Entries by Tobias Hall

Guest Blog – When Pain Persists

Guest Blog - When Pain Persists

Persistent pain

The following is a guest blog that was written by a very impressive young Vic Uni student by the name of Emily McCarthy who recently interviewed us on a health science module she is currently sitting.

When pain persists                                                                                                                                    

One in five New Zealanders live with chronic pain. Having never experienced persistent pain herself, Emily, a student at Victoria University, went on a journey to understand chronic pain and how it is managed in Aotearoa. 

I recently flew over the handlebars of my mountain bike and gashed my knee – deep. The pain kicked in when I made it back to my car. I flushed the wound with saline, pulled the flesh together with butterfly tape, wrapped it in a bandage. Pain protects.  

For the next week, it hurt to put pressure on my knee. My gash made me hobble, favouring my left leg while resting my right. The edges of the wound grew towards each other. Pain heals. 

When I went biking again the following fortnight, I slowed down on that gnarly corner, made it round unscathed. Pain teaches.

The pain was transient. And it was helpful, my body and brain’s way of working as a team to tell me to clean my wound, to take it easy while I healed, to teach me a lesson about risky activities. 

That’s what pain is meant to do, and it’s great when that’s where it stops. But sometimes pain goes overboard. It lasts for months, sometimes in the absence of tissue damage or threats. Pain persists.

“Pain is really good,” Dr Hazel Godfrey told me. Hazel is an academic who researches pain. “It’s just that when it goes wrong it’s really awful for the person and their family.” Hazel’s insights come from two places – her academic research and her lived experience. Hazel has fibromyalgia. 

There are a multitude of pathways to persistent pain. Changes in the brain, lasting tissue damage, aberrations in the way the mind and body communicate with each other – all can cause chronic pain. 

Hazel was diagnosed with fibromyalgia in her first year of university. “I just started getting tired – abnormally tired – and sore all over.” Her pain made it hard to think, hard to sit for long periods of time, hard to operate as she’d been used to. It intruded. Hazel’s experience fit the description of fibromyalgia – fatigue, widespread muscle and joint pain, pressure-induced pain at specific trigger points, and no explanatory cause. 

Sometimes pain makes no sense – a 2012 survey found that doctors were unable to identify the source of chronic pain in one in ten patients. But even without a diagnosis, the pain is very real.

Hazel is one of 763,000 New Zealand adults living with chronic pain – that’s one in every five. And with population aging, she’ll be joined by more kiwis each year – persistent pain disproportionately affects older people.  

Pain takes a toll. People who live with pain can find it hard to sleep, maintain relationships, keep jobs, do their groceries. Pain can be debilitating. At its worst, Hazel’s pain left her effectively bedridden for a year. 

On top of the physical effects of pain, people living with chronic pain often experience anxiety, depression, and other mental health challenges. Knowing what it’s like to live with pain, Hazel described the associated mental health challenges as “not surprising.” Chronic pain is pervasive. 

The impacts of pain go beyond the individual. The estimated financial costs of chronic pain in Aotearoa reached up to $5.3 billion in 2016, with lost productivity being the most significant contributor. If you attempt to put a dollar figure on the loss of wellbeing experienced by people living with persistent pain, the total cost approaches $15 billion each year – more than two times the GDP of Fiji.  

So what solutions are available for people living with chronic pain? Well, there are no silver bullets – managing pain is a science and an art. 

Toby Hall the lead cincician at  Featherston Street Pain Clinic, certainly views it that way. He describes himself as a mechanic, a mechanic with intuition, the ability to listen and empathize, observe and understand. “Pain links up to a person’s inner self,” Toby told me. It can’t be diagnosed with a blood test or seen under a microscope. It can’t be cured with a pill. “It’s a very subjective part of life.” 

Depending on the person, the prescription differs. But for Toby, movement is at the core. “Movement is medicine.” Gone are the days of recommending bedrest and neck braces. To manage pain, you must move

Toby encourages his patients to adhere to his prescribed movements like a dentist tells you to brush your teeth. “I teach people really simple strengthening exercises but I try to get them to do those exercises for five minutes a day everyday forever.” 

When I asked Hazel how she manages her pain, she told me that it’s like a fulltime job. To live her life well with pain, Hazel has to stretch, go for walks, use a foam roller. She has to eat healthy, stay connected to her support network, rest. Frankly, these sound like great tips for all of us. But for Hazel, they’re non-negotiable – pain will exploit any lapse in vigilance. “I’m hyper-organised,” Hazel told me, “I have two diaries.” 

Medication also plays a role. There are issues – Toby mentions the US opioid crisis and Hazel mentions the prohibitive cost of cannabidiol in Aotearoa – but some things work for some people. Researchers are hunting for new medicines for pain management that aren’t addictive – but it’s a long hunt and only part of the puzzle. 

When I asked Hazel whether there were any developments in pain management on the horizon that she was optimistic about, she burst my bubble instantly. “Sadly no.” Part of Hazel’s pain management journey has been coming to terms with the reality that there is no simple cure. She doesn’t expect that she’ll ever get to live free from pain, but over time she has come to accept that she can live a good life with pain. “But it’s always complicated, and sometimes I still get very frustrated.”

Something Hazel was very clear about is the fact that pain doesn’t exist in a vacuum. “The person in pain doesn’t exist apart from the world.” 

For her pain management strategies to work, Hazel needs the support of her family, friends, and workplace. “If you’re working towards these things on your own it’s not very likely to succeed.”

Hazel’s friends and family are crucial to her wellbeing. “They…remind me when I’m having a bad time that it does ease, it’s just that it’s hard to see…in that moment.” 

And her workplace knows about her fibromyalgia. She views telling them as essential: flexible working arrangements enable her to manage her pain while being active in the workforce. 

Talking about her pain isn’t just about getting the support she needs for herself. Hazel also sees it as a way to heighten understanding of the prevalence of the issue, bust through stigma, and provide a supportive community for others living with pain. Acknowledging the presence and impacts of chronic pain in Aotearoa, making the invisible visible, can go a long way. 

Toby and Hazel’s approaches to pain management – movement, support networks, persistence, the involvement of allied health professions, and a focus on the body and brain – are evidence-based. But good chronic pain care isn’t always easy to access. 

Waitlists for pain management programmes in Aotearoa are months long. Hazel’s helping with research into online tools for pain management, but acknowledges that in-person care remains critical. Getting really sick seems to be one of the best ways to reduce your wait time. “I was so unwell it meant I got fast tracked,” Hazel told me as she reflected on her referral to a 12-week pain management programme.  

In 2018, Aotearoa had an estimated 11 fulltime pain medicine specialists. Based on international recommendations, that’s less than a quarter of what we should have. 

We don’t have a national pain management strategy, while similar countries – like Australia – do. And funding for pain management is often threatened. 

“Because it doesn’t kill you directly it doesn’t get the money,” Hazel said bluntly.

Every now and then I run my thumb over the mountain biking scar on my knee. The skin is puckered and purple but the pain is long gone. I’m lucky. For me, pain protects, heals, and teaches. But for too many kiwis, pain persists. 

For something that costs so much – personally, nationally – it seems like Aotearoa has plenty of room for improvement. 

(This blog was written as part of an assignment in a Victoria University Science Communication paper – more details here. Hazel coordinates and lectures for a Vic Uni paper called Science in Every Day Life, which has a module on chronic pain – more details here.)

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10 Lifestyle Factors That Impact Your Pain

10 Lifestyle Factors That Impact Your Pain

Lifestyle

Experiencing chronic pain is an ordeal, and often a multifaceted approach to pain treatment is necessary to make a significant and lasting difference.

Being aware of the lifestyle factors that influence pain may help to change how we approach our pain treatments. 

 

 

 

Sleep

Sleep

If pain interrupts our sleep, or we are too stressed to fall asleep and get enough hours of rest every night, our body is not healing and recovering like it should. If you wake up feeling like a truck hit you, addressing your sleeping problems can make a positive difference in your pain, and healing journey. 

 

 

 

 

Weight/Blood Pressure

Blood Pressure

Research suggests that people with a higher BMI are more likely to suffer chronic pain. It is unclear to why this is. Some evidence suggests that chronic pain itself leads in a maladaptive relationship to high blood pressure. On the flipside losing weight is associated with better pain outcomes. Acute pain puts the body in fight or flight response and makes us more tolerant to pain. When the pain is chronic though, higher blood pressure increases pain sensitivity

(Sacco, Meschi et al. The Relationship Between Blood Pressure and Pain). 

The role of weight gain is massively over-emphasised in clinical settings. Weight loss in and of itself is not an effective or holistic rehab plan and should only be one small part of a far more in depth, kind  and thoughtful pain management protocol. Especially if you are suffering so much pain that you can’t do the exercise needed to lose the weight. 

 

Nutrition

Nutrition

A healthy diet is an essentially part of avoiding chronic disease. Depending on the kind of pain you have, different dietary approaches are promising. Increased omega-3 intake might help with inflammatory pain. Avoiding polyamines (as found in soy and nuts) can reduce hyperalgesia; broccoli, spinach and vitamin E have a possible effect on diabetic neuropathy. Fasting shows evidence to help improve mood in pain patients who also suffer from depression. Chronic pain is associated with increased cardiovascular risk and a balanced diet helps mitigate the impact of both issues, which makes it an extremely worthwhile topic for pain sufferers. 

 

 

 

Exercise & Activity

Exercise and Activity

Certain kinds of exercise might be more useful for certain pain conditions. Personally tailored advise with relevant movements are more successful than general exercise. 

For many people with chronic pain it is important to be able to return to their preferred activities of daily living, may they be playing team sports or getting out into nature for gardening, a walk, or a multi day tramp. Many studies show improvements of mood and sleep with increased exercise, and doing what you love surrounded by friends, family and/or nature further helps with co-morbidities and perception of chronic pain. 

 

 

Smoking

Smoking

While no direct causation between smoking and pain is proven, smokers report more pain. Quitting smoking reduces the risk of cardiovascular mortality which is highly correlated with chronic pain. It’s a no-brainer. 

 

 

 

 

 

Mental Health/Stress

Mental Health and Stress

Chronic pain is closely associated with depression and anxiety – both of which effect how you perceive pain, and also make pain harder to deal with. Many chronic pain cases cannot be effectively managed without taking factors such as stress and mood, and further, depression and anxiety into consideration. 

 

 

 

 

Alcohol

Alcohol

A big lifestyle factor in pain management is the consumption of alcohol. In ancient times it has been used for its numbing effects but this is transitory and requires high doses. Nowadays it needs to be considered that it interferes with many medications for pain and creates  other co-morbitities which can worsen pain. 

 

 

 

 

 

Work/occupational factors

Work/occupational factors

Unemployed people are more likely to report chronic pain. Factors like the job market and other people’s reactions to pain are major players in the perception and persistence of pain. The fear of re-injury and needing to return to work after taking time off for injuries or pain determine the experience as well. 

 

 

 

 

Co-Morbidity

Co-Morbidity

If you suffer from other chronic conditions, such as coronary heart disease, or obstructive pulmonary disease, you are more likely to report chronic pain than the general population. One suggested mechanism is the added challenges for people with chronic pain to exercise, increasing their cardiovascular risk. Other consideration are chronic conditions turning up the volume and making pain more intense in an already challenged body, and the influence of stress and disability from other diseases. Chronic pain cannot be treated in isolation; the whole person with any other illnesses needs to be considered. 

 

 

Pain

Pain

It sounds silly but the main risk of suffering pain is pain. If you already experience pain, you are more likely to develop pain at other sites or acute pain becoming chronic. It is important to address any pains as soon as possible to avoid changes in the brain to make you more susceptible to pain. If you are willing to fight all the battles you have a far better chance of winning the war. 

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Achilles Tendinopathy

Achilles Tendinopathy

Achilles Tendinopathy

What is Achilles Tendinopathy?

Many people experience problems with their Achilles tendon. 24% of athletes suffer Achilles injuries at some point in their lives. As we progress in age, we are more prone to Achilles issues, and men are three times more likely to have an Achilles rupture than women. The Achilles is a common tendon, and it is one where three different muscles merge, gastrocnemius, soleus, and the lesser known plantaris. It is the strongest tendon in the body, and works a bit like a spring. When it is stretched during running as the heel hits the ground, it stores energy that is released as we push off the foot minimising the work the muscles have to do.

Causes of Achilles Tendinopathy

The most common issues that cause Achilles tendon pain are insertional tendinitis, mid-body tendinitis, and paratenonitis.

Insertional tendinitis refers to pain around the Achilles attachment to the heel bone, the calcaneus.

Mid-body tendinitis affects the Achilles tendon further up, closer towards the calf muscles.

The paratenon is a thin sheet of elastin rich cells surrounding the tendon, bundling the tendon collagen fibres into a unit that still allows movement in between.

This is where paratenonitis occurs. When it gets inflamed, excess fibrin causes adhesions. In a chronic condition, this is a form of scar tissue, less of the healthy collagen type I and too much scar-like collagen III.

How Can I Help Achilles Tendinopathy?

Traditional management of Achilles pain includes reducing activity, non-steroidal anti-inflammatory drugs, physiotherapy (eccentric stretching exercises, progressive tendon loading), change of aggravating footwear.

Extracorporeal Shockwave Treatment

Extracorporeal shockwave treatment has proven to reduce pain by 60% in persistent tendinopathies without the side effects and risks of surgery. Nevertheless, surgery does have its place in extreme circumstances and is the recommended form of treatment if the tendon is ruptured by at least half. Surgical Therapy has about 80% of success but also depending on the study, up to 40% complications.

Early treatment of Achilles tendon pain promises better outcomes.

Extracorporeal shockwave was initially used to break up kidney stones and has since shown impressive outcomes for musculoskeletal complaints, including achilles and other tendinopathies. It is also commonly used to treat tennis or golfer’s elbow, rotator cuff tendinopathy, plantar fasciitis, and Morton’s neuroma . Shockwave therapy improves blood flow to the painful area, breaks up adhesions, facilitating the natural healing process. Another affected pathway is on the pain perception through activating serotoninergic systems increasing the pain threshold on a chemical level. See Effectiveness and Safety of Shockwave Therapy in Tendinopathies here

Final Thoughts

In clinical practice, as a rule of thumb, we believe the longer you leave it and put up with your pains and niggles, the longer it will take to get rid of them. Seeing an expert early, and not giving up if the physio exercises did not get you the promised result will more than likely eventually get you over the finish line.

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Brief Reflections On Achilles Tendon Pain

Brief Reflections On Achilles Tendon Pain

Achilles Tendonopathy

Many people experience problems with their achilles tendon. 24% of athletes suffer achilles injuries at some point in their lifes. As we progress in age, we are more prone to achilles issues, and men are three times more likely to have an achilles rupture than women.

The achilles is a common tendon, where three different muscles merge, gastrocnemius, soleus, and the lesser known plantaris. It is the strongest tendon in the body, and works a bit like a spring. When it is stretched during running as the heel hits te ground, it stores energy that is released as we push off the foot minimising the work the muscles have to do. 

The most common ailments are insertional tendinitis, mid-body tendinitis, and paratenonitis.

The first one refers to pain around the achilles attachment to the heelbone, the calcaneous. Mid-body tendinitis affects the achilles tendon further up, closer towards the calf muscles.

The paratenon affected in the latter is a thin sheet of elastin rich cells surrounding the tendon, bundling the tendon collagen fibres into a unit that still allows movement inbetween. Tenosynovitis and tenovaginitis fall in this category. When it gets inflamed, excess fibrin causes adhesions. In a chronic condition, this is simplified scar tissue, less of the healthy collagen type I and too much scar-like collagen III. 

Conservative management includes reducing activity, non-steroidal anti-inflammatory drugs, physiotherapy (eccentric stretching exercises, progressive tendon loading), change of aggravating footwear. 

Extracorporeal shockwave treatment has proven to reduce pain by 60% in persistent tendinopathies without the side effects and risks of surgery. Nevertheless, surgery has its place and is the recommended form of treatment if the tendon is ruptured by at least half. Surgical Therapy has about 80% of success but also depending on the study, up to 40% complications. 

Early treatment promises better outcomes. Extracorporeal shockwave was initially used to break up kidney stones, and has since shown impressive outcomes for musculoskeletal complaints, including achilles and other tendinopathies, and various other pains, such as but not limited to tennis or golfer’s elbow, rotator cuff tendinopathy, plantar fasciitis, and Morton’s neuroma (https://meridian.allenpress.com/japma/article-abstract/106/2/93/151426/Extracorporeal-Shockwave-Therapy-in-Patients-with?redirectedFrom=fulltext).

It is thought to improve blood flow to the area, and break up adhesions, facilitating the natural healing process. Another affected pathway is on the pain perception through activating serotoninergic systems increasing the pain threshold on a chemical level. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029898/?report=reader#!po=36.9565)

It is a safe treatment, even helping in the treatment of cancer patients. (https://link.springer.com/article/10.1007/s00520-019-05046-y) 

In clinical practise, as a rule of thumb we believe the longer you leave it and put up with your pains and niggles, the longer it will take to get rid of them. Seeing a specialist early, and not giving up if the physio exercises did not get you the promised release, will have better – and faster – outcomes.

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Foot Pain – Plantar Fasciitis –  Back Pain – The Scar Tissue Connection

Foot Pain - Plantar Fasciitis -  Back Pain - The Scar Tissue Connection

Back Pain

Gut Bacteria & Health… What?

This article is about resolving chronic mechanical pain, not about the gut. Bear with me however, because it is useful to reflect on the way our knowledge our bodies progresses. 

It seems like only a scientific moment ago we had virtually no awareness of the importance of the gut biome to our health. In fact, we have only been aware of the existence of microscopic life itself for a handful of generations, and aware of the importance of gut bacteria for a few short years. In a handful of years we have watched our general awareness of gut bacteria’s significance shift from virtually zero to common knowledge. It is now common knowledge that the health of the lifeforms in our gut do not only dictate whether we have a tummy upset but are implicated as playing a role in everything from Alzheimer’s to eczema.

The ultimate value of any development in our understanding of health is determined by whether we can actually use that information to become healthier and stronger. The dawning of our awareness of the ecosystem within our gut most definitely has value in this respect. It is early days but there are a rapidly growing number of us finding we are able to use this awareness to improve our health, mood, wellbeing and quality of life through what we choose to eat… and let’s be honest ‘what we don’t eat’. 

The basic realisation we have had about the gut ecosystem may yet prove to form somewhat of a ‘unifying theory’, tying together many of the problems we suffer within our digestive and nervous systems. Somewhat astonishingly we are learning that we rely on the gut bacteria to manufacture the neurotransmitters that are used in the brain for example. It’s a lot of understanding in a very short space of time, understanding that we can put to good use.

Weakness, Scar Tissue & Chronic Pain

Wouldn’t it be wonderful if there was some similar (to the gut bacteria discovery) unified understanding of what caused our pandemic of perpetual back pain, plantar fasciitis, osteoarthritis pain, knee pain, hip pain, bursitis etc. Some new model of understanding that we could put into action and have more of us get out of pain. It just so happens that I believe there is.

I believe that there is a binary theory that holds together the majority of our aches and pains. In the same way that the food/bacteria combination dictates so much of our health there are a  pair of interconnected factors that drive much of our physical pain. Muscle weakness & scar tissue.

It’s a combination of muscle weakness and microscopic scar tissue that drives a significant number of the stubborn aches and pains that we suffer with. 

The science is most definitely ‘in’ on the weakness topic. An absence of strong, well coordinated muscle contractions around joints in the body is known to be a major contributor in many chronic pain conditions. This is the truth we are referencing when we feel stubborn pain in our back and say to ourselves ‘I really need to work on my core’. 

The confounding fact about weakness however that you often don’t get the kind of results you might hope for when you instruct chronic pain sufferers to fix themselves with strength exercises. The fact that so many fail in this endeavor points clearly to the need for recognition and management of other factors.

When the bodies soft tissues are subjected to repetitive strain, they can over time lay down scar tissue as a means of reinforcing and protecting themselves. In the same way that inflammation can run riot and cause problems for the body, scar tissue can cause adhesions that inhibit movement and create additional pain and irritation of tissues.

The most surprising thing about this learning for most of us is the fact that scar tissue can build incrementally. Most of us have been conditioned to believe that scar tissue is only laid down at times of major trauma. The truth is however that tracts of microscopic scar tissue can build up over time and they are a major cause of pain.

For many chronic pain sufferers there is a seminal moment where they find that the back pain/shoulder pain/neck pain they have been working on has responded well to rehab work but that they are still fundamentally in pain. For these hard working and motivated individuals who have truly had enough there is a mixture of relief at having resolved a bunch of pain, mixed with frustration that the strength/gym/rehab work was not the whole job.

There are many possible reasons why rehab can fail to resolve the entirety of a chronic pain condition. Incorrect exercises and/execution of exercises can cause rehab to fail. Undue amounts of emotional stress can perpetuate pain in a way that prevents rehab from taking hold. Stiff joints that need to mobilized can cause pain to linger long after muscles have been strengthened. Muscles that are simply too stressed and irritated to respond to exercises can prevent rehab from working. I am however going on record here and saying that scar-like adhesions are the number one reason why valid rehab protocols fail. 

Bringing It All Together

The key to great pain management is flexibility. Most stubborn pain is far too complex and layered for a ridged approach to its management. A stubborn pain complaint in your knee, ankle, hip or back for example almost certainly involves the joint, the muscle, the ligament, the fascia, the tendon and the central nervous system. Pain that has set up camp for years ultimately impacts all of the tissues in the area and even neighboring areas too. A whole box of tricks is often required to make meaningful and lasting change to chronic pain.

In the instance of the scar tissue/muscle weakness combo which underpins so many stubborn pains, a 2 pronged attack is warranted. Firstly a consistent and focused clinical attack on the scar tissue needs to be undertaken. Treating scar tissue like this basically involves heaps of weekly visits to a clinician who knows how to break it up using a combination of blunt scraping tools and deep joint stretching. Over time the scar tissue breaks up and remodels usually leaving you in a lot less pain. Once this process is complete or at least well under way a careful and extremely specific strength routine must be developed to target the primary muscles that have weakened as part of the condition.

Once there is a widespread understanding of these principles (as there now is with gut flora) we will have a breakthrough in the amount of chronic pain we suffer as a culture. The combination of strength work and scar tissue remodeling is not enough to make us all pain free or save the world; but it will make a huge difference I promise you. And it is entirely possible that it will be enough to make you totally pain free.

For many pain sufferers merging strength work that targets the right muscles in the right way with deep release of scar tissue adhesions is the game changer they had been looking for. It’s a beautiful thing. There is nothing quite like the feeling you get when you realise you are finally getting better!

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You Are Living In The Midst Of A Lower Body Pain Pandemic – Why?

You Are Living In The Midst Of A Lower Body Pain Pandemic - Why?

Hip Pain

Normalising Pain

You have lived your entire life in the middle of a pain pandemic, that almost no one talks about. We suffer terribly with pain and disability, even (some say especially) in the world’s wealthiest countries. Large population based studies indicate that somewhere between 30-50% of people in developed countries suffer with chronic pain. The researchers behind these studies predict a steady increase in these rates of pain due to our  increasingly sedentary lifestyle  and an aging population.

I wasn’t alive in the 1600’s, so it’s hard for me to know for sure, but I would imagine that people just accepted the fact that rotten teeth were a completely normal part of the aging process. If everyone you know had rotten teeth by the time they were 30 it’s highly likely that in the absence of any deeper scientific insight you would simply assume that dental decay was a normal part of the aging process.

If this was the case, it most certainly reflects our current cultural attitude towards back pain, hip pain, knee pain, ankle pain and foot pain. We by and large accept them as part of the aging process. It is only natural to assume that the health issues we face en masse are a normal part of reality.

Imagine you are visiting in your time machine, chatting with your dentally challenged foreparents in the 1600’s. The conversation turns to dentistry, and they tell you their black teeth are ‘just old age’. What would you want to explain to them??

In our luxurious ‘first world’ life is good, better than it’s ever been before maybe, at least  in terms of the broader conditions most conducive to a long healthy life. We don’t have to hunt large aggressive wild animals for food anymore, yet we are still sitting on top of the food chain. We live in warm dry homes. Very few of us perform gruelling manual jobs. We breath clean air for the most part. We are well fed, well healed and well vaccinated. We have ample time to move our bodies in whatever way we choose. We don’t have to fight to maintain our territory. We have comfortable furniture and nice squishy mattresses.

Desk work is far from ideal, but realistically it isn’t coal mining and it isn’t hunting. In the latter cases we are talking about careers where death and dismemberment are ever present risks.

Seemingly life is not that hard on our bodies, yet we suffer with an unfathomably widespread pandemic of lower body pain. A pandemic that we have normalised so wholeheartedly that it is quite normal for people to hold some expectation and acceptance of stubborn pain beyond the age of 40. Possibly much like the presumable acceptance of universally black teeth in people over 30 in the 1600’s.

How Much Pain? Heaps!

It is hard for anything to compete with the likes of refined sugar, smoking and alcohol in terms of impact on societal wellness. The impact these highly lethal yet culturally sanctioned products have our health makes for disturbing reading.  But you might be surprised how competitive chronic pain can be. Pain is a legitimate major public health issue, especially when you take into account …

– All the pain, in and of itself.

-All the physical disabilities associated with chronic pain.

– The financial cost to society through loss the of productivity, impact on   individual careers and healthcare spending created by chronic pain.

– The well documented (and completely awful) impact chronic pain has on mental health.

– The incredibly serious mental and physical impact of pain medications have on pain sufferers. Including the shocking death toll of opioid based pain medications in certain developed nations

– The well documented interaction of chronic pain and poverty.

– The common and tragic illicit drug addiction that can arise from chronic pain (this is a huge topic in the US).

– The death toll on operating tables, the failed surgeries and post surgical infections.

-The fact that chronic pain can wreak havoc on close relationships.

-The serious long term harm done to people’s cardiovascular system through forced inactivity (this is an extremely common and and largely untold epidemiological story that impacts a very significant number of people)

It is very difficult to put total numbers on the amount of heel pain, ankle pain, ankle sprains, iliotibial band pain, knee pain, hip pain, plantar fasciitis and back pain that we suffer with in our society. Such is the enormity of this situation we don’t stand much of a chance in effectively unifying the statistics. In reality though, the data on individual complaints easily speaks to the bigger grimmer picture. The data on back pain alone is indicative of a profoundly serious global healthcare issue.

We have no longer term need to dwell on pain statistics, thankfully! It is a little dull even from my perspective. The journey with our own pain is a rehab journey – that’s where the rubber hits the road. Bearing in mind that to fix something we must first accept that it is malfunctioning: let’s take a few moments to stand back for a moment and survey the cultural-wide carnage. This may help reduce your sense of suffering alone, and hopefully reinforce the idea that something is genuinely not right with ‘us’

Lower Back Pain

Lower Back Pain

Lower Back Pain

The World Health Organisation have officially christened lower back pain ‘a major cause of disability’ across all Industrialized nations. The WHO have also stated clearly that back pain is the leading cause of work absence throughout the developed world.

The 2010 ‘Global Burden Of Disease Study’ placed back pain among the ‘10 most impactful conditions to people’s overall wellbeing in developed countries’.

In industrialised societies the lifetime frequency of back pain is estimated at 60-70%.

Studies in the United Kingdom have revealed back pain as being the leading cause of disability in young adults and attributes 100 million lost work days per year in the UK alone.

A survey carried out in Sweden during the 1980’s identified back pain as the cause in 21 of their 28 million total lost work days in Sweden per year.

The US estimate for the financial cost of back pain to society through people missing work alone – is between 100-200 billion dollars per year. *Even allowing for a few mental health days and hangovers being blamed on

back pain, these numbers should have the power to shock.

Hip Pain & Knee Pain

Hip & Knee Pain

Hip & Knee Pain

In the UK research indicates the percentage of 65+ year olds reporting hip pain is 19.2%. While the percentage of 65+ year olds reporting knee pain is 32.6%. The percentage suffering both hip or knee pain was 40.7%.

General health status scores of elderly people are similar to those of people aged under 65 yr in those who aren’t living with chronic pain.. This shows a correlation between pain and wellness in older adults.

A study carried out in the US indicated that a total of 14.3% of participants aged 60+ reported significant hip pain on ‘most days’ in the 6 weeks leading up to the survey.

Knee pain is estimated to affect approximately 25% of all adults, at levels that limit function, mobility and quality of life

From 1991 to 2006, the numbers of total knee replacement in the United Kingdom more than tripled.

In the US, the rate of knee replacements among individuals over 65 years increased about eight-fold from 1979 to 2002.

Ankle Pain & Ankle Sprains

Ankle Pain & Ankle Sprains

Ankle Pain & Ankle Sprains

Sprained ankles have been estimated to constitute up to 30% of injuries seen in sports medicine clinics and are the most common musculoskeletal injury by far.

25,000 Americans a day sprain their ankle, and more than 1 million visit emergency rooms each year because of ankle injuries.

Lateral ankle sprain accounts for up to 20% of all sports-related injuries. Indoor and court sports have been shown to carry the highest risk of ankle sprains.

UK study estimates 302,000 new ankle sprains and 42,000 new severe ankle sprain patients bad enough to attend emergency departments in the UK every year.

A US Army study found that ankle sprains are the most common foot and ankle injury in active-duty Army personnel with a rate of 103 sprains per 1000 persons per year.

Approximately 40 percent of those who suffer an ankle sprain are estimated to experience chronic ankle pain, even after being treated for their initial injury.

Studies indicate that ankle sprains are not simply a matter of bad luck, certain people suffer re-occurring sprains and many others live their whole life without ant ankle sprains.

Heel Pain & Plantar Fasciitis

Heel Pain & Plantar Fasciitis

Heel Pain & Plantar Fasciitis

Approximately one million doctors visits per year in US are due to plantar fasciitis.

Some literature on plantar fasciitis shows the prevalence rates among a population of runners to be as high as 22%.

Heel pain has long been recognized as highly prevalent in the senior population, which impacts approximately one third seniors older than 65 years.

There is data that indicates the type of functional issues seen in the feet of plantar fasciitis and heel pain sufferers is associated with poor balance and increased risk of falls.

Heel pain is the most common in active people over the age of 40.

Osteoarthritis

Osteoarthritis

Osteoarthritis

According to the CDC in the US today there are estimated 54 million people with osteoarthritis.

Osteoarthritis is the most common cause of disability in adults globally .

The lifetime risk is of developing symptomatic knee osteoarthritis in Western Society is 45%.The lifetime risk is of developing hip osteoarthritis with noticeable symptoms is 25%.

There are 14 million individuals in the U.S. who have symptomatic knee osteoarthritis at any given time. Nearly 2 million of these are people under the age of 45.

The overall rate of osteoarthritis in military service members is 26 percent higher than the general population, at age 20 to 24 it is twice as high as the general population aged 40 and older. 

A study in 2012 demonstrated that osteoarthritis was the highest cause of work loss and affected more than 20 million individuals in the U.S. The estimated cost to the economy is more than $100 billion annually.

What I hope that you can sense here is that for there to be this much pain afflicting people who essentially every advantage in life there is surely something up?????

Opiate Prescription

For a better  acknowledgement of how severely we struggle with pain: there is some value in being at aware of the opioid crisis that has plagued the US over the past 20 years. Prescription opioids are a justifiable tool for about 0.0001% of pain sufferers. The class of poor unfortunate souls who have suffered the likes of extensive burns or nerve damage. Significant trauma and significant disease, are sound justifications for the use of this class of drugs.

At the height of the American opioid epidemic in 2012; the number of annual prescriptions peaked at 255 million. OxyContin is to heroin what treacle is to table sugar; the distinctions are more micro-molecular than they are meaningful. So realistically this was a case of 255 million ‘heroin’ doses being dispensed to chronic pain sufferers by American doctors in 2012. A huge number of these patients would have been back pain, hip pain, knee pain, foot pain sufferers and the like.

Statistics published in the American Journal of Public Health: estimate that there were between 17,000 and 32,000 deaths from prescription opioids during 2016. Each of whom was someone’s mum, dad or at least someone’s child, lest we forget what stats represent.

On top of the thousands of deaths you can safely assume that for each death there are perhaps 5-10 or even 20 other patients living an utterly miserable addicted existence.

The American CDC estimates the total economic burden of prescription opioid misuse in the US is $78.5 billion a year.

Realistically, all the stats are glorified guesses, no one really knows how bad it all is. Death certificates for the 42’000 total opioid overdoses in 2016 do not make a distinction between deaths caused by illegal opioids like heroin, and deaths caused by prescription opioids.

These opioid deaths are not like the inevitable toll we associate with extreme medicine, like emergency open heart procedures where it was touch and go for the patient pre-admission. These are deaths caused by pain relief medications!!!!

If chiropractors dismembered 30,000 Americans during 2016, that would be shocking would it not? It should be even more shocking that a single class of prescription pain medications (with very few sane applications) does. For some reason we tend to leave these kind of stats under the rug, while others not so much. If chiropractors killed 300 Americans a year you would hear ALL about it… lest they should kill 30 thousand.

The human story behind the medically endorsed and executed opioid death toll includes the ‘surface symptom’ that is chronic pain. It also includes the profound physical unwellness, emotional trauma, physical trauma, cycles of abuse, poverty, stress, poor diet, a lack of proper rehabilitation and a severe lack of education.

The type of patients who become opioid statistics are nearly always either the hardest of the hard, or the fragilest of fragile… or both. As a collective they cost society more than all the other pain sufferers put together. They require more help and support than all the other pain sufferers put together… literally! The reality is that an inconveniently massive amount of love, care, rehabilitation, support and education is needed for many of these patients to stand any chance of a normal pain free life.

To respond to all this, not with acknowledgement, not with support, not with rehabilitation, but instead ‘systemically sponsored’ drug dependency and societal ‘addict stigmatisation’ is heart breaking stuff. And the fact this happens in our supposedly modern world speaks deeply to our struggle with chronic pain.

The Rest

For the sake of brevity I have carefully left out all the IT Band issues, bursitis, piriformis syndromes, achilles pain, calf pain, groin strains, hamstring issues, sciatic pain, disc injuries, shin splints, stress fractures, bunions, ingrowing toe nails, Morton’s neuroma and others. But rest assured they add up in a big way.

I know this is a bit dry, but at least now you are fully aware of the vast and very human mess you are a part of when you live with pain.

 

Okay, So Why Does A Global Culture That Has Been To The Moon Struggle So Much With Something As Basic As Musculoskeletal Pain? Is Pain Management Harder Than Rocket Science?

So to my mind there are really only 2 worthwhile questions to ask next once we have become enlightened as to how severe our pain epidemic is.

Very important question no. 1 – Is there an actual reason or reasons for all this pain, or is it just an inevitable part of being human?

Answer – Yes there are some really obvious reasons if you know what to look for! And no, on the scale that it exists now it most definitely isn’t an inevitable part of being human. 

Very important question no. 2 – If it isn’t just an inevitability is there actually anything we can do about all this pain

Answer – Yes there is a great deal that can be done to heal, halt and reverse the pandemic of lower body pain we suffer with. We can heal this, both as individuals and as a society. We are going to move past this the same way we moved past smallpox, polio, endemic dental disease and a host of other crappy chapters in our collective medical history.

Pain management isn’t rocket science, you can trust me when I say that many of the most effective solutions are almost shockingly simplistic. As one small example of this – I personally know several hundred people who would be very happy to tell you that I helped them to resolve their severely debilitating heel pain using a porcelain soup spoon. And while many chronic pain sufferers do have complex webs of physical weakness, physical scar tissue and even emotional trauma that hold their back pain and knee pain together – in most of those cases it is really just about layering simple solutions on top of simple solutions. It really isn’t rocket science I promise you.

For most patients being stuck with chronic hip, ankle or knee  pain is a bit like having a nasty splinter in your finger; but also being part of a tribe in which almost no one understands how to get splinters out. That splinter could cause you a lot of problems – but not for the want of a complex brain surgery-like procedure – just for the want of some pretty simple wisdom. If you know how to get a splinter out splinters aren’t a big problem. If you don’t know how to get splinters out, over time they can cause carnage.

If you peel back the real reasons we struggle so much with pain they are complex, cultural, quasi-scientific and somewhat philosophical. If you want to understand that better have a read of this LINK TO ORTHOPEDIC BLOG.

But we aren’t here to unpack how we got here dear reader. We are here to unpack what is actually causing all this chronic lower body (back – hip – knee – ankle – foot). And we are also here to unpack what we are actually going to do about managing all this pain.

So Hit Me With It Then – What Causes All This Lower Body Pain?

I am going to make this really really simple for you, and that’s going to be easy because on the level that we need to understand it here it is simple. The following principles are more than likely all you will ever need to know in terms of what causes your lower body pain. Bearing in mind – if we know roughly what is causing our pain we can make far more educated choices around which type of solutions we roll out. Because in the end all this talk is only for the purpose of bringing us closer to effective tools so that we can get ourselves free.

The following causes of our lower body pain pandemic are inevitably not the whole story. But they are enough to guide 99% of us to get rid of 99% of our pain if we are willing to make them , and it could be the basis of a our holistic roadmap for full rehabilitation.

Cause 1 – Hard Flat Surfaces

Our ancestors lived in the big outdoors with their feet in the mud. A million generations of your direct ancestors didn’t walk on hard flat ground like concrete and tarmac, they walked on variably soft undulating ground. Natural surfaces hug the sole of the foot as you walk on them which means that the arch receives support – and the entire foot benefits from shock absorption.

It would be very hard to overstate the impact (literally) our sudden shift from soft undulating ground to hard flat ground. After millions of generations spent evolving on and adapting to soft surfaces, 5 human lifetimes ago we invented cobble stones and flag stones and rest is hard homogenous history.

Imagine in your minds eye jumping down from a high seawall onto soft sand, and choosing to land heels first with straight legs. Most of us can clearly imagine doing this for fun, not only on sand but on a range of other natural surfaces. Now visualise the same experiment, jumping down from a high seawall –  but this time landing on concrete, again with heels first and straight legs. It shouldn’t  take much imagination to get a sense of how dangerous this could be. The difference between the impact of hard industrailiased ground on the tissues in our lower body and the impact natural surfaces have on the lower body is vast. This visualisation gives you a window into the increased stress that our joints an soft tissues are subjected to over the course of an entire lifetime.

With no arch support and no shock absorption our tissues are subjected to massively increased rates of microtrauma and general wear and tear. In addition to this the lack of muscle activity and balance control required to get from a-b on completely flat surfaces engenders muscle wasting in the muscles of the core and lower limb. If you go for a long walk in the forest away from any tracks you will get a chance to marinate in this truth. It is actually pretty hard work getting around in the big outdoors. But it certainly isn’t hard work strolling along the conveniently flat and homogenised surface in an urban street. The lack of challenge presented by industrially fabricated surfaces causes insidious patterns of muscle wasting in our body’s and a gradual loss of effective balance (aka proprioception). Needless to say, muscle wasting is an excellent ingredient that one might include when cooking up a recipe for chronic pains like back pain, hip pain, knee pain and ankle pain.

The combination of microtrauma induced through lack of support and shock absorption, and muscle wasting induced by the lack of work involved in moving around the planets surface make for a potent mix of pain inducing cellular changes in our body’s. As is the case with any form of stress we do of course have greatly varied levels of susceptibility to the creeping ravages of  hard ground. Those of us with high arches, flat feet and wide hip angles are all examples of those who tend to suffer more than their fair share of the pain inflicted upon us by this incredibly convenient but ‘biomechanically toxic’ aspect of our modern world.

Cause 2 – Sedentary Lifestyle

Unlike the hard surfaces, the impact of excessive and prolonged periods of activity is a far more well known causative agent in pandemic of pain we are amongst. Admittedly we are far more aware of the impact that prolonged sitting has on the neck and shoulders, than we are of the impact sitting can have on the lower body. This is probably simple because we are far more attuned to the more obvious changes that happen to peoples spinal posture over time. But excessive sitting has just as much impact on alignment in the lower body as it does the upper body, just in a less visible way.

The obvious impact sitting has is that it leads to gradual loss of muscle mass. In the shoulders and spine this means loss of the upper back and core muscles. In the lower body this means a loss of tone in the stabilisers of the hip and thigh. All of which happens far more quietly and insidiously deep in behind the hip, and under the desk.

In addition to the loss of muscle mass in the lower body, excessive sitting creates loss of joint mobility and a loss of elasticity in the soft tissues of the lower body. Shortened hamstrings and shortened hip flexors are the most well known of these chronic adaptations that contribute greatly to the pool of chronic pain and disability in our world.

The legacy of all the sitting we do often bears its bitter tasting fruits during times of increased activity as opposed to during the sitting itself. What this means is that when we injure our hamstring in the masters soccer match it isn’t a true injury, but a chronically shortened hamstring that has failed to rise to the occasion. Due to 26 thousand hours of ‘chair time’ in the preceding year. When we ask our chronically shortened tissues to move, often they can’t, especially as we get older. But it isn’t age that is the cause, it is what we spend our years doing that determines what pain we have. The longer we smoke the more we cough, the longer we keep sitting the more we ache. Neither are age related they are both just bad habits.

Cause 3 – Physical Injuries & Scar Tissue

Injuries are probably the most over-estimated and over-rated cause of pain in our cultural pain paradigm. And scar tissue may be the most under-rated and under-estimated cause of pain in our world. This can seem like somewhat of a contradiction in terms unless you understand that scar tissue can often come about as the result of repetitive strain and persistent lifestyle factors like poor posture.

A true injury is when we are are 100% healthy one minute and then broken the next. Many of the back injuries, ankle injuries and knee injuries we experience are however a little more complex than that. It is often our weaknesses that come to the surface during relatively minor incidents, which masquerade as true injuries. This being said there are obviously many other occasions when we sustain true injuries.

Regardless of whether they come from weakness or genuine bad luck, many of our injuries leave us with lasting challenges. This is obviously true of the majors like back pain and whiplash injuries after major car crashes, but it is in many ways just as true of the common garden variety ankle sprains.

Physical injuries cause chronic pain through the legacy of scar tissue and muscle wasting. Ineffective rehabilitation is injury management that doesn’t deal effectively with the scar tissue and muscle wasting left by classic ankle sprains. And FYI effective injury rehab is the exception not the rule in our society. These principles where chronic pain is the long term result of an injury applies to neck painshoulder pain, back pain, hip pain, knee pain, ankle pain and foot pain.

By virtue of the sheer quantity of weight bearing the lower body does it frequently cops the worst of what scar tissue and muscle wasting have to offer. In addition, we depend so heavily on the tissues of the lower body for movement they by and large have greater scope for manifesting chronic disability.

Cause 4 – Lack Of Education

Consider for a moment how well you look after your teeth. Five minutes in the morning and 5 minutes in the evening, erry damn day!! Regular check ups, semi-regular visits to a hygienist. If hey you have pain in a tooth you seek help immediately. And at least if you are one of the few slackers who don’t stick with the dental program, you most likely know that you should.

In contrast consider how the average person looks after their spine.. It’s fair to say that since the rise of yoga (borrowed from another culture) there a few westerners who take some time out to care for their spine. But mostly we don’t have anything like the same kind of routine ‘spinal hygiene’ built int9 our lifestyle. We don’t generally don’t work on the mobility and strength of our spine tissues in religious way. And those of us who do aren’t anything like as regular with that process as we are with our teeth.

The reason we care for our teeth so well is that we are carefully educated and indoctrinated from an early age. By the time we are 7 year old we have an excellent grasp of what it is that impacts the wellbeing of our teeth, and we know exactly what we need to do about it.

If you go onto a busy street in any city in the developed world 100 people what you should do about your tooth lain you will get near enough 100 really consistent responses. In fact 100 out of 100 will even know how you could have prevented it from hurting in the first place. On The other hand, if you head onto the same street and ask 100 people what you should do about your back pain you will scarcely the same answer twice, and take my world for the fact that very few of them will be high quality responses. We have absolutely no consensus and very little understanding of what really causes problems like back pain, hip pain and knee pain. And even fewer of us know what the real processes are for resolving these complaints once they become chronic. This is due to a lack of education… systematically and even amongst healthcare professionals.

Cause 5 –  Stress & Emotional Trauma 

The research has shown conclusively that there is is a profound connection between psychosocial stress, trauma and chronic pain. Broadly speaking there are 2 primary ways in which chronic emotional disturbances create and influence chronic pains like back pain and hip pain. The first is habituation of muscle tension and stress related postures which cause the type of physical changes we associate with chronic pain. The second is chronic activation of pain pathways deep in the central nervous system.

Much of our ancestry is made up of animals that were prey times for much bigger toothier critters. And all prey animals are equipped with a freeze reflex that compliments the fight or fight system.

There is a big advantage to having a freeze reflex. if you get grabbed by a big cat and you freeze instantly there is a reasonable chance it will assume you are already dead and not go in for the full neck bite. Being frozen up, only partially chomped and seemingly dead gives you a small but real evolutionary advantage. If the predator is distracted by another predator or goes off to fetch its Cubs for dinner you have a chance to escape.

Being on the inside of the freeze reflex is not a fun place to be, just ask anyone who has been there. In the moment when you feel like you need to be your strongest your body completely shuts off all motor control. As far as the nervous system goes, the freeze responds is like driving a car at 100km per hour and suddenly applying the handbrake without coming off the gas. It can be terrifying to feel weak and defenseless in a moment where we naturally want to feel strong.

Animals are far better than us at literally ‘shaking off’ traumatic events. The tremble and shake to release the freeze response and then run like the clappers. Humans have developed a tendency to react very badly to freezing moments. Having large  frontal lobes as we do means in moments like that we make snap judgements like ‘I am totally powerless to defend myself’. These impressions carry with them the tendency to ball up the freeze response moments rather than express it effectively.

‘Unprocessed freezing up’ is how we carry trauma in our bodies. And the double shitty news is that it doesn’t only happen with the big stuff. Even small events can  create this kind of reaction in our bodies, and it’s basically how we convert lots of small stressful moments into a build up of anxiety, fear, stress and the other emotions that we use to cover them up like anger.

Carrying these layers of unprocessed trauma in our nervous system is how many of us ultimately covert our stress and trauma into chronic pain. Chronic muscle tension and irritable nerve pathways are unsurprising knock-on effects of trauma responses stuck in the body over the longer term.

In Conclusion 

So now you know (assuming you are willing to take my word for all this) that our lower body pain pandemic is not the big achy mystery it might have been – given how much there is out there.

The point of this article was firstly to acknowledge what a pain pickle we are in as a society, and perhaps reassure you that you aren’t alone if you are struggling with chronic pain. And secondly to demystify all this pain, as a start point on the journey towards full rehabilitation and recovery. Because good news I have to share is each and every one the lower body pain causes I have touched on here comes with a wide range of reciprocal and effective solutions.

The scar tissue that causes so much of our knee pain and ankle pain can be broken down. The muscle wasting causing our back pain can be resorted with the right exercises. The impact of hard surfaces can be mitigated with exercises and custom orthotics to provide support and shock absorption to our joints. We can learn about how to take better care of our muscles, joints and soft tissues.  And our trauma can be healed and released, often with surprisingly simple tools and exercises.

And when we put all this together for ourselves in a way that works for us – we will have taken a small but hugely meaningful bite out of the largely silent pain pandemic we are living in the midst of.

Multi Media Versions of this Blog Post below:

Make sure you don’t miss parts 2, 3, 4 and 5 of this information series – go check them out on the links below now:

Part 2 of Pain Pandemic

Part 3 of Pain Pandemic

Part 4 of Pain Pandemic

Part 5 of Pain Pandemic

Prefer listening to the Podcast? Click here to tune into Episode 1:

Episode 2:

Episode 3:

Episode 4:

Episode 5 :

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Is Plantar Fasciitis Taping An Effective Treatment?

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What Is Plantar Fasciitis Really?

Plantar Fasciitis is not the most useful or the most descriptive of names for what the condition really is. Given that an ‘it is’ is technically a condition that involves inflammation –  modern research having shown that plantar fasciitis is not caused by inflammation. 

Nearly all plantar fasciitis patients have successfully self-diagnosed before they walk into a clinic, but very few actually understand the underlying physical process. And if you suffer with chronic pain, knowing what is actually going in is a kind of useful start point.

Plantar fasciitis is a form of repetitive strain injury that occurs in the sole of the foot. Like all repetitive strain injuries, plantar fasciitis relates in part to lifestyle (think footwear choices / hobbies etc.), partly to environment (think concrete/tarmac etc.), partly to genetics (think flat feet, knock knee’s etc.); and also like all repetitive strain injuries – plantar fasciitis sucks to live with. 

Repetitive strain in the sole of the foot caused by a combination of factors, that all conspire to create scar tissue. So plantar fasciitis is essentially repetitive strain, leading to a build up of scar tissue in the sole of your foot. To be clear, we aren’t talking about the happy, well resolved type of scar tissue either – we are talking about really grumpy scar tissue that is a lot like a partially unhealed wound.

So What About Plantar Fasciitis Taping Then?

Ultimately the value of plantar fasciitis taping is determined 100% by whether it works for YOU, both in the long and short term. It is worth bearing in mind at all times however that while it might make life easier, plantar fasciitis taping will never break up the scar tissue in your foot. That being said, there are some general principles to be aware of when choosing treatment options for plantar fasciitis, including the taping part of the jigsaw. 

The most effective treatments  vary from person to person in cases of plantar fasciitis. Within the treatment buffet, there can be value in selecting treatments that achieve any of the following .. 

Treatments for plantar fasciitis that reduce impact strain on plantar fascia. These can include custom insoles, careful footwear choices and plantar fasciitis taping.

Treatments for plantar fasciitis that increase blood flow to the plantar fascia. These can include extracorporeal shockwave therapy, acupuncture, acupressure, hot and cold therapy and Graston technique.

Treatments for plantar fasciitis that break up scar tissue in the foot. These can include  extracorporeal shockwave therapy, acupuncture and Graston technique.

Treatments for plantar fasciitis that reduce pain signals. This can include acupressure, acupuncture, Graston technique, massage, hot & cold and of course pain medications.

Treatments for plantar fasciitis that address muscle weakness in the ankle, knee & hip. This is basically only possible through consistent use of specific strength exercises.

While plantar fasciitis taping is definitely useful in the short term, most patients report that they have better results with less hassle in the long term using a combination of custom orthotics, treatments that promote blood flow, scar tissue release and strength exercises. 

Plantar fasciitis taping can definitely be used to support the arches and to reduce some of the impact strain that occurs in the plantar fascia when you walk and run; particularly when you are in pain management mode as opposed to later on when you are in rehab mode.

Plantar fasciitis taping is generally considered to be more of a short term ‘stop gap’ measure that can get you through until more permanent solutions like those mentioned above can be actioned. This is to take nothing away from the value of taping to get you out of a tight spot. 

Plantar fasciitis taping is especially useful if your pain treatment and rehab process is still pending, and you have some activity, training or sporting performance that you need to get through. 

The upside of plantar fasciitis taping is that it is relieving, quick and cost effective. The downside of plantar fasciitis taping is that for most people it is quite temporary and doesn’t get to the heart of the plantar fasciitis issue… scar tissue!!!

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A Cure For Plantar Fasciitis Heel Pain? – Two Treatments To Try And Rule Them All

A Cure For Plantar Fasciitis Heel Pain?
Two Treatments To Try And Rule Them All

Pain middle of foot

I love helping people move past their pain and find the kind of freedom and happiness that comes with being free of physical limitation. As a  general pain management enthusiast I wish that there were clear cut ‘cures’ for more of our pain conditions – including plantar fasciitis heel pain. But for the most part pain management just isn’t simple. Life can be pretty un-neat and tidy.

The good news though, is that while I never feel comfortable talking about ‘cures’- there are some very very powerful tools out there for those of you who wish that there was a clear cut cure for plantar fasciitis heel pain.

As I have stated before in this blog I do not claim to be able to ‘cure’ ANY of the conditions I help people to manage. The truth is that if even your dentist can’t claim to be able to ‘cure’ you of dental issues (and he/she can’t) then no one can claim to be able to cure you of plantar fasciitis heel pain.

For as long as you live on the urban terrain with its concrete, paving stones & tarmac you will be at risk not only of plantar fasciitis heel pain but other types of foot pain, knee pain, hip pain and back pain.

It is a little known fact that concrete is as bad for your joints and soft tissues as sugar is for your teeth and gums.

That being said – an interesting question I was asked by a student recently was ‘If you were trying to successfully ‘cure’ plantar fasciitis heel pain for as many people as possible –  which treatment would you use if you could only use two’? ‘’Well’’ I said ‘’ If I wanted to get the best possible outcomes for as many plantar fasciitis and heel pain sufferers with only 2 methods I would use extracorporeal shockwave wave therapy & graston technique ’’.

My response was based on the fact that plantar fasciitis heel pain is caused by a build up of microscopic scar like tissue in the soft tissues of the foot. With the repetitive strain of stomping around on hard, artificial surfaces for a lifetime, a percentage of us succumb to pain. For some it’s the feet as with plantar fasciitis and for others it’s the ankles, knees, hips and spine.. just depends.

Things can get really bad when we develop scar tissue in the soft tissues of the foot. For plantar fasciitis heel pain sufferers with major scar tissue the pain can become very chronic and very stubborn. Yet even after years of pain when I use shockwave therapy and graston technique on their plantar fascia they so often improve in a very short space of time.

All the popular treatments for plantar fasciitis heel pain have their place. Taping is effective for plantar fasciitis heel pain, so is acupuncture, so is stretching. Vibration massage to the soft tissue is an excellent treatment for plantar fasciitis heel pain. I could make a long list. But if I was forced to choose two treatments to try and ‘cure’ someone’s plantar fasciitisheel pain it would definitely be graston technique and extracorporeal shockwave therapy.

Let’s be real for a minute though.

You wouldn’t bother going to a gym with only one kind of machine. You wouldn’t choose to try and survive on one kind of food for the rest of your life; and you wouldn’t expect me to treat (let alone try to cure) something as notoriously tricky as plantar fasciitis heel pain with only one kind of treatment.. would you?

Treating plantar fasciitis heel pain and pretty much any pain you care to mention is one of those topics in life where flexibility and agility are key qualities of treatment.

In the same way that an accomplished boxer must have a variety of punches combined with good head movement and footwork, a good pain clinician must have numerous tricks up their sleeve. If you forced me to treat (let alone try to cure) plantar fasciitis heel pain using just one technique I would feel like a 1 armed boxer with both legs tied together. A nasty jab would remain but not much else !

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Reflections on Walnuts & What They Can Tell Us About Pain

Reflections on Walnuts & What They Can Tell Us About Pain

Walnuts

Walnuts Are Healthy!

Walnuts are delicious, they also make an extremely worthwhile nutritional contribution to many recipes and dishes the world over. 

To say that walnuts are nutritious is a whopping understatement.

Walnuts contain healthy fats, fibre, vitamins and minerals — and that’s just for starters. There’s so much professional interest in walnuts within the nutrition research community that for the past 50 years, scientists have an annual walnut gathering at the University of California.

Walnuts are an excellent source of antioxidants that help fight oxidative damage in our cells, this basically means diseases prevention across the board.

The nutrients in walnuts have been shown to decrease inflammation, which is a key factor in many chronic diseases.

The polyphenols in walnuts may reduce your risk of certain cancers, including breast, prostate and colorectal cancers. However, more human studies are needed to confirm this.

The polyphenols in walnuts are thought to potentially decrease the risk of certain cancers, including breast, prostate and colorectal cancers.

The list of proven and potential benefits (indicated by clues in simple studies) is a long one… and its always getting longer.

Walnuts Are Scary!!

Knowing the walnut through my own eyes (and only knowing a small amount about nutrition as I do) it is hard to imagine how there could be any downside. Going solely by the research and by my own experience with them I would recommend walnuts to anyone, why wouldn’t I? Well.. anaphylaxis is why I wouldn’t !!!

Even though they go particularly well for me; within moments of consuming a walnut, a percentage of humans feel a terrifyingly intense prickling heat pass through their body as the precursor of a very quick and uncomfortable death by asphyxiation (in the absence of emergency care of course). This somewhat inconvenient side effect to walnut consumption is caused by a dramatic immune response to their nuttiness – which shuts down the respiratory system blocking up and shutting down. For a few unfortunate souls, the walnut can kill as quickly as western brown snake venom. 

So despite all their well-documented virtues walnuts can kill… quickly. Now I don’t know the first thing about severe allergies and how they come to be. I do know that there is a powerful truth held in this walnut fact that teaches me a great deal about what it is to be human. And also about navigating pain, and when I say pain I mean all the classic musculoskeletal issues like sciatic pain, back pain, shoulder pain, hip pain, neck pain, foot pain, headaches.

Humans – Same Same But Different!  

As members of the 8 billion strong, 1 million-year-old human genome project we share a great deal, we all have heaps in common. There are many degrees of ‘universality’ however, and there is also much that we don’t have in common. 

Some things in life are like the straight-up 50/50 cats vs dogs debate. In another part of the grey spectrum, you could say that we all have 2 eyes which seems like a pretty reasonable statement, but some do not have 2 eyes. You could also say ‘we all’ love chocolate or puppies but then again obviously there would be quite a few exceptions. From these perspectives it can seem like all of life is ‘horses for courses’ –  yet there are undeniable exceptions to the ‘horses for courses’ rule. 

There is not a single one of us who can live for 6 months without water. None of us can live without a heart that’s pumping. We all breathe air. There’s a critical dose of brown snake venom that would kill every single one of us. None of us can bench press an orca. 

I know what you are thinking… but strictly speaking Chuck Norris is not human, so he can’t be counted as the exception to the latter rules

Gluten Is Yum… But Scary For Some!

I remember when I first realised that I was moderately gluten intolerant. I had struggled with my energy levels and gut health for the longest time and thought I would give up gluten for a while to see if it helped.

I felt pretty much the same for a week or 2 of no gluten, but on week 3 I noticed a shift in my wellbeing. I noticed that my workouts were going a little better and my long-standing reliance on afternoon naps had reduced. By week 4 I started to feel like a completely different person. It was like someone had lit a fire that had been merely smoldering for as long as I could remember. 

This experience turned me into a gluten evangelists overnight, I wanted everyone to try it, and I honestly believed that most if not all would find it transformative on some level. The truth is though I was wrong, many people who give up gluten don’t find the kind of noticeable positive changes that I did. 

I have noticed with myself and others over the years, that sometimes we discover what works for us and mistakenly assume that it is the right thing for everyone else too.. maybe it’s just a human trait. Once I had tasted how sweet life was without gluten for me I wanted to spread the good word. It’s a well-intentioned thing but also often a misguided thing based on whopping presuppositions about the ‘sameness’ of our bodies and what they need. And let us not forget the walnut thing!!

What Does This Have To Do With Pain?

I rarely hear anyone (even the professionals) talk about this, but there are actually many different kinds of pain. You and I can have seemingly identical lower back pain, and yet be suffering from wildly different underlying disorders.  The scientific literature refers to back pain in a catch-all way “non-specific lower back pain” as if its a single entity. We as individual people also tend to assume our back pain journey will inform others of what will work for them – not always of course but it is quite common.

More often than not our friends and family recommendations about pain treatments are based on a tiny amount of first-person experience and data.  This kind of word of mouth’ can still be useful when it is shared gently and with an open mind. It’s great to share with friends and family what worked for us, but we should remember how complex a topic pain is. Something that works brilliantly for my back pain could make yours 10x worse, and that difference is very much between you and your clinicians!

Walnuts and gluten are an excellent reminder of how cautious we should be about assuming that other peoples physical journey will be the same as our own. They are also an excellent reminder that we should keep an open mind about what treatments we ourselves pursue. We are all the same but in some physical areas, we differ greatly on the same topic.

You might be really struggling to find a back pain or sciatic pain solution that works for you – you might have tried heaps of stuff and found it didn’t work. But just because the pain management that seems to work for many others works for them and not you, it doesn’t imply that you are unfixable – it implies that you are simply different! If you have a stubborn pain complaint that you are struggling with keep an open mind, and keep faith that while all our bodies do heal in different ways – they do generally still heal when they are given what it is there need.

Stubborn cases of sciatic pain, back pain, headaches, migraines, shoulder pain, plantar fasciitis, heel pain, neck pain, ankle pain and knee pain are all signs that we need to heal something – realign something – stop doing something – strengthen something – move something … they are seldom a sign that we are ‘broken’!! And the journey towards healing is seldom 1 size fits all. So go nuts and be willing to try out a wide spectrum of approaches!

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Where Do Our Beliefs About Pain Come From – Warning: LONG READ

Where Do Our Beliefs About Pain Come From?
Warning: LONG READ

Stubborn Pain

A History Lesson… Sigh…

I don’t think for a minute you really came here for a medical history lesson. Neither did I to be honest. I just want you to understand your pain in a way that empowers you to move past it.

The simple fact is that regardless of whether you have back pain, hip pain, sciatic pain or headaches –  you have an infinitely better chance of getting pain free if you understand not only your pain – but where your current understanding of pain comes from. Cliché phrase or not – knowledge truly is power when it comes to navigating your way free from complaints like back pain, headaches and sciatic pain.

Understanding where your existing knowledge of pain comes from is a deeply practical foundation. It is the start point of a software update that will empower you to navigate your pain more skillfully.

We have no real consensus about what we should do about most of our pains, or what really causes them. But there are definitely some common assumptions many of us share. S0, how is it that we reach adulthood with a certain number of core assumptions around issues like sciatic pain? Well, there are various channels but the vast majority of the breadcrumbs on the ‘pain beliefs trail’ lead straight to the front door of modern orthopaedics.

There is no question that the orthopaedic profession is the pre-eminent force that has shaped our mainstream understanding of pain; and it  almost certainly will have shaped many of your own basic assumptions about your pain. It’s likely that you are currently fairly unmoved by this fact – I would argue that you should be somewhat concerned by it however. To understand why, you may benefit from bearing with me while I whisk you through the orthopaedic back story.

Professional Evolution

The evolution of healthcare professions is complex, contextual and cultural. There are many worldly forces that shape their development. Just as individual lifeforms are shaped over time by their interaction with the physical environment – healthcare professions are shaped over time by their interaction with the cultural ecosystem that incubates them.

In many ways the evolution of healing professions is often not dissimilar to the evolution of political parties; culture and context are what mould the clay. Healthcare professions claim to be forged out of science, and of course it plays a huge role – but historically they are shaped more so by the full and rich tapestry of happenings that is human history.

In the healthcare trenches themselves, where the skills and understandings are formed,  there are two types of evolution that drive improvements – the evolution of science (sound theories and hard data) – but also healing professions evolve as skills/art forms (the actual tools and tricks developed in the front line. Orthopedics is no exception to this rule, and in its case the expansion is to this day driven far more by the art than it is science.

Picture 300 years of personal transport evolution –  from horse to Tesla. You basically see a steady and linear improvement in performance over 300 years. With a few secondary subjective sub plots like styling. That’s what the evolution of a science looks like.

Now picture 300 years of painting and sculpture – it’s way more complex and subjective. There is undeniable evolution, but there’s also personal expression / experimentation / technical skill / religious influences / cultural influences / philosophies and theories on life being expressed. That’s what the evolution of an art form looks like.

So as you are going to find out – modern orthopaedic surgery has mostly shaped by culture, history and the evolving ‘art’ of surgery – as opposed to it having being shaped by hard scientific principles like quality research data.

If we were able to go back to the surgical story, as a time traveling fly on the wall. Orthopaedic surgery would appear to us very clearly as a brutally painful yet well-intentioned art form.  An art form, where most of what was painted on the canvas is blood and bone splinters – for better or worse. But interestingly if we went back to the very early beginnings of the orthopaedist there was no blood whatsoever – but plenty more about that later.

Professions Are People

Melted down to their purest and realest form, heath care professions are something highly organic – groups of people! When the abstractions that are theories, wards, boards, committees, universities, and associations are said and done: professions are made up of human beings.

Healthcare’s shop window is calm, clean, caring, scientific and collaborative. A focused light – guiding us towards better health. But in the back office of the shop there are always groups of human beings, human beings just like you and me. Struggling to figure out very complex problems, and often struggling even more to agree with each other about the answers to important questions. And that’s exactly what you find behind the professional veil when you look back at the evolution of modern pain management.

The story of a healthcare profession is a story about humans, more specifically it’s a heroes story. A story about humans trying to rescue other humans from their physical suffering. And you know how it is with hero stories, never straightforward.

Like most heroes, healthcare professions must often fight for their own salvation as well as for their patients-  they are driven in large part by their own egos and their own survival instinct. And then of course there is the inevitable Dark Side factor that comes with power, the power to heal or harm others.

People are full to the brim with complexities and imperfections, and healthcare professions are made up of people!

The easiest way to understand orthopaedics is to look at its autobiography as you would the career of an individual person who had pioneered a novel healthcare profession. This is because an uninterrupted and undeniable human element has been the primary force behind the way the profession navigated the last 300 years.

So, for the purpose of deeper insight into where our own understanding of our pain came from, we’re going to rip through the orthopaedic origins movie script: as if it was the story of a single man who has lived 300 years. And we’ll call him Robert – to honour an amazing man named Robert Jones, who was one of a now extinct breed – true orthopaedists. A man who once changed the world, and saved more young men’s lives than can be counted.

The Early Days

Believe it or not, the way we approach our pain in the 2020’s is still firmly tethered to the management of childhood diseases in 1741. It is also tied to an dynastic history of disease, war, ambition, inter-professional healthcare piracy.

In 2021, there is a class of life events that virtually all of us have experienced by the time we’re 30. The standard graduations, relationship break ups and seasonal flu’s. In 1741 having your baby die was on that list. Two thirds of all babies born in London in 1741 were stone dead before their 5th birthday candle.

There are some specific reasons why the (now so cushy) North European childhood was so dangerous less than 300 years ago. I hope you’re ready for this, take a deep breath…

Ricketts – small pox – polio – scarlet fever – yellow fever – diphtheria – influenza – cholera – measles – flux – worms – Saint Anthonie’s fire – ulcerative pharyngitis – pertussis – whooping cough – dysentery – summer diarrhea – purulent lung disease – varicella – tuberculous meningitis – tuberculosis of the lung – tuberculosis of the spine – coryza maligna – ‘nine-day fits’ – neonatal tetanus – post streptococcal nephritis – bacillary dysentery -typhoid fever – lobar pneumonia – hip joint abscesses – abdominal purpura – infectious hepatitis – scarlatina rubella – congenital syphilis – rheumatic fever & malaria.

1741 is so recent, it is only about 4 people ago, if you go by today’s average lifespan. Yet, living through the violent and diabolically slow strangulation of your child by a bacterial predator like diphtheria was a common occurrence. No prevention, no antibiotics, no hospital, no pain relief, no respirator. Hard for us to imagine, thankfully.  It may be worth flagging these historical tid bits to the next person who complains to you about how bad the healthcare system is today.

As you might imagine, the survivors of all that childhood disease were often in pretty appalling condition too. Large numbers of children had deformities and disabilities caused by diseases like polio, metabolic disorders like rickets, and congenital issues like club foot.

A crippled orphan on a London street in 1741 was about as shocking and noteworthy as a pigeon with a deformed wing is in 2021.

Europe 1741 was not a great time in human history to be a crippled child either. While many ancient cultures had viewed issues like club foot as a reason for compassion and care: it was within cultural norms for Europe in the 1700’s to see a club foot as a sign that a child was inherently evil. Not only was there a lack of interest in the care of the bedraggled malnourished and crippled children – open contempt for them was quite normal.

This is the world that gave birth to our hero Robert.

Roberts dad was a surgeon, and Robert himself was an unusually sparkly diamond in the rough. Robert had developed an unusual and compassionate interest in the charitable care of crippled children. He had been inspired by his extensive reading on how the Greeks and Romans managed childhood deformities… a lost art.

In 1741 Robert wrote a book – OrthopediaThe Art Of Correcting And Preventing Deformities In Children’. 

The book was designed to help parents, teachers and caregivers work on preventing deformities in children. In his book, Robert defined exercise therapy as the most important treatment for childhood deformities and disease. He also placed great emphasis on proper design of shoes and chairs.

This is the beginning of the modern worlds acceptance of exercise therapy as a legitimate part of mainstream healthcare. A fantastic contribution to our collective wellbeing.

In the writing of his book Robert had minted the word Orthopaedics, derived from Greek words. Orthos = straighten &  paedia = children. Orthopaedics – the art of straightening deformed and disabled children.

Robert knew a lot, enough to be able to help children in ways that very few others could.  He was a pioneer. But in the healthcare world good ideas are not a guarantee of success. To further his cause Robert would need to gain some credibility. Credibility and reputation are the pick the shovel that dig up the necessary raw material for building any healthcare profession – lots and lots of patients!

In 1741 general surgeons were considered the pre-eminent experts in the world of serious healthcare – so becoming a surgeon was a straight forward path to some level of professional credibility. So Robert made the easy decision to tread the same bloody path his father had cut. He applied for a surgical internship, and was promptly rejected. This rejection was a seminal moment in Roberts career, and proved to be one that would shape him for many years to come.

Credibility – access to patients – and rejection by the surgical fraternity would all prove to be major themes that shaped the orthopaedic profession. Themes that would eventually come to define many of its greatest successes, and failures.

At that time though, Robert just dusted himself off and redirected his efforts. He settled for a doctors certificate instead. Many doctors treated  children with clubfoot. As a doctor he would be able to pursue his interests in that at least.

‘This is the genesis of the orthopaedic specialty’s integration with the medical fraternity.  Individuals with an interest in (the then obscure) topic of childhood deformities taking on doctors qualifications – thus gaining professional credibility and access to patients’.

Once he was established as a doctor, Robert had greater access to patients. His practice and general standing at that time was not dissimilar to a modern physiotherapist, with 2 major differences. He used far more ‘devices’ like braces and splints than a modern physio – and all his patients were crippled children, who couldn’t pay. Orthopaedists were a bit like Plunkett nurses in the sense that orthopaedics was more or less a charitable endeavour.

All of which was fine by Robert, he just wanted to make the world a better place by easing the suffering he saw in so many impoverished children .

Some productive time passed. Robert the doctor/ orthopaedist was able to do some valuable and truly pioneering work. But like so many ambitious young men, in addition to his altruisms Robert had an innate thirst for knowledge and greater recognition. Also, no matter how much clinical success he attained, deep down he still felt a bit like a failed surgeon. Somewhat like modern day chiropractors and osteopaths  Robert was as qualified as any of his more mainstream peers –  but was perceived in his day to be less credible than a surgeon. The awareness of this served to fuel his growing professional ambition.

Becoming Mainstream

By chance, in 1826 Robert stumbled across a German doctor, who was having some success treating children with club foot by cutting the Achilles tendon. It was a procedure that Robert immediately and wholeheartedly integrated with his practice. And it turned out that this ‘Achilles tenotomy’ procedure was to be a revolution in the treatment of clubfoot.

Harnessing the power of ‘tenotomy’ (which dramatically improved the mobility of a child with clubfoot) opened Roberts mind to a world of new orthopaedic possibilities, beyond straps and braces. Were there other tendons that could be cut to reduce pain and shame inducing deformities?

Much of Roberts work relied on braces for terrible deformities of the spine caused by diseases like polio and tuberculosis. The notion of assisting these conditions by cutting tendons around the spine logically presented itself. The possible dawn of a new era in correcting childhood deformities.

Tenotomy added a glimpse of the potential application of surgery to his his chosen field. Robert had already secretly craved the recognition that came with being a surgeon – and seeing its potential clinical uses inevitably stoked this fire.

Either way, from circa 1826 onward Robert claimed tenotomy as an orthopaedic principle. And to us it might seem strange that a healthcare provider who wasn’t a surgeon could spontaneously start snipping the achilles tendons of their child patients.

Surgeons are a fiercely territorial species, so there was a professional risk in performing tenotomy’s when you were a low ranking Orthopaedist . But at the time, embracing tenotomy was a pretty safe professional step for Bob. The simple fact was that surgeons at that time couldn’t have cared less about children with clubfoot.

There were no real surgical specialities in the 17-1800’s, all surgeons were essentially generalists. Tenotomy was such a minor procedure compared to the surgeries of the day, that it was deemed inconsequential. Most of the glory was in the fast and dirty removal of major body parts. Robert could start performing tenotomy’s without being professionally harassed by surgeons in the same way that your doctor can burn off warts and remove splinters without impinging on a surgeons professional boundaries.

**Imagine a time when peoples general level of health was so poor, and the healthcare they received was so harsh; that cutting through a childs achilles tendon with no anaesthetic was categorised in the same we categorise the minor procedures performed at a GP’s office.

A self styled doctor who’d been rejected as a surgical intern had quietly established a small surgical procedure as his own. Without drawing any unwanted attention from fiercely territorial surgeons. This was a pivotal moment in Roberts professional evolution**

**Despite being overlooked by surgeons, the orthopedists  decision to add the cutting of tendons to their use of exercises, buckles, braces and exercises was anything but inconsequential. You could make a case for it being a pivotal moment in the genesis of modern healthcare. A moment that would impact millions of lives in generations to come. If you’ve had surgery that wasn’t for a major bone or joint trauma  – you are part of a history that began with the simple snip of childs achilles tendon.

Up to this point in human history, surgery was used almost exclusively for major trauma and life threatening illness, and for good reason. Prior to anaesthetic and sanitization, surgery was an horrifically painful and dangerous tool, literally the stuff of horror movies. 

In healthcare, the more quality tools you have access to, greater your ability to heal. Combining tenotomy and the traditional orthopaedic braces, exercises etc. was hugely successful. There were many more children that Robert could help. And on top of that, it was time for some good fortune.

During the early 1800’s there was at last the beginnings of an interest in children’s health, and in the concept of charitable work. The first charities in human history were childrens charities geared towards easing the suffering associated with poverty.

Philanthropic interest in the care of crippled children suddenly meant Robert was ideally placed to gain funding for the first of many Orthopaedic Children’s Hospitals. The trappings of this newfound financial backing from wealthy patrons, allowed Robert to consolidate orthopaedics as a recognisable medical specialty. As opposed to the healthcare niche it had been up to that point.**

**Despite its growing professional profile, orthopaedics was still entirely focused on disabled children. At no point had the question of treatment for biomechanical pain or injury pain arisen.  Nor were adults included in Roberts scope of care. Adults with injuries, diseases and biomechanical pain were treated by bonesetters, barbers, regular physicians and surgeons. Roberts was about as interested in adult back pain, hip pain, shoulder pain, headaches, foot pain and knee pain as dentists are in ingrowing toenails and bunions.  

During the late 1800’s urbanisation meant greatly increased population density and this had a profound effect on healthcare. People were becoming less geographically spread out. This meant sick people became far more accessible to healthcare providers. Urbanisation and jobs also meant people were increasingly able to pay for healthcare.

For the first time Robert started to make some money, through providing care to those who were able to pay for it. Inevitably he felt the universal (and in his case well deserved) warm fuzzy feelings that come with profit – after a long period of hard charitable work and personal sacrifice. The shift away from orthopaedics as a charitable endeavour had begun.**

** At its inception orthopaedics was a humanitarian cause. It occupied the same type of niche as animal charities do in modern society. Modern orthopaedics in contrast is part of a multi-billion dollar industry, backed by colossal biomedical corporations; who profit immensely from the design and manufacture of surgical technologies.

Urbanization also led to the establishment of the first general hospitals. Dangerous places, with higher mortality rates than many of history’s worst war zones. Places where the average surgeon did not hand wash at any point in a shift – not even between disease autopsies and delivering babies. **

**A curious historical fact, given that Hippocrates himself was a staunch advocate of medical hygiene practices – nearly 2000 years earlier). Healthcare can be forgetful process – and as you will soon see there is none more forgetful than modern orthopaedics.

The 1800’s were a time when the words ‘Mary has been taken to hospital’ would have struck the same chord that ‘mary has stage 4 breast cancer’ does today. Hospital was more or less a death sentence. When the worst happened to those with money, they would pay to have their sick and broken body parts hacked off at home in their own kitchen, as it was far safer.

Many died in the hospital settings. But they proved to be a place where Robert and his orthopaedic tools could thrive; and continue the process of merging into the fully mainstream.

Resources in the hospital setting allowed Robert to develop more specialised equipment. His presence in mainstream hospitals also led to a further expansion of Roberts job description. He began treating adults for the first time, and as part of that he began managing hip dislocations with traction. Another seemingly insignificant shift of Roberts professional boundaries that would ‘echo in eternity’.

** Roberts (once again seemingly minor) addition of traction for dislocated hips to his repertoire was in reality the start of something big.  It was the beginning of modern orthopaedics taking control of trauma management. In the 1800’s treatment of injuries was a fiercely guarded part of the surgeons territory.  But like tenotomy for clubfoot, surgeons were not overly interested in relocating hips. Without realising it the surgeons were giving up ground to a then minor profession, one that would soon grow immensely in power and prestige.

The small opening into the world of injury care that dislocated hips offered ultimately led to something we take for granted – orthopaedics caring for injuries and ‘injury pain’. 

Robert was making quiet incursions into surgical territory, and blurring professional boundaries that would later be completely overrun. All thus far unnoticed by the brooding alpha specialty of surgery. Robert was already a part of the mainstream, but he was still as low down in the hospital food chain as a modern physiotherapist is. So for the time being keeping his head down was important.

The deeper truth about Roberts knowledge sat in contrast to his relatively low rank. When he moved into the hospital setting in the late 1800’s, he did so with a formidable toolkit and a great deal of knowledge. He was different to a surgeon, but not of lesser value. It was even possible that Robert was able to do more good than a surgeon, and he knew it. He had built a legitimate, effective and hugely important healthcare speciality from nothing. Either way, there was no science or research to say a surgeon was more valuable than an orthopaedist, it was hospital politics that dictated that perception.

** Humans are complex, and as a result much of what we create is complex too. On the one hand, healthcare systems are high functioning and sophisticated constructs. One of the creations that truly set us apart as a species. On the other hand, healthcare is every bit as primitive and hierarchical as any chimpanzee troop. Even in today’s hospitals there is a strict dominance hierarchy. Behind the undeniably sophisticated veneer of hyper- modernism, if you peel back the layers, an ancient structure is easily revealed.

Dominant chimps flex muscle and strong alliances. Surgeons flex certificates, titles and professional influence. A Dominant chimp is concerned with control of access to resources and territory. The surgical species is concerned with access to certain groups of patients and control of everything that is associated with their management. In the late 1800’s that lion’s share was largely bone fractures – bone trauma was the surgeons guarded territory.

In modern hospitals, surgeons (specialists) and anaesthetists are at the top of the food chain.  Surgical interns and high grade nurses sit somewhere in the middle. Lower grade nurses and healthcare assistants at the bottom. The hierarchy is reflected across the board, from who gets paid the most to who makes all the decisions (and of course who swings on the nicest tyres in the nicest office).

 The dominance hierarchy in hosptals is built on the concept that those at the top always hold the most knowledge, which is not always the case (just ask any senior nurse).  The big holes in the 18th Century’s incarnation of this dogmatic framework would form the hand grips that orthopaedists would use to climb to the top of the medical food chain. The simple fact is that while a surgeon or specialist may know a lot about certain things, there is always much that they don’t know.

Despite all the frustrations of being a low ranking primate, hospital was still a chance for Robert and his bag of tricks to truly shine. He was successfully filling the space created by a knowledge vacuum. But unbeknown to him, the medical mainstream that was about to swallow Roberts’ fledgling speciality whole – with what easily still stands as healthcare’s greatest success to this day. Robert the orthopaedist had created and occupied a niche that was essentially about to vanish in the biological blink of an eye.

A momentous event in human history was about to unfold. An event that looking back now, arguably makes the invention of the microchip appear as trivial as the invention of a new pizza topping.

 

Germ Theory

In the 50,000 years prior to orthopaedics inception we had done a pretty one sided job of wiping out nearly all our natural predators; possibly with a small bit of help from climatic events and the like. In any case, we came out of the dark ages seemingly having removed ourselves from the food chain. In reality however, nothing could have been further from the truth, and we didn’t even know it..

During the latter part of the 1800’s, after an eternity spent being unwittingly preyed upon in vast numbers by bacteria, viruses and parasites – ‘we’ finally cottoned on to the fact. It turned out that in a very real sense we were still very much on a low rung of an invisible food chain.

We found out ‘overnight’ that we were being preyed upon by an utterly invisible yet enormously powerful world of microscopic monsters; so many in number that they outnumber the stars in the night sky. And each potentially every bit as terrifying as any large predator. There has surely never been a more shocking and bizarre scientific discovery before or since.

Millions of us (the majority of whom were frail children) were still being savagely and constantly predated upon – by a microscopic world that no one even knew existed.

Like everyone else, Robert had been utterly oblivious to the fact that conditions like polio and tuberculosis were caused by a microscopic lifeforms attacking a child’s body. And that tuberculosis smuggles into children through contaminated milk. (Or even that the rickets epidemic was caused by a lack of vitamin D for that matter.) Naturally, Robert and the entire medical world had simply assumed that poverty was just so hard that it caused children to deform.

In the period between 1881 to 1914, the previously unseen and unidentified causative agents of more than 30 infectious childhood diseases were identified. And a cascade of solutions that transformed humanities existence followed. Penicillin, immunisation, pasteurisation, sanitation, improved sewage systems, supplements, antimicrobial agents. And the rest is healthier history.

In a very short space of time, the core of Robert the old school orthopaedist’s work was all but wiped out. He thought that he had been treating the effects of poverty had been treating diseases all along. And now those diseases were gone, Robert found himself in a very scary new normal.

Robert was of course pleased and amazed that the scourge of horrifying children’s disease had finally been broken. But being pleased about that didn’t help his own innate human needs for recognition survival. It was a deeply traumatic and helpless moment in Robert’s professional life, and it left its mark. No one enjoys having their entire life’s work obliterated in an instant by someone else’s life’s work, that’s just human nature. And Robert was after all only human.

In any case, there was no longer enough work to support Robert’s area of specialty or his standard of living. Success for the humanity at large represented professional extinction to Robert.

**The professional, scientific and philosophical shock of discovering that 95% of bone and joint deformities were caused by diseases left a permanent mark on orthopaedics. A mark that remains to this very day. 

As a result of the impression left by germ theory, modern orthopaedic surgeons still essentially divide the world of musculoskeletal pain into 3 classifications –  congenital deformities – injuries –  diseases.

Their knowledge of congenital deformities (that happen before birth) and injuries prescription-dated germ theory and remained intact. After the advent of germ theory they created a 3rd explanation for everything else that would go wrong with the musculoskeletal system – ‘diseases.’

Paraphrasing their approach to pain management in the latter part of the 20th and early 21st centuries reads like this… 

 ‘Everything that isn’t an injury or a congenital disorder is some form disease process’. 

When in fact the vast majority are caused by long standing biomechanical issues.

 At the time it was an understandable conclusion for a profession that nearly became extinct – due to a whole world of diseases it didn’t even know existed

Pains that are caused by persistent issues with movement (like poor posture/weakness/faulty gait patterns) are classified like diseases by modern orthopaedics. Because of the old impressions that scientific progress in the field of microbiology left on a previous generation of orthopaedists.

In turn, germ theory thinking would subsequently impact the entire modern worlds (that means yours) understanding of pain: through the influence of orthopaedics.

Symptoms of biomechanical strain in the body have been henceforth given confusing names like diseases prevalent in the 1800’s. Severs disease, osgood schlatters disease, scheuermann’s disease, carpal tunnel, osteoarthritis, chondromalacia patella, tenosynovitis, tendonitis,, sciatica, degenerative disc disease, sub-acromial bursitis, migraine, lumbago, sciatica.

Names that obscure their true biomechanical nature from generations of sufferers.  Even on its 21st century websites run by the orthopaedic profession would still refer to their collective job description as ‘the treatment of trauma and musculoskeletal disease’.  

 The orthopaedic profession still to this day holds firmly to a disease-like concept of pain – because of the seemingly indelible impression left by it’s near death experience experienced at the hands of germ theory.

No meaningful attempt whatsoever has been made by orthopaedics to explain or acknowledge musculoskeletal pains underlying biomechanical nature – a job which has ultimately been left to other professions. 

Other professions who have gradually moved into the knowledge vacuum, much like orthopaedics once did when it moved into the hospital setting alongside surgeons.

 In terms of the public consciousness we have been forced to our own distinctions in order to navigate pain management. We subtly assume that pain is made up of a milder set of disorders (weak core and a bit of back pain for eg.) that we should see an osteopath etc. for  – and a more serious set of disease states that we should see an orthopaedic surgeon with an MRI scanner for (osteoarthritis – calcified tendons – carpal tunnel).***

***The truth is that of course there are a few instances where this is more or less the case.

 In the 99.9% type percentile of stubborn pain cases the disc disease / the bursitis / the weak core / the poor posture – are all part of a spectrum where the breadcrumbs lead back to biomechanics – its faulty movement that causes your hip to wear out – not a disease called arthritis.

Some forms of arthritis are auto-immune states and genetics admittedly play a role in the manifestation of all painful conditions to some extent. The point here is that ‘osteoarthritis’ for example is a disease style diagnosis that offers no description of the actual cartilage degeneration or its primary cause.

 The primary causative agent behind childhood sickness and deformity in the 1800’s was not poverty – it was microbial disease.

 The primary causative agent behind adult pain and tissue degeneration in the 21st century is not disease – its biomechanical weaknesses and imbalances.

 If this biomechanical truth received the same amount of attention now as microbial truth did in the 1800’s –orthopaedics would experience another near-death experience!!

 But back to the story…

Germ theory could so easily have been a professional mass extinction event. But true to form, Robert adapted.

Fortunately, by the time germ theory reared its head Robert was an established part of the medical hierarchy; and he had already dipped his toe in milder forms of trauma and congenital deformity This meant that he had some small amount of scope to explore other areas. And by 1907 he was treating more adults than children. There wasn’t much interest at first, and it wasn’t easy. But there were enough in the way of milder injuries and club feet around to bring in some work. Robert could basically continue to function like a hospital physiotherapist; but times were lean and his dreams of ascending the medical food chain had never looked more improbable: germ theory having placed his profession into a form of hibernation.

There was however a bit of good fortune headed Bob’s way. Just as the microscope took from Bob with one hand, it gave him a gift with the other.

Progress in our understanding of hygiene meant that surgery could be performed without the same astronomically high risk of infection. And on top of that, anaesthetic showed up for the first time. These changes that made surgery a far more accessible art form. The surgical door that was never far from Bob’s mind cracked open a jar. Adaptation and prestige were beckoning once again. The opportunity for survival that presented itself was in occupying the management of musculoskeletal injuries. Robert was at this stage the true expert on the musculoskeletal system and he knew a bit about surgery – surgeons were generalists – he knew that specialisation their inevitable superior. He was however headed for dangerous territory as the management of physical trauma was a fiercely guarded surgical privilege.

Robert’s position in the hospital food chain had improved with time. This meant he could eventually ride the wave of progress in surgical hygiene and tentatively branch out from cutting tendons.  He could perform a few small surgical procedures, as long as they were only on chronic complaints; and not on surgical territory. But of course, it would not go completely unnoticed by the keen eyed brooding alpha profession.

As news of Roberts surgical insurgency circled; the inevitable happened. Surgeons registered a challenge to the pecking order. Naturally they began thumping on tree roots and pissing everywhere, but the times where Robert was willing to tiptoe around surgeons were coming to an end.

The beginnings of a long and bitter turf war over professional boundaries and the management of injuries to the musculoskeletal system took root. A battle that was about to be accelerated massively by a conflict of a different kind.

 

Word War 1

WW1 gave rise to a style of conflict and types of suffering the world had never seen before. Howitzer cannons and machine guns inflicted high velocity trauma. But those weapons also meant fighting in the open was simply no longer an option. This meant troops living in filthy trenches for months and years at a time. The increase in fire power may have killed more through the filthy conditions it created than it did blasting holes in people. **

**The Howitzer cannon created the trenches – and the trenches almost certainly incubated spanish flu – it follows that Mr Howitzer deserves much of the credit for the spanish flu. Spanish flu accounted for more human deaths than two world wars and the holocaust combined. Quite an invention.

WW1 was a time of great opportunity and prosperity for influenza. But it was not the only species that saw an opportunity to strengthen its position in the ecosystem. The new rules and technology of war meant unprecedented numbers of high impact skeletal injuries – and shocking rates of infection. Never missing a chance to flex its muscle, general surgery had soon taken the reins.

Bullish about its experience with trauma and its shiny new understanding of hygiene; WW1 was a challenge that general surgery felt certain that it was more than equal to. Unfortunately for the young men of Europe, surgery was catastrophically wrong in that confident self-assessment.

It is one thing to work on an open fracture in a relatively clean hospital ward. It’s another thing to work on an open fracture that’s been contaminated with mud and fecal matter -then dropped several times by stretcher bearers on its sludgy 2-mile journey to the operating table.

It is one thing to surgically repair a fracture – and another thing to get that same soldier to a point where he can return to a job without severe lifelong disability.

Rehabilitation and surgery are skill sets that bear absolutely no resemblance to one another. Despite bearing the divine professional authority to monopolise trauma care, from very early in the war it became apparent that surgeons were not up to the task.

Soldiers with open fractures were removed from the field with a grave lack of care; operated on and dispatched with no meaningful after care or rehabilitation processes in place. Fractures were not properly splinted before or after surgery. There was no consistency of care. And after the fact – occupational therapy was not even a passing thought.**

**Surgeons are concerned with the mechanics of surgical procedures – not the context of the surgery. Civilian life is relatively forgiving of this kind of narrow view. WW1 could not have been any more unforgiving of it. At the beginning of the war 90% of open femur fractures were fatal, due to poor care ‘off the table. And of the survivors, almost all were left with very severe long-term disability to due to appallingly sloppy fracture care and a lack of rehabilitation.

With hindsight, it’s almost hilarious that there were questions over whether Robert would be of use in the war effort. Knowing more about the care and rehabilitation of the musculoskeletal system than a 100 surgeons as he did. Robert was ultra-qualified for the healthcare challenges presented by this new form or warfare. But the reality is that there was a great deal of resistance to the presence of orthopaedists in the theatre of war.**

**The basic surgical assertion at the time was that taking orthopaedists to war was like taking a massage therapist to a 10 car pile- up on a motorway. At best a pointless exercise –  but at worst a dangerous one –  on account of them getting in the way of the real work that needed to be done.

But the reality was that high velocity rounds and shrapnel made for exactly the type of musculoskeletal injuries that Robert could design management processes for. It was time for his knowledge, understanding and integrity to shine, in history’s muddiest bloodiest mess.

Tendon and nerve injuries could be braced in much the same way as polio patients.

Soft tissue injuries could be carefully immobilised. Robert knew how to save lives and prevent bone deformities by splinting fractures before they were moved.  He created systematic pre and post-surgical fracture care. He gave injury prevention advice to soldiers. He developed systematic splinting procedures; and developed structured rehabilitation for wounded soldiers. The tools of the biomechanical specialist, the same ones he had used to help countless crippled and deformed children – were effortlessly adapted to help freshly crippled and deformed soldiers.**

**While surgeons were in sole charge of fracture care the mortality rate for an open thigh bone fracture in WW1 was 90%. Once Bob was involved in the war effort that mortality went down to 20% – due to careful splinting of fractures before they were stretchered. This one statistic above all others gives an indication of the value orthopaedics bought to the world during WW1.

WW1 revealed the truth about Robert. He was at least as useful as a surgeon in many instances, and far more use than a surgeon in many others. Naturally there was ferocious resistance from surgeons from start to finish. But once the military machine itself had glimpsed the bloody truth about general surgery’s sloppy and ignorant approach to fracture care there was no going back. In war the truth about Robert became undeniable. When it came to muscles joints and bones Robert was the expert.

Robert had entered the war as an officer but by the end was conferred the rank of major general and knighted. Queen and country knew of his true value to the collective.  But more significantly to Robert, by the end of the war he was given equal and shared responsibility for bone and joint trauma. Equal with the surgeons at last!

On a human level, it was a huge relief to finally be acknowledged appropriately. Robert was finally receiving the type of credit he was severely overdue for; and understandably he liked it. He had finally laid the first major building block of becoming not just a healthcare speciality, but a full blown surgical speciality.

Thanks to the war, Robert had successfully adapted to a post-germ theory world, and not only survived, but thrived. The rehabilitation of soldiers after the war merged seamlessly with the care of industrial civilian trauma. Orthopaedics had moved on from dwindling childhood diseases, to the treatment of disabled adults and even the management of injuries.

But Robert still faced challenges, and demons! His ultimate goal was to assume complete control of musculoskeletal injury care – and he would not rest until he could take his rightful place.

The surgeons had conceded much ground to Robert during their time behind the trenches, he was now essentially their professional equal in the eyes of the crown. But despite this shift in the hierarchy, surgeons still held significant authority in peacetime. Healthcare’s political root system doesn’t budge easily. General surgery campaigned hard to discredit Robert on the grounds that he wasn’t a ‘real surgeon’ for decades. But Robert had seen the bloody proof that he should be fully in control of all musculoskeletal disorders. His surgical skill had slowly expanded over the many years of tackling ‘smaller’ procedures – and his superior knowledge of the musculoskeletal system made him the natural choice to take charge of all musculoskeletal care.

Success has a track record for intoxicating and corrupting human beings, and partial success can be even worse. Like so many high-achievers Robert also had his own very human ego to deal with. A century or more of never-ending comparison with surgeons had begun to consume his character. He was certain that the only way to be truly fulfilled was to become a fully-fledged surgical specialty – and not have to share the territory. He had become fixated with becoming the alpha. Roberts character had changed (into the nearly universal, unappealing and egoic profressional character that would be passed on to countless future orthopaedic surgeons).

 

A Tough Decision

Ultimately and unsurprisingly it was the pressure applied by surgeons, that forced Roberts final metamorphosis into a fully-fledged surgical specialist.

The last stand that general surgery chose in defending its territory was the argument that Roberts toolkit was holistic in nature; therefore he couldn’t be ‘a real surgeon’ – and shouldn’t be allowed to treat trauma. His practice was split evenly between surgeries and the more traditional rehab exercises, braces, splints and frames etc. This enabled the surgeons to argue that ‘surgery is a speciality… so it cannot be effectively pursued by a generalist’. After all Robert had been through to prove himself this argument actually proved to be persuasive; it gained some traction and threatened to derail Roberts plans to monopolise musculoskeletal care.

You could argue that given it’s perspective the orthopaedic profession didn’t have much choice in what came next. Tuberculosis was all but gone, rickets was gone, polio was all but gone, and WW1 was over. What remained in terms of a prospects for a strong healthy profession was the rising tide of factory and railroad injuries covered by workers compensation. This was no work that they wanted to share with general surgeons. On top of that they had spent 200 years providing irrefutable proof of their expertise, and yet were still vulnerable to attack; and unable to establish their rightful place in the healthcare system.

At this stage in the story Roberts driving force was no longer ‘the best treatment’ , it was success and survival – through the achievement of a lifelong goal. Without realising it he had allowed the healthcare politics to corrupt his decision making. Robert was not entirely conscious of this – and he justified what followed on the basis that he was better at treating musculoskeletal trauma than surgeons, which of course he was.

A very difficult choice needed to be made – for the survival of the profession.

Robert had realised that if he didn’t give away the braces, splints and straps of his professionally low-ranking past; he would never fulfil his dream of becoming a fully-fledged surgical silver back. The tools that had established the profession and changed untold millions of lives were now holding back the profession from a triumphant ending to its 100 year turf war with general surgery. And just like that.. it was done.

All the exercises, braces, splints, frames and casts went. Orthopaedists became orthopaedic surgeons and the ‘generalists can’t be surgeons’ argument was put to bed. It was check-mate. General surgeons were forced to let go of injuries to joints, bones, muscles and connective tissue. Bob gave away 200 years of orthopaedic heritage and superb clinical outcomes for his own survival and the prestige of a shiny blade.

The underlying post-war irony of all this was that Robert success had been predicated on his holistic mind-set. His ability was in clearly seeing the whole picture of an injury, and providing comprehensive rehab solutions (on and off the table). Yet, he had chosen the prestige, power and ultimately profit of vanquishing his old foe, and becoming a surgeon.

By 1948 the art of bracing and rehabilitation had completely yielded itself to the art of surgery.  From then on, orthopaedic students learned about how to perform surgery – no more rehabilitation. Ironically similar to those narrowly focused surgeons who made such a terrible mess of treating fractures in WW1.

The orthopaedic decision to specialise in surgery pre-determined the lack of appropriate rehabilitative care we receive for our diabolical levels of biomechanical pain in society to this day. The speciality in complete charge of our musculoskeletal care had given away all of the tools of its rehabilitative past in.  The gatekeeper to our societies healthcare for the musculoskeletal system had decided that there was only one type of intervention it was interested in. Digest this while understanding that surgical procedures are relevant in the care of less than 1% of the pain and disability that 21st century humans experience. But at least back in the mid-20th this paradigm tended well to the huge number of injuries that people suffered in an age of poor occupational health & safety – orthopaedic surgeons always were and still are excellent at treating bad injuries.

 

The Modern Era

For better or worse Robert had received his medical knighthood as a full surgical speciality, and shaken off the stigma of his low ranking medical origins. Going into WW2 – Robert was the surgical specialist in the driving seat. And he once again did an impressive job. His ability to manage trauma in the field was reaching new heights. WW2 further cemented orthopaedics as the pre-eminent speciality in all things musculoskeletal – somewhat ironically – given that all of its powerful rehabilitative tools and insights had been consciously and deliberately deleted from its CV in order to pursue surgical glory.

During WW2 the emerging field of physiotherapy filled the vacuum left by the orthopaedic re-invention and tended to rehabilitation, but with a fraction of Roberts experience and training.

In spite of his successes in WW2, like an elite soldier on a post-conflict come down Robert found himself in yet another existential slump. Childhood disease was gone. The physical trauma of two world wars was over. And now on top of that health and safety standards meant that industrial accidents were dwindling fast. This only left sports injuries and car accidents in the waiting room – but that’s not enough to live on. After the dust had settled on the WW2 mess was finally a fully grown bristling male surgeon but in the post-war era he had no one to fix. But of course you know by now – the orthopaedic profession has more lives than a cruise ship full of cats.

Robert was once again was required to adapt.  And there were three remaining opportunities for professional survival. Biomechanical pain – the wear and tear that comes about when biomechanical pain isn’t managed properly (osteoarthritis – bursitis – calcified tendons) and as always major injuries.

So on top of the car crash level injuries – all the neck pain, shoulder pain, back pain, hip pain, knee pain, ankle pain, osteoarthritis, disc protrusions, rotator cuff tears, bursitis, cruciate ligament tears etc. etc. would all be claimed as Roberts new territory. Despite mostly having been of zero interest to him over the preceding 3 centuries.

After WW1 orthopaedic surgeons poured societies biomechanical pains through the filters they developed during the chapters of war and disease that forged their profession. If by now you understand how influential they are – and the ‘life lessons’ of their past – you will understand why we manage and understand pain so poorly today.

 Their early conditioning led them to the belief that surgery represents ultimate credibility – the ‘highest expression’ of meaningful healthcare. And that physical deformity is a major cause of suffering that can be corrected.

 Their near-death experience with germ theory had left them with a strong intuitive sense that stubborn pains were ‘types of disease to be diagnosed and treated’ – even when they weren’t.

 Their experience in a centuries long turf war with general surgeons left them a strong sense of entrepreneurialism, competition and somewhat ill tempered.. or at least lacking in bedside or inter-professional manners. It also left them with a reinforcement of the (subconscious?) belief that surgery is ‘they key to success’.

 Their experiences with war left them with a rightful sense of confidence in the expertise in treating major injuries.

 The subtleties and complexities of what causes modern biomechanical pain (postural issues – weak core – flat feet etc.) amd the types of problems it leads to (osteoarthritis – bursitis – Osgood schlatters)  didn’t get a look In during all this. And yet orthopaedic surgeons had the professional clout to monopolise biomechanical pain from the very moment became of interest.

In the modern world our basline approach to pain has been pre-determined by the survival story of orthopaedics.

 Biomechanical issues like back pain are often believed to be caused by injury – as opposed to persistent muscle imbalance.

 Complex biomechanical issues like osteoarthritis are often thought of as incurable diseases to be ‘cut out’ or ‘fused’ – as opposed to signs of chronic biomechanical strain and inefficient movement.

 Complex injuries like the majority of cruciate ligament tears are thought of as simple injuries – as opposed to signs that the ligament had weakened over time. 

Biomechanical pain became something that you diagnosed like a disease or something you explained as an injury. But even more disturbing is the fact that without a shred of scientific rigour biomechanical pain suddenly became something that you might performing surgery on.

 

A Less Than Glorious Ending

During the latter part of the 20th C Robert faced his proferssional extinction for what would have seemed like the 100thtime. His original role in treating crippled street urchins was a distant memory. There were no more opportunities to shine in the theatre of global war. Progressive industrial health and safety shrank the number of serious injuries in the population down to a tiny fraction of what there had been in the preceding century. All of his major incarnations had become irrelevant – each only leaving a residue of the former workload associated with each.  So to survive, he pulled himself up by his boot straps and set about tackling the only musculoskeletal problem that were left in any real numbers, the back pain, the osteoarthritis and the sports injuries etc.

Robert took what he had learned over 200 years of shrapnel wounds, industrial accidents and childhood disease and applied it to the challenge of modern pain, modern biomechanical dysfunction, and the creeping incremental tissue damage it causes.

He re-interpreted what he had learned from disease, poverty, and war – and applied these lessons to the remaining (and far less serious) challenges that the industrial and microchip revolutions created presented to the human body. But he did this after setting aside the exercise prescription, braces and straps and occupational rehab that he cut his teeth on. He did have the option of breathing life back into these tools (as they are surely more relevant to modern biomechanical pain than surgical tools) – but the simple fact is that they lacked the prestige of surgery – and from the standpoint of a ‘career move’ for Robert they would have constituted a huge step backwards.

Instead a new set of tools and devices would be designed to serve the new market he was targeting. Tools that would retain the prestigious rank of surgeon while targeting his new ‘target market’. Franken-tools that would ironcially be inspired by his distant therapeutic past – spuriously validated by his excellent track record with trauma – but that would fit into the story of his ambition. Surgical devices.

Robert had forged (during war time) close alliances within the political and industrial machine; this meant that he was able to easily partner with large biomedical corporations and develop new surgical devices to suit his needs. To treat biomechanical pain he would pioneer ways of fusing painful joints with plates, pins, rods and metal bars. He cut away torn cartilage, and he would invent the prosthetic joint replacements.

**As he did all this Robert was referencing his earlier experience with ‘devices’ and ‘supports’.  But he was also merging with a vast commercial enterprise, and birthing a new multi-billion dollar industry. He was creating a market and ensuring the long term survival of the profession – partly to the benefit of society – and partly at the expense of untold millions of dangerous, needless, unscientific and highly invasive surgical procedures.

Conclusion

There is a shocking fact about orthopaedic surgery that is revealed at this point in the story. Unlike many other specialties, the evolution of the orthopaedics specialty was not based on hard science.

There was virtually no rigorously designed clinical data guiding any part of the story we have just walked through. Despite what we are led to believe – story of orthopaedics is almost exclusively a history lesson not a science lesson. It is the evolution of an art form not the evolution of science. This evolution of orthopaedic surgery has been based on theories, expert opinion, trial, error, adaptation, medical politics, and war.**

Current high-level reviews (amalgamations of many studies) of the scientific literature conducted by orthopaedic scholars have already discussed the serious problems with a widespread lack of quality research supporting the use of orthopaedic interventions for chronic pain. This is essentially common knowledge among those who are familiar with the state of the orthopaedic evidence base.

Orthopaedics’ failure to rise to the challenges presented by an epidemic of modern back pain perfectly illustrates its failures to translate its skills  into safe and effectively treatment for modern pain syndromes. The circumstantial evidence alone is concerning – given that the increase in disability caused by back pain sharply increased to epidemic levels in developed countries following WW2 . During the price era that orthopaedists took over its care. But more incisively the specific data regarding the efficacy of the modern orthopaedic approach to back pain is damning. In academic circles this essentially common knowledge,  preeminent orthopaedic scholars like Gordon Waddell having made it their life’s work to assimilate this data

After decades of rolling out unsafe and unproven spinal surgeries as a primary therapy for back pain we now know from reputable sources and long painful experience that surgery is rarely the correct way to treat back pain – as highlighted by this Harvard article.

Repeat spinal surgery for example is an extremely risky treatment option with diminishing returns. Around 50% of primary spinal surgeries are considered successful,  and some studies estimate up to 74% of back surgeries ultimately fail – these are poor clinical outcomes yielded from risky procedures. But no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively – there are expensive and highly risky procedures that present extremely poor outcomes for patients.

There have never been any studies comparing spinal fusion to a placebo procedure, astonishing but true. Perhaps part of the reason for this is the concerning lack or orthopaedic surgeons who engage in research. Or maybe it is because they are more interested in designing studies to prove that they have a stronger grip strength than other doctors, like this one.

When he took his scalpel into the biomechanical realm in the latter part of the 20th century; Robert did so as a further expression of his human ambition. As humans often are, he was entirely consumed by whether he could, rather than when he should. And the scariest thing of all is that he was so influential that he wasn’t required to support his decisions with high quality scientific proof. His expert opinion which carried the weight of his successes in 2 world wars, and a few scraps of poor quality experimental data were sufficient. 

Even in the 21st century only 3% of what is published in orthopaedic journals meets the necessary criteria to be called ‘high quality evidence’. The topic of evidence based care in orthopaedics and pain management at large is awkward to say the least, there really isn’t much of it to this very day. The Illustrious British Medical Journal itself has weighed in on the scandalously poor evidence levels to support orthopaedic surgical procedures for pain.

On top of all this, modern orthopaedic research that does exist has utterly unavoidable and convoluted financial connections; to a mulit- billion dollar industry that puts food on the table in the home of every orthopaedic surgeon on the planet; by manufacturing surgical devices. Which without utterly mindless faith makes near impossible for the rest of us to really know what’s what in the professions research methdologies.

This mess brings us up to the present day. And you now know the back story behind most of what we have been led to believe about pain in our society. We absorbed it from the powerful and ambitious gatekeepers of modern musculoskeletal healthcare. Gatekeepers who’s medical philosphy  was forged in past glory treating Victorian childhood diseases open bone fractures in the trenches of WW1.

But how is it that the beliefs and attitudes orthopaedists collected during their epic story of professional survival became our attitudes and beliefs about pain in 2021?

Our media, government, health system and education system are where the vast majority of our understandings about health are incubated. And all of these resources have used orthopaedic surgery as ‘pains expert witness’ for the past 70 or more years. Because of the professional pre-eminence in musculoskeletal care that orthopaedics emerged with after its successes in  WW1. That is how orthopaedic beliefs became public beliefs.

When society wants to build a bridge – it calls civil engineers. When ‘society’ has a question about heart disease – it calls cardiologists. And when’ society’ wants to know about pain – it calls orthopaedic surgeons. But cardiologists have always been into heart diseases and civil engineers have always been bridge buffs. But as you know now – orthopaedists have not always been in the pain, far from it. Orthopaedic’s legitimate areas of speciality are skeletal deformities and high impact trauma, not the rehabilitation of biomechanical pain. Their modern dominion over biomechanical pain has been little more than an over-confident bluff. 

There’s no question that an orthopaedic surgeon’s ability to heal broken bones and repair ligaments is still of great value, it always was. There are also occasions when only a joint replacement will do. But in terms of serving the bulk of societies pain, following WW2, after 200 years of successful adaptation: Orthopaedics reached the zenith of its efficacy and hit a therapeutic brick wall. Because as far as biomechanical pain is concerned – Robert’s story is one of a butterfly that turned into a caterpillar.

At the beginning of this story I stated that way we approach our pain in the 2020’s is still firmly tethered to the management of childhood diseases in 1741. This is because the orthopaedic profession imprinted on a ‘disease model’ of modern pain in it’s interpretation of the challenges it presented. This above all others is the primary corruption of understanding and science that has left us so profoundly and systematically confused about the topic of pain to this day. Secondary is the misinterpretation and inflation of injury as a factor in modern pain. The truth is that genuine injuries to healthy tissue play a far larger role than disease processes in generation the pain so many of us now suffer – but only a very small part in our pain as a whole.

Modern pain is caused by a trifecta of lifestyle – biomechanics – environment. Not a pairing of diseases & injuries: these concepts are orthopaedic baggage shipped in from much harder times. This is the corrupted legacy of orthopaedics that holds us back from a healing for the millions of chronic pain sufferers in our society – through a mainstream embrace of rehabilitation principles and high quality biomechanical care.

Pain is not a disease – it’s a symptom.

Weakness is not a disease – it’s a lifestyle/movement issue.

Normal back pain is almost never an injury, nor it is an indication for x-rays and surgery – it’s a stubborn muscle imbalance informed by complex lifestyle factors.

Osgood Schlatters disease is not a disease – it’s caused when biomechanical imbalances effect immature bone and soft tissue in the human knee.

Bursitis is not a disease calling for a steroid injection – it’s irritation of soft tissue that is in need improved posture biomechanical efficiency.

Osteoarthritis is not a disease – it’s a failure in the joint cartilage – caused by repetitive strain in the joint – that like any form of some of us are more genetically susceptible to than others.

Hip pain is not an indication that osteoarthritis is looming – only a small percentage of hip pain patients have osteoarthritis and only a small percentage of them need surgical care.

In cases where surgery is warranted for chronic pain – years of diligent rehabilitation should precede and and follow the procedure; in order to restore the soft tissues and stabilising muscles to full health and strength. 

Neck pain is not an indication that you need an x-ray or a conversation with a surgeon – except in extremely traumatic and exceptional circumstances. Neck pain is a sign that your biomechanics, lifestyle and wellbeing need to be closely scrutinized.

Spinal discs don’t degenerate because of ‘disc disease’ – they degenerate when they are injured or persistently overloaded.

X-rays and scans do not assess biomechanical issues – therefore they cannot explain the overwhelming majority of pains we suffer with.

Surgery is to pain management what civil war is to politics – it is supposed to be a desperate last resort – not a default solution !!

The current scientific evidence indicates that many modern orthopaedic surgeries are no better than a placebo.

These and many besides are the re-learnings you may need to undergo as a modern pain sufferer. As you free yourself from the legacy of orthopaedics and the hold it has had over our understanding of pain.

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