“Why do I keep getting pain even though I am no longer injured?”
I hear this question often, and it can be a tricky concept to get your head around as there are so many elements to consider – with most seeming almost invisible. Let’s say that tissue healing has been achieved, and pain and swelling is no longer an issue, but it either just keeps getting injured with seemingly insignificant activity or force, or you just can’t achieve the speed or distance you could before.
An easy example of this is the classic rolled ankle; rolling your ankle inwards is usually a result of not looking where you are going or doing something out of the ordinary. Ankle injuries account for 25% of all sporting injuries and interfere more with sporting participation than any other injury. There is also a 70-80% injury recurrence rate, along with symptoms of instability and apprehension following an initial episode.
Even those most dedicated to their rehab plan may struggle to complete it. The reason for this has to do with proprioception – basically, our sense of spatial awareness. Proprioception is tied to the central nervous system (CNS), and takes information from various receptors to stimulate our peripheral nervous system (PNS – muscle, ligaments, tendons). We use this data to move efficiently, and when one system struggles the other gets stronger to compensate; this is often helpful, but if a system does become distracted then the risk of injury can increase as the data becomes less reliable. For instance, jumping on a trampoline with your rolled ankle distracts the CNS, leaving your joint proprioception to do the task of placing your foot to land correctly and jump back up.
The peripheral nervous system – anything outside of the brain and spinal cord – gives the CNS feedback, conveying touch, temperature, pain and position. Unfortunately, when we get injured, our pain receptors, although doing their job to keep us safe, can muck up the efficiency of this system. By nature, pain will inhibit the function of stabilising muscles (responsible for sustained postural positions). If our local stabilisers are now not functioning properly, then our global muscles must step up to help; unfortunately, they aren’t wired to do the job as well, but they can do it. The result: we can still move and get on with life, but we aren’t as efficient.
As part of the return to full capacity approach in rehab, this muscle system also needs to be retrained. Because you generally feel 95% by the time you get over the initial pain and debilitation it is often hard to understand the benefit of some of the simpler exercises we’ll have you do and how they will get you back to 100%. The thing is, our brains are great at learning and adapting and have this amazing ability to re route movement, re-learn old movement plans and further refine current movement plans all through adapting to feedback sent in from the outside – so if you persevere with exercises that do the trick without overloading the area, you can get rid of your “dodgy ankle” for good.
In a nutshell, retraining the proprioceptive system is about starting with basic tasks which tell your CNS where your PNS is, then challenging the environment in a gentle way so it can relearn which muscles to activate, how much and when without the need to compensate or cheat. Too hard and you will over-compensate, too easy and you won’t improve. Just right will feel ridiculously hard at first but become super easy within a very short space of time. This is where the correct diagnosis of an injury and an assessment of the associated movement patterns are crucial to let you get back to your 100%, because there’s no one-size-fits-all situation!
Sarah Pelham is a SportsLab Physiotherapist at our Albany Clinic. She is a whiz in both acute and chronic injuries. Sarah enjoys trail running, but we think she does it all for the post-race sausage and beer.