Wednesday, October 16, 2013

Ignore the Pain.

Our scene opens at the UCSF Human Performance Center Orthopedic Institute. I have finally gotten straight with my insurance company who is paying these bills and how and when, secured a new referral from my sports med doctor, and managed to book a new appointment with my PT. I've had three rough weeks back-to-back running-wise, two of the three getting in 10 miles or less, and also been dealing with soreness & stiffness in all kinds of random places even after several days of rest.

We went through the same hour-long evaluation process as when I first came in back in May, a barrage of strength & mobility & alignment tests looking at every muscle group and joint from the pelvis down. When we first did this back in May, the main findings were:

  • Pelvis uneven & slightly sheared => left leg slightly shorter. (Not surprising, since I've had to have my pelvis snapped back into place for that exact issue every 6-8 weeks for the last couple of years. He has to realign it every time I'm there. I asked if this was cause or effect & he said it's really impossible to tell.)
  • Hip flexors obscenely tight, especially on the right (the side I tore).
  • Quads obscenely tight
  • Right lower back obscenely tight
  • Hip/glute/core strength very good, but slightly less good on the right
  • Hamstring strength good but not amazing; inner right hamstring noticeably weaker.

This past Tuesday, after three months of PT & two months working on my own, the verdict was thusly:

  • Pelvis still uneven & sheared => left leg still shorter. (Again, not surprising.)
  • Right hip flexor still tight, but much improved over my last visit in July. (Hell yeah, rolling & stretching!)
  • Left hip flexor slightly looser, but the right has loosened up enough so that the left one is actually the slightly tighter one now.
  • Quads still obscenely right. (Quote: "Your quads are *ridiculous*.")
  • Overall, strength is really good. Hamstring strength much improved. Left leg is wicked strong in all directions!
  • Right glute med is okay, but slightly weaker than the left. Likely the asymmetries are somehow making my strength work less effective on the right side.

Thanks in no small part (I'm sure) to all the Olympic lifting & extra core strength work I've been doing, my squatting has gotten much better. When I attempt an overhead press squat, though (arms straight up as if you're holding a bar above your head, elbows behind ears, back straight, then squat), my right foot always tries to rotate to the right or come off the ground at the arch. This also happens very slightly in my single-leg squats on that side.

The same issue also showed up in the ankle strength test he did. It's solid in every direction except one. When I rotate my right foot internally like this...

...I have a hard time resisting force when someone pushes against the inside edge of my foot. On the left side, it's no problem. Being balanced in this way is important for runners because an imbalance can lead to an unbalanced footstrike & toe-off, which can lead to mechanical issues all the way up the kinetic chain. While this is probably not causing my hip issues, it is certainly not helping.

He also noticed that while I have good ankle mobility in terms of plantar flexion (toes pointed) & dorsiflexion (toes pointed up, heel pointed down), I have some restriction rotating my ankle inward when it's dorsiflexed, which can also mess with toe-off mechanics, which can then mess with anything further up.

The upshot?

"There is still work to do, but you are in MUCH better shape now than when I first saw you."


We also talked about the pain I'm having now--sometimes in my hip flexor at the site of the original injury, sometimes radiating down my right quad, sometimes in my right hip stabilizer muscles, sometimes in my adductors, and sometimes in totally random spots (IT band, just above the knee, inner knee, that giant tendon that runs down the back of your thigh & connects your hamstrings to your knee). I explained how I'd had about two months of pain-free running, and then suddenly in the last three weeks or so, everything hurts, and at the first sign of pain in my right hip flexors I stop running & rest it for several days.

This is when he told me about some new research in chronic pain. (I am certain I am going to get some of the details wrong here, but this is the general gist of what he explained.)

First of all, nearly all tissue is as about healed as it can be 3-6 months post-injury. Pain that goes on longer than that--chronic or persistent pain--is rarely about tissue damage. Does that mean it's all in your head? Well, yes, but technically, all pain is all in your head--we feel it thanks to a series of neurotransmitters released in our brains. With acute pain, those chemicals are produced in response to tissue damage. So the question is, what causes them to be produced when there isn't tissue damage anymore?

Essentially what happens is that, in an effort to protect areas that have taken a long time to heal, the body produces more neurotransmitters at the site of the injury, making the nervous system hypersensitive to even slight discomfort in that area and causing the brain to generate pain signals that are MUCH more intense than they should be. As a result, the person does everything they can to move or use that area as little as possible. Frustration and anxiety about the pain can also contribute to the body being unable to close the "pain gate" appropriately once the tissue is almost healed. If the normal pain channels between your body and your brain are like roads, he explained, injuries that go on long enough can create pain "super-highways" to that site that make you extremely attuned to sensations in that area (and nearby ones as well).

Which is not good. Apparently this type of chronic or persistent pain is *incredibly* hard to treat and undo since it's not related to actual tissue damage, and in some people, sometimes seems to become permanent (probably due to the extra neurotransmitters going, "Weeeeeee!!! It's working!!! S/he's not using the muscle!!!").

"So what you have to do," he told me, "is ignore it."

Um, exsqueeze me? Did a medical professional just tell me to stop listening so hard to my body?

'Chu talkin' 'bout, Doc?

"The moderate pain you're feeling in your hip flexor is probably not real, and certainly not indicative of tissue damage at this point, and the best thing you can do is re-train your nervous system by teaching it that sending those signals doesn't get the result it wants."

My red light, he said, is 6/10 on the pain scale. Anything under that and I am to ignore it & run through it. (Most of the time the pain I'm feeling that's causing me to take multiple days off is 2-4/10, not because of the pain itself, but because I worry that running on it risks re-injuring it.) If I do get to 6/10, I get 2 days off, and then I go back to running. The critical thing is that I don't send my brain & body the message that this hypersensitivity in my hip flexor is an acceptable situation.


  • Continue doing all my normal strength stuff
  • Extra strength work for my glute meds on the right side via standing clam shells (kind of like this, but staying in one spot, and using only my right leg)
  • Strength work for the small lower leg muscles that help resist force as described above. Basically I stick my right leg straight out, wrap a TheraBand around my right toes / ball of foot & hold the ends, shove my left foot against the band to create leverage, then rotate my foot inward & pull against the band for 30-40 reps at a time. (I did about 30 during PT & it was *exhausting*.)

  • Get my hips, spine, & ankle re-aligned at each visit; gradually increase ankle mobility. (This is something he has to do by hand, apparently, as there's no easy way for me to do it on my own.)
  • Continue rolling / stretching out hip flexors; be sure not to neglect the left side.
  • Stretch the quads aggressively 5 times a day, for a full minute each time. ("I'm going to write 5 times a day & then maybe you'll do it 3 times.")
  • Roll adductors, if possible. (I am considering this gadget since getting at the adductors is annoying.)
  • Stretch adductors daily via the figure four stretch.
  • Roll calves with the stick a few times a week.
  • Get back to doing single-leg calf raises. They like to see 10K / half marathoners able to do 50-60 in a row on each leg with no problem, & 75-100 for marathoners. (Get calf cramps? Forget the electrolytes. Do more calf raises.) I'm supposed to start with however many I can do at once, then gradually increase each day until I'm in the 75-100 range.
  • Ignore the pain (within reason).

So things are looking up. I went home Tuesday & ran 5 miles with, yes, some hip flexor pain, but it never progressed past 2-3/10, so I kept running. That's a win.

I'm running Let's Go 510 10K on Saturday, mostly just to see what racing feels like right now. And friends, I. Cannot. WAIT. My goal this week is to try to get in ~24 miles, including ~8ish on Saturday (1 mile warm up + 6.2 race + 1 mile cool down). Physically I don't feel any different than I did before my PT session, but there is something psychologically reassuring about being explicitly told "Yes, you're on the right track, and nothing is getting worse." :)


  1. If you think about it next time you see him, I would love to see the research on what he was talking about re:chronic pain. Maybe he can email you the links if it's available on line?

    1. Yes! He actually said he was going to give me some youtube links that explain it in plain language, but then we both forgot. I'm going to call & see if someone in the office can get them & email them. I'll see if I can get actual research sources as well.

    2. Thanks so much! I look forward to it!

  2. So, last dude who told me that had me doing hill sprints on a complete fracture of the femur. Yes, it's all in your head, but it's a signal of something physical. Be cautious.

  3. It does seem like very odd advice from a physio, but it's worth trying (carefully). I also stopped reading and went glassy eyed with jealousy when I noticed the pile of books you casually dropped into a photo. I have Italy Envy.

  4. Just to be completely redundant, I'd also urge caution. I am very curious about the chronic pain research he was referencing -- seems like a good idea to look into that a little bit. The other thing I'm suspicious about is the pain scale indicators -- it seems so subjective! However, I guess if you've had detailed discussions about what YOU consider various levels of pain, then maybe it's ok? Just that one person's 6 is not another person's 6.

    Last note: good luck on Saturday!! I was really hoping to come spectate/cheer, but something came up.