Sprains and Strains - Ask Dr. P

Can Shockwave Therapy Help Plantar Fasciitis?

by Pain Doc | May 16, 2023 | Foot and Ankle Pain, Sprains and Strains

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment option that is used for various musculoskeletal conditions, including:

plantar fasciitis
iliotibial (IT) band syndrome
shin splints
patellar tendonitis
frozen shoulder (adhesive capsulitis)
tennis elbow (epicondylitis)
post-surgical fibrosis (fibrous tissue growth)

ESWT involves the application of high-energy sound waves to the affected area to stimulate healing and reduce pain. The two main types of shockwave devices are piezoelectric and radial.

Piezoelectric machines have an applicator that contains an array of crystals made of ceramic material that are embedded in a concave bowl. A voltage is applied, which causes the crystals to deform very quickly. This generates a mechanical wave. The waves from the crystal array are focused by the concave bowl and directed into the patient’s body, through which it travels. Piezoelectric machines generate a high pitched, short “tick” sound with each pulse. The pulse frequency is varied by varying the power to the applicator. It is important to note that since the energy waves generated by piezoelectric machines are focused into a small area, treating large areas takes a lot of time/ treatment sessions.

Radial shockwave machines generate an energy wave using kinetic energy. An electromagnet inside the applicator accelerates a metal rod, called a “bullet,” against a strike plate. The strike plates are attachments to the applicator, and come in different sizes. Small attachments will concentrate the wave energy into a smaller area, but again, will require multiple treatments to cover large areas such as for shin splints or IT band treatment. Larger attachments will cover more area, but the energy is attenuated more because of this. Radial shockwave machines generate energy waves that cover more area than a piezoelectric generated wave, but are not as focused.

ESWT for plantar fasciitis:

Procedure: During ESWT, a handheld device delivers shockwaves to the plantar fascia, which is the tissue causing the pain and inflammation. The shockwaves help to break up scar tissue, promote blood flow, and stimulate the healing process.

Treatment sessions: ESWT is typically administered in a series of sessions, usually spaced about one week apart. The number of sessions required can vary, but it typically ranges from three to six sessions.

Effectiveness: ESWT has been shown to be effective in relieving pain and improving function in many patients with plantar fasciitis. Research studies have demonstrated positive outcomes, with reductions in pain and improvements in foot function.

Side effects: ESWT is generally considered safe, and serious complications are rare. However, some individuals may experience mild side effects such as temporary pain, redness, bruising, swelling, or numbness in the treated area.

Post-treatment: Following ESWT, it’s important to follow your healthcare provider’s instructions for post-treatment care. This may include rest, ice application, stretching exercises, and avoiding activities that may aggravate the condition. Physical therapy and orthotics may also be recommended to aid in the recovery process.

Suitability: ESWT is typically considered when conservative treatments, such as rest, stretching, orthotics, and medications, have failed to provide sufficient relief. Your healthcare provider will assess your individual case and determine if ESWT is a suitable option for you.

It’s worth noting that while ESWT can be effective for many people, individual results may vary.

Since it is a relatively save procedure with rare serious side effects, extracorporeal shockwave therapy is safe to do at home. There are personal devices available such as this one that allow consumers to apply the treatment to themselves. While it isn’t cheap, it is a fraction of the cost of the professional models and is just as effective.

The benefits of owning your own extracorporeal shockwave machine is that, if you have a chronic problem, such as in your shoulder, that surfaces a couple times a year, you can save a lot of money by doing the treatment yourself. A typical ESWT treatment at a physical therapist or chiropractor office runs anywhere from $50-$200/treatment, and they require you to get at least six; often more.

Bottom Line: whether you seek Extracorporeal Shockwave treatment from a therapist, or invest in your own machine, it can help your body heal from slow-healing soft tissue injuries by breaking down abnormal scar tissue and stimulating regeneration of newer tissue.

The Stages of Pain and Tissue Repair

by Pain Doc | Oct 6, 2019 | Sprains and Strains

Musculoskeletal pain typically involves a movable joint—the articulation (connection) of two bones that, working with muscles, help generate movement and force. Common culprits are the knees, hips, spine and shoulder. The source of pain can be tendons, ligaments, cartilage, bursae, muscle tissue and/or bone.

Acute pain refers to pain that is sharp and intense in nature as opposed to diffuse and duller intensity. It comes from either a new injury or damage event, or an exacerbation (flare up) of a prior injury; i.e. re-injury. What I mean by “damage event” is that you do not have to experience an external injury such as a fall or sports accident in order to experience acute pain. It can be the result of gradual wear and tear of a joint, such as acute onset knee pain that starts the moment cartilage erodes down to the bone; or a lumbar disc that spontaneously bursts after many years of weakening.

When pain is acute, there is redness, swelling, heat and sharp pain. These are the four hallmarks of inflammation. Inflammation, while it gets negative press, is actually a life-saving, natural process when it occurs in response to tissue damage. Its purpose is to summon all the biological and biochemical agents that are necessary to limit tissue damage and initiate healing. Without going into too much detail, there are a host of biochemicals released by injured tissues and cells that (1) cause blood vessels to dilate and become more permeable, which produces swelling; (2) regulate blood clotting to stem bleeding; (3) initiate fibroblast activity—the cells that secrete fibrous, reparative tissue over the damage; and (4) summon macrophages to the area– large cells that clean up debris.

The goal of treatment during the acute phase of pain is to reduce pain intensity; reduce swelling, and stabilize the injured area to prevent aggravation. RICE—Rest, Ice, Compress, and Elevate the area– is a good guideline for managing acute pain. You need to be patient, as healing takes time; and do the things that help your body heal naturally on its own. This will determine how well your healing goes, and in some cases will mean the difference between healing 100% or developing chronic pain from the damaged tissue.

As a side note, be cautious using anti-inflammatory medications after you sustain an injury. Remember, the inflammatory process is part of the tissue healing process so you don’t want to suppress it entirely; just manage its intensity. Diligently applying cold therapy is a better option; use the NSAIDs and cortisone only when the pain is unbearable and you cannot afford to be without the use of that painful body part for very long.

The acute stage lasts 1-3 days and is followed by the sub-acute stage, which may last several weeks. During this stage, swelling subsides, fibrosis is finishing up, blood vessels are repaired and pain gradually decreases. The goal of treatment during the sub-acute stage is to introduce movement, reduce pain and enhance healing. This includes active and passive joint mobilization, massage/soft tissue work; and sometimes pro-healing modalities such as infrared, laser and pulsed EMF.

The last stage of an injury/damage event is remodeling. The newly formed tissue and fibers become more organized and stable as you move the damaged area through its normal range of motion. This can last several months, and even years. The goal of treatment during remodeling is strengthening and restoring range of motion. Therapies include joint mobilization, spinal manipulation, soft tissue work such as active release therapy; and resistance and coordination exercises such as weights, theraband, and balancing exercises.

Chronic musculoskeletal pain refers to pain that remains after an injury or damage event has gone through the acute, sub-acute and remodeling phases. Chronic pain is typically less intense and more diffuse (less focalized), and may be intermittent (comes and goes). For some people, chronic pain significantly reduces quality of life by causing impairment in the ability to engage in certain activities of daily living such as bending at the waist, lifting, and raising one’s arm above shoulder level.

Chronic pain can assume psychosomatic qualities, where the individual can actually perpetuate and even worsen the pain through his/her thoughts and beliefs; i.e. believing and accepting one’s pain to be catastrophic and life-changing. When this occurs, it negatively changes behavior in a way that inhibits pain resolution. The person becomes over-cautious and limits his/her activities to avoid pain, which promotes atrophy, weakness and loss of muscle coordination. Because of this, a standard of care for musculoskeletal pain is to encourage the patient to have a positive attitude during his recovery; continue with his everyday work and leisure activities as best he/she can, and work through the pain and try to tolerate it as the area heals, remodels and strengthens.

Is Chronic Pain a Life Sentence?

Since chronic pain has gone through the stages of healing, can it ever be resolved 100%? By definition, chronic pain is persistent, ongoing pain. But there are cases where chronic pain made a turn for the good, and totally disappeared, even after decades of pain. What is necessary for this to happen is the tissues–ligaments, tendons, muscles, or cartilage– need to have some regenerative capacity left, and those regenerative capacities need to be optimized so that the healing is enough to stop the pain generating areas. Pain that doesn’t go away at first is often a sign of sub-optimal healing. The key is to find out what is causing this; remove it, and do things to enhance your body’s ability to regenerate the damaged area such as changing your diet, doing prescribed, therapeutic exercises and even changing your mindset if necessary. Only then do you have a chance to eliminate chronic pain once and for all.

Treating Chronic Repetitive Strain Syndromes

by Pain Doc | Mar 19, 2011 | Sprains and Strains

If your job, hobby, or recreational activities involve repetitive movement patterns you may develop a repetitive strain injury, or RSI. Also known as overuse injuries, cumulative trauma disorders, and musculoskeletal disorders these types of conditions are characterized by pain, inflammation, swelling, and reduced joint movement.

Some of the more well-know causes of RSIs include:

typing/data entry (wrist tendonitis, epicondylitis)
hair styling (wrist tendonitis)
using vibrational tools (wrist, hand tendonitis)
carrying small children (deQuervain’s syndrome)
tennis (lateral epicondylitis; i.e. tennis elbow)
golf (medial epicondylitis; i.e. golfer’s elbow)
running (achilles tendonitis)
bowling (medial epicondylitis, wrist tendonitis)

RSIs mostly affect tendons, ligaments, bursae, and neural sheaths but they can affect muscle fibers as well. What happens is the offending activity places unusually high demand on these structures resulting in microscopic tears to the tissues. A very gradual inflammatory response follows, which then takes a life of its own. At this point the patient notices that the pain is more frequent and doesn’t go away with rest, and he/she may reach for an over the counter non-steroidal anti-inflammatory like Motrin.

What makes repetitive strain injuries so persistent is that they are caused by an activity the individual needs ( job) or loves (favorite sport) to do, and essentially he/ she “re-injures” the condition with the activity until it gets to an advanced stage.

Most of the time a repetitive strain injury is transient; i.e. it appears for several weeks then disappears. The patient resorts to icing, rest, temporary discontinuation of the offending activity, over the counter meds, massage therapy, bracing, and in some cases, cortisone shots.

In some people, the pain turns chronic; i.e. doesn’t entirely go away even after weeks and months since the onset. If you are experiencing this, it can be due to improperly healed microtears causing abnormal muscle and tendon performance; and perhaps trigger points which are believed to be concentrations of nerve endings at an old injury site.

When the condition is chronic, you can attempt to do the therapy in the video above. You use a flat edged massage instrument to “strip” the muscle close to where it attaches to the joint. This can help loosen any fibrous adhesions (“stickiness”) that may be interfering with muscle and tendon movement. It also mildly agitates the area (be careful not to overdo it) and increases blood flow, which can stimulate repair by fibroblasts, special cells that synthesize collagen.

This therapy is not to be done when the condition is acute (recent onset, hot, red, swelling). Doing so will make it worse. Try it only when it has reached a chronic stage and inflammation is absent. If it causes an unusual increase in pain, discontinue and apply ice.

When You Get Whiplash Neck Pain from a Car Accident

by Pain Doc | Aug 26, 2010 | Neck Pain, Sprains and Strains

Ever get rear-ended while waiting in traffic or at a stop sign? It’s a scary moment: the calmness of being out in your car is viciously interrupted by screeching tires and a loud crash and bending metal. It’s over in two seconds, but a lot happens to your body in that one second.

If a high speed camera was available to record your mishap, it would show your body violently moving forward with the car, back sinking into your car seat, your head slowly arching backwards at an unnatural angle; your neck muscles tense up; your head coming to a stop in its backwards path and then reversing directions to move forward again, through a complete arc until your neck is fully flexed forward in an unnatural position; coming to a stop again, and then reversing directions and fully extending a few degrees less than before, and then reversing and flexing forward again, then righting itself. That is your basic whiplash injury.

You’ll notice your neck become stiff, but very gradually. You may be a bit dazed, and have a headache come on in about an hour. You’ll likely feel tired.

As the day wears on, your neck is getting increasingly stiff and painful. You may feel the onset of soreness in your upper shoulders and upper back; even your lower back. You may have pain in your chest wall where the seatbelt dug into.

2-3 days after the accident your neck will reach maximum stiffness. You will have difficulty turning your neck. You’ll find yourself turning your whole body in order to see to one side.

So what is happening? You have sustained what’s called a cervical acceleration-deceleration sprain strain injury; commonly known as whiplash. Car accidents are a common cause of whiplash, but they can occur on roller coasters and similar jerky rides, horse riding, sky diving, and even wild dancing. When this happens, tiny tears develop in the muscle tissue and fascia (muscle covering) which starts to release the inflammatory products of swelling. The swelling is gradual, like a pinhole leak, which explains why it takes 2-3 days to reach max pain. What makes a whiplash worse than other sprain strain injuries is that, due to the flexibility of the neck, spinal ligaments also incur damage.

When your neck flexed violently forward, the capsular ligaments and interspinous ligaments likely got damaged. The capsular ligaments hold your neck bones together from the back; the interspinous ligaments hold them together at the spinous processes (the bumps you feel along your spine are the tips of the spinous processes).

interspinous ligament rupture

When these ligaments injure, the swelling goes inside the joint space, building up pressure essentially splinting (immobilizing) the joint. In severe cases, the ligaments can rupture (tear) causing dangerous instability, and you have a very serious condition that requires a visit to the ER. A head halo support or neck brace is usually attached to prevent the instability from causing damage to your spinal cord.

TREATMENT:

Obviously, it’s a good idea to go to the hospital if you were involved in a significant car accident and feel you’ve been injured. The ER doctor will rule out serious conditions like ligament rupture, bleeding in the brain (subdural hematoma), and bone fractures. Once those are ruled out, he/she will diagnose you as having a sprain strain injury and will usually prescribe pain meds (anti inflammatories and muscle relaxants). You will be given home care instructions.

With whiplash, the goal is to first reduce the pain and swelling. You will do this by applying an ice pack to your neck. Here’s a YouTube video on Whiplash Home Care – icing and stretches that illustrates the information to follow.

Buy two gel ice packs at your local drugstore (9″ x 6″ size); put in freezer. Make a cervical roll using a small bath towel or hand towel: roll it up tightly into a cylinder 1′ long with a radius of five inches. Place it on the floor.

Place one ice pack on top of the roll, and one right under (next) to it. Put a kitchen towlette on top of the ice to prevent iceburn. Lie down, face up with the center of the back of your neck on top of the cervical roll/ice pack. The other ice pack is for your upper back muscles. Put a pillow under your knees for comfort, dim the lights and rest for 20 minutes. Repeat this every two hours, for 2-3 days.

On the second day, while icing slowly turn your neck to the right as far as you can, then to the left, then to center. Then, arch your neck and touch the carpet with the crown of your head and hold for 20 seconds. Repeat these motions ten times. Do this for each of your icing session, still at 20 minutes every 2 hours. This helps to regain full neck range of motion.

On the 4th day, alternate ice with 10 minutes of moist heat using a hot water bottle with 150 degree water heated on your stove, and a wet face towel for heat conduction, on your neck and back muscles.

As the pain decreases, engage in active stretching exercises. About two weeks post crash, or when the pain has gone down 90% and you have full range of motion in your neck, do neck strengthening exercises. It is important to do these rehab exercises as they help align the reparative tissue in the axis of contraction of the muscles. This will help reduce the chances of chronic pain and loss of range of motion following the accident.

Since the original publication of this article, I’ve researched a new modality called Pulsed Electromagnetic Field therapy, or Pulsed EMF, or PEMF for short. The link explains it in detail, but basically it is the external application of low frequency, low amplitude electromagnetic fields, similar to the natural EM fields your body produces, to impart energy to them. EM fields are used to drive movement of molecules in and out of the cells, which includes nutrients, waste products, proteins and other factors involved in life processes. When cells are sick or injured, this process is not efficient. Pulsed EMF imparts a boost of energy (in fact, it is considered “Energy medicine”) which helps injured/sick cells perform their biological functions more efficiently, promoting accelerated healing and improved symptoms (less pain).

Apply PEMF to your neck three times a day for 15 minutes, for 2-3 days following the accident. You should experience a noticeable reduction in pain each time, an hour or so after treatment.