*****
There is a notion -- particularly in sports medicine -- that the only possible injury sources are muscle, tendon, or bone:"Hey, Doc! My leg hurts!"
"You probably just pulled a muscle. Go see a PT."
[3 weeks later]
"Hey, PT! I've been strengthening my leg, but it still hurts!"
"You probably have tendonitis. Let's massage and ultrasound it."
[3 weeks later]
"........STILL HURTS!"
"Gosh, I guess we better get an MRI or bone-scan. Maybe your leg is broken."
This "Muscle-Tendon-Bone" (MTB) paradigm is reliable for acute injury -- the football player with a thigh bruise, or the soccer player with the sprained ankle -- but its utility for non-traumatic, gradual onset chronic condition is very poor. Because, by definition, muscle, tendon, and bone are three of the fastest healing tissues in the body. And as such, given enough time (usually no more than six weeks), they will heal on their own.
Therefore, those have issues -- pain, weakness, or poor control -- usually have a fourth tissue involved:
THE NERVE.
In the fall of 2001, the Journal of Orthopedic Sports Physical Therapy had two issues devoted entirely to neurological issues in sports injury and rehabilitation. Indeed, Editor Richard Di Fabio's introduction, entitled "Athletes Have Nerves!", shares this blogger's exasperation with "conventional MTB treatment":
"....Clinicians [must] look over the horizon and discover relevant scientific findings in disciplines that might initially seem irrelevant. We have only recently discovered that athletes have nerves. Now, the core of rehabilitation following knee injury has been forever changed by the literature in neurophysiology, neuromotor control, and motor learning."
His tongue-in-cheek declaration of this"recent discovery" of an alternative to MTB is refreshing, if not frustrating: because, here we are, 9 years later, and few in the sports medicine community even consider "Nerve" in their evaluation and intervention of pathologies of all kinds.
*****
When I first see a patient, I always do two things:(1) Watch how they move
(2) Ask them about their spine
The former relates to motor control: How do you control your body? Is it normal or "weird"? Pathology can arise and thrive simply by abnormal control. The latter relates to the "power supply" -- the spinal cord and nerves -- and how well it is "flowing" to the affected body part.
In the very least I get confused looks (at worst, disgruntled no-shows) from patients when I address The Nerve.
"Why is he looking at my BACK when my KNEE hurts?"
Patient understanding has improved since I've begun using this Allegory:
Your refrigerator is broken: you open it up, its contents are lukewarm, the motor isn't running. Things are beginning to ripen. What to do? You call the repairman, who may look at the compressor, or the fan, or the refridgerant. He finds some flaws, repairs and replaces them.
Problem solved, right?
You restock the fridge with food. And at first it seems fine -- the inside gets pretty cool, but soon enough, it stops running again. You call the repairmen back, or maybe you seek out another repairman, who tries something else.
This goes on and on. What to do?
You could go to a third repairman, who might recommend a full overhaul. Or perhaps a trip to the store for a brand new fridge: both expensive and frustrating choices.
Or you could CHECK THE FUSEBOX.
The fusebox -- the modulation of power to the refridgerator -- controls all. An overloaded fuse will repeatedly blow and, no matter what you do to the fridge: no fuse, no power.The same applies to physical pathology. You must examine the power supply -- The Nerves. Because, no matter what you do to the fridge, no matter how fancy the fan or compressor...you ain't "plugged in", you ain't wrastlin'!
As such, no matter how hard you work toward tissue healing, strengthening, stretching -- if you don't have ideal neurological exchange, your condition may not fully resolve.
The Faulty Power Supply: Four Potential Problems
A faulty power supply -- typically the spine, but infrequently peripheral nerves -- can cause for main problems:
(1) Pain
In acute cervical or lumbar strains, the spine can be the primary pain producer: directly through pain referral (more generalized limb symptoms) or radiculopathy (following a precise nerve pattern). In more chronic cases, the spine can amplifiy (e.g. "turn up the volume") on true orthopedic (MTB) pathology.
(2) Weird Sensations
These include parasthesias such as burning, tingling, numbness, or any other "weird" sensations unlike typical injury pain.
(3) Muscle Weakness
(4) Abnormal Motor Control
If I find neurological findings, what I then tell patients is, "We're gonna treat your (insert extremity condition HERE), but if we also don't address The Nerve, then it's like fixing the fridge, loading it full of food, only to have it spoil and have to start all over because we keep blowing the fuse."
After that explanation, the patient is much more amenable to this multi-dimensional approach to care. And, far more often than not, they get better and stay that way.
For interesting case examples highlighting The Fridge and the Fuse Box, stay tuned...
