By Richard Blake, DPM
The 3 aspects of pain – mechanical, inflammatory, and neuropathic – should be considered, tracked and discussed at every visit for patients on a rehabilitation pathway.
In this book on mechanical treatments for various injuries and pain syndromes, a discussion into the 3 sources of pain is as crucial as an understanding of the 3 phases of rehabilitation and what phase your patient presents with at each visit. Treating the patient out of phase can be dangerous as in only treating mechanical pain when there is so much nerve and inflammatory pain present.
In medicine, we constantly deal with the 3 sources of pain: mechanical, inflammatory, and neuropathic. Many injuries can have components of all 3 aspects of pain. Treatment of an injury may need strictly mechanical treatment (like a varus wedge, Aircast Airlift PTTD Brace, strengthening for chronic posterior tibial symptoms), or strictly anti-inflammatory measures for arch strain after an episode of overuse (like 5 minutes ice roll of the arch with a frozen sports bottle), or strictly nerve treatment for a flare-up of Morton’s neuroma (like topical Neuro-Eze or Neuro-One creams, warm water soaks, pain free massage or neural flossing 3 times a day). However, the treatment of many problems tends to involve more than 1 source of pain, and the recognition of this problem can vary from visit to visit, as the nerves get more or less hypersensitive, or the inflammation gets in and out of control.
An injury can start as a simple mechanical issue (like excessive supination weakening the peroneal tendons and allowing them to strain), or an inflammatory issue (like stubbing a big toe which already had some arthritis), or a nerve issue (like overstretching the sciatica nerve during stretching the gastrocnemius, especially if they have some genu recurvatum), yet 1 issue can lead to the other 2 sources of pain developing with inflammation typically first, and nerve hypersensitivity developing later as a general rule with plenty of exceptions. Even in the treatment of inflammatory arthritis (inflammatory) or complex regional pain syndrome (neuropathic), mechanical treatments to immobilize, rest trigger points, etc., can be vital.
An example to illustrate this point would be a sesamoid fracture. Imagine an athlete running barefoot on the beach striking the tibial sesamoid on a rock hidden under the sand. The injury is acute, inflammation sets in, and the body starts to compensate by walking on the outside of the foot. After several weeks, with no reduction in pain, the nervous system takes over and the area becomes hypersensitive, and the lateral side of the foot becomes painful. When you see the patient for a visit, you would assume that a mechanical off-weighting of the sesamoid should alleviate all the symptoms. But, this is not true when the inflammation or nerve hypersensitivity takes over protecting the area. There are so many scenarios where the patient needs treatment for all 3 sources of pain: mechanical protection of the bone, anti-inflammatory measures, and a decrease in nerve hypersensitivity. This can involve a simple or complex treatment plan based on how the patient responds. Each office visit should involve some thought into each of these 3 sources of pain. Some nerve pain responds to anti-inflammatory treatment, or mechanical treatment, but not always. Some inflammatory pain responds to mechanical changes, but not always.
Morton’s neuroma is a common problem that has a variety of treatments in these 3 areas that must be individualized to the patient. It is a nerve problem, of course, but can respond to mechanical and anti-inflammatory treatment alone. Thus, metatarsal padding or custom orthotic devices to off-weight the sore area and spread out the metatarsals, and 1 or 2 cortisone shots, can do the trick. But, when this does not help, think about nerve treatment. Perhaps this nerve treatment may involve alcohol shots, neural flossing of the sciatic nerve, topical nerve medications like Neuro-One or Neuro-Eze (OTC) or prescription compounded medications, oral nerve medications like Lyrica, low back treatments if the source (or another nerve irritation) is above the foot, etc. If you constantly think about these 3 sources of pain, then you will be able to change treatments when one direction is not as helpful as you like in getting the overall pain between 0-2 consistently.
Practical Biomechanics Question #23: Even though this book is on mechanical treatments of injuries and mechanical causes of injuries, what other 2 areas of treatment do you have to consider?
Practical Biomechanics Question #24: Using the 3 sources of pain, explain how this works when treating a sore heel?
Richard Blake, DPM, MS, is adjunct faculty at the California School of Podiatric Medicine. He has practiced podiatry at the Sports and Orthopedic Institute of St. Francis Memorial Hospital in San Francisco, CA. His book, Practical Biomechanics for the Podiatrist, Book 1, is available from Amazon.com and Barnesandnoble.com, as well as from the publisher at bookbaby.com.
