “sensitized”, meaning the body learns to carry a pain signal because the circuit has been continually reactivated. The degree of stimulus needed to activate the signal gradually lessens to the point that non damaging stress to the body can result in pain. Your body’s protective mechanism becomes less accurate in assessing what is damaging and what is not.

Emotions, beliefs, stress level, and fears can help or hurt the healing process. Negative thoughts, called “catastrophizing “ in medical literature, include such behaviors as worrying about something serious being wrong, fears of what this could mean in the future, or focusing on your pain level. When catastrophizing, a stress hormone cortisol level is increased, pain thresholds are lowered, and circulating inflammatory mediators in the blood are increased (R.R. Edwards et al. / Pain 140 (2008) 135–144). The result is you hurt more and your body’s inflammatory response is increased. Your alarm system becomes hyperactive, and usual daily activities can become painful, prompting the individual to be less active. This can lead to fear of movement/activity, disuse, and de-conditioning, making your tissues less healthy and, therefore, less tolerant of stress, thus perpetuating the cycle. This can be a slippery slope, leading to decreased quality of life and/or depression.

For anyone experiencing pain over time, part of the rehab process is to address and encourage not only healing of unhealthy tissues but also calming the individual’s nervous system. There are good resources available to better understand this process including a book called “Explain Pain” (Butler D. and Moseley L. Noigroup Publications; in 2003). We have found that education and understanding are key components in successfully assisting individuals through the rehabilitation process. All injuries, not just long term chronic pain states, frequently have components of abnormal pain physiology that contribute to their perpetuation. We have found the following general advice helpful to our patients in resolving acute and chronic pain:

1. Understand what is contributing to the perpetuation of your pain and what you can do to minimize it. Are you overstressing your tissues throughout the day with bad postural habits and a poorly setup workstation? If so, change it and improve the situation. View the following link to correct your work station and sitting alignment http://www.youtube.com/watch?v=cHelFza49K8
2. Understand what happens to a nervous system that suffers chronic pain. Know that your body’s “alarm system” may not be an accurate assessor of what is damaging to your tissues. Discuss with your therapist how to tell the difference between good and bad pain.
3. Try to ease your worry that something more serious may be wrong. Talk about your concerns, fears, and symptoms with your therapist. If there is something that warrants further investigation he or she can help direct you. Worry is only helpful if it causes you to take a necessary action. Otherwise, it increases your inflammatory response and pain level for no good reason.
4. Do not focus on your pain. I am not saying to always ignore your symptoms, especially when you have done something that may have exacerbated your condition. However, constant vigilance of your pain level has been shown to decrease your pain threshold and increase your body’s inflammatory response, making you feel worse. Divert your attention elsewhere and enjoy your day.
5. Try to stay in the moment. If you are having pain, do your best not to project into the future how you will feel later today, tomorrow, or how it may impact you as time passes. Be confident you will heal and that your symptoms will pass. A positive attitude and belief that you will do well is one of the most important factors contributing to how well you will do in the future.
6. Remember, part of eliminating pain and working through the rehab process is to make you healthier from a global perspective. What are your specific needs and biggest deficits? Do you need healthy diet? More sleep? Do you do dissipate stress poorly? Do you exercise regularly? Do you have personal relationships that need attention? Are you in a stressful work setting? Poor organization skills, etc.? Work on your areas that need attention. A helpful book that everyone should read in this area is Spontaneous Healing, by Dr. Andrew Weil
7. Breathing and meditation activities have repeatedly been shown to reduce stress, improve health, and reduce pain states. Discuss this with your clinician.
8. Get more sleep than you think you need.
9. Do something for youself that you enjoy everyday.
10. Do something kind for someone else every day. You will get more benefit from it than they will.
11. Try to laugh as much as you can! It reduces stress and things seem to hurt less when you do.
12. Try to learn something new every day. When your focus is elsewhere pain is less.
13. Do some form of cardiovascular exercise regularly that will not exacerbate your condition. It is theorized to dissipate inflammation and is the strongest producer of natural endorphins (happy chemicals) we know of that are helpful in reducing pain.
14. Work on your prescribed exercise program and movement strategies learned in physical therapy. This is a key component! The cliché is true that you will get out of it what you put into it.
15. When adding new physical activities, do so in a slow, graded manner. This allows your tissues and nervous system to adapt without setting off the alarm system causing pain.
16. Have a plan and carry it out.
17. You have the key to healing yourself. Professionals are your guide through the process!

By Clarke Tanner PT, MPT, CMPT, ATC, CSCS

If you are experiencing pain, take action to eliminate it! We can help. Let us help you get back to the activities you enjoy. Call 804 320-2220 and setup an appointment today.

THRIVE PT is a specialized manually based orthopedic, spine, and sports physical therapy practice that provides individualized care to its patients. All of our therapists have specialty training, advanced certifications in orthopedic manual therapy, and extensive post graduate course work, and are highly qualified to help you reach your therapy goals. Our methods include hands-on corrective treatment, movement training, dry needling, and therapeutic exercise provided exclusively by your therapist. Our objective is to teach you how to move efficiently and painlessly and to educate you on how to stay healthy. We can help you achieve your goals to lead a healthy, active life--in a word, THRIVE!

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