The protect – expose continuum
We know that pain is multidimensional and can have many contributors. The good news is that recovery is also multidimensional and affords us lots of options for how to get better. The entire rehabilitation process has been aptly summarised by Greg Lehman when he said, ‘calm shit down, build shit back up.’ What he means is that we have a continuum between two extremes when treating pain or injury: protection on the one hand and exposure on the other.
The protect – expose continuum.
The ‘protect’ phase also includes acute injury management (e.g., immediately after an injury [elevation, compression etc.]) and the ‘expose’ phase often includes injury management down the track (e.g., the weeks, months and years following an injury). In addition to finding the balance between modifying/protecting and adapting/exposing, we are also concurrently addressing anything that might be sensitising us (ie., treating the cup). Another way to think through the protect/expose dynamic is seen in the schema below.
‘Deload’ here represents the ‘protect’ phase (ie., calm shit down), and ‘re-load’ and ‘progressive overload’ represent stages of the ‘expose’ phase (ie., build shit back up).
This frames the rehab process with deloading first to desensitise the painful area (e.g., perhaps reducing the load, changing technique, limiting your ROM, considering taping/bracing, considering heat/ice, reducing training frequency etc.), and reloading slowly again over time. The challenge when you’re de-loading is not doing too little! Athletes may temporarily stop training when pain occurs. This obviously causes the pain to decrease. Nevertheless, because they have avoiding loading the injured site (also known as stress shielding), the tissue and the athlete unwittingly lose even more load capacity (see pain cycle below).
The pain cycle
The pain cycle.
When pain decreases, one can be tricked into believing their injury has healed. Athletes predictably want to return to training ASAP, so the process is usually rushed giving way to the same training error that initially caused their injury!
Throughout the entire rehab process, you should:
- Adhere to pain rules, while
- remaining as active as possible.
The pain rules
- Keep your pain <5/10 pain during the training/exercise (in other words, can you hide your pain?), and
- no exacerbation of pain following training/exercise (the following ~48hrs)
Pain visual analog scale from 0 (no pain) to 10 (worst imaginable pain).
While not explicitly a pain rule, the trend in pain over a longer time frame is also helpful. Monitoring the changes in your pain over time can provide some helpful background knowledge regarding sensitivity.
We must not break pain rules as,
- breaking them may increase our risk of serious tissue pathology, and
- we can sensitise the nervous system with persistent pain provocation.
- Consider the following analogy. If we continually perform heavy bicep curls, our muscles will adapt over time and get stronger. Similarly, if we continually expose ourselves to high pain scores, our nervous system can also adapt over time and “learn” pain.
You may have been told not to do anything that causes you pain; that you should stop activity if your pain is even 1-2/10. However I find this advice unhelpful and overprotective. We know hurt does not always equal harm.
Adapted from Explain Pain’s ‘Twin Peaks’ figure showing what happens after injury regarding pain and tissue tolerance.
In the Twin Peaks image above, notice the ‘tissue capacity’ line is a bit lower after injury – this makes sense right? Also notice the ‘pain experienced’ line is much lower after injury. This is important as it demonstrates the large buffer that exists after injury. You can be ‘sore but safe’ when doing activities you love.
Adhering to pain rules takes some trial and error!
The analogy I use here is that the entire rehabilitation process is more akin to cooking than baking. Cooking affords some flexibility and trial and error (variability with included ingredients, amounts, taste testing etc.). Baking is more rigid and requires one to follow a recipe. Rehabilitation is never a recipe approach and always involves some trial and error due to the complex interactions between a myriad of variables. I like to say to my patients I explore with them, rather than direct at them.
Remaining as active as possible means endeavouring to continue exercise and activity, including,
- Sports-specific training
- Resistance training (aiming for >1 session per week of multi joint strength training)
- Cardiovascular training (aiming for >75mins vigorous or 150mins moderate intensity training per week)
Thanks for reading!
Please book in if you need an expert guide during this process! We can also rule out anything serious or sinister where the above information may not be applicable!
