Understanding overuse and repetitive strain injuries
We all know of people who have suffered from an overuse or repetitive strain injury (RSI). Tennis elbow, carpal tunnel, shoulder impingement and runner’s knee are conditions affecting different parts of the body but with one thing in common: they can all be considered RSIs. Often tricky to manage, it’s not uncommon for these injuries to take a long time to get better.
Despite the knowledge accumulated, common therapeutic approaches such as anti-inflammatory drugs, exercises and manual therapy can fall short in their management. The reality is that science still doesn’t have a full grasp of these injuries, and the widely-held belief that the tendons (or muscles) are permanently inflamed may not be entirely accurate. But there are also new exciting ways of viewing and explaining RSIs, so keep reading… good stuff coming up!
The repetitive strain or overuse
As the name ‘repetitive strain injury’ suggests, our body tissues (ie. tendons, ligament etc.) can get injured when we repeatedly perform the same task over and over again. Unsurprisingly, RSIs are among the most common injuries affecting people at their workplaces, from computer-based workers to builders. The NHS website refers to them as ‘work-related upper limb disorders’, although any activity such as sports, playing musical instruments or computer-games can lead to overuse. You don’t have to play tennis to have Tennis Elbow!
RSIs are commonly associated with a problem in the muscles or tendons, in fact it is not uncommon to hear people saying they have ‘tendinitis’. However, tendons are not the only affected tissues, fluid filled sacs in-and-around our joints called bursae (‘bursitis’) or fat pads can also be the ‘victim’ of an RSI. But this is only the half of it. These injuries often involve an intricate play between the nervous and immune systems making RSIs pretty difficult to study.
Tendinopathy, tendinitis, tendinosis...
How often have you heard of these terms being used interchangeably? Terminology can be confusing. Tendinopathy comes from the Latin disease (‘-pathos’) of the tendon and is the most general term to indicate tendon issues. The suffix ‘-itis’ refers to the presence of inflammation whereas ‘-osis’ to degeneration (tissue breakdown) taking place in the tendon. Each term may be appropriate for a certain stage of the RSI. But for long lasting RSIs, ‘tendonalgia’ is now commonly used, as we now know there is often very little inflammation or tissue degeneration going on in the actual tendons.
Is it inflamed or not?
As you seek help from your doctor to deal with carpal tunnel or tennis elbow, you’ll more than likely get told to rest, ice the area, and take anti-inflammatory drugs to ease the pain. All of this advice is based on the assumption that there should be some sort of inflammation going on. Just like when you badly roll an ankle or smash your elbow and things are red, warm and puffy; inflammation is a good sign that your body is doing its job at repairing itself.
But that’s not what research seems to show for RSIs. Aside from the initial stage of the injury, by the time patients present to healthcare professionals with an unresolving RSI, we do not find the classical signs of inflammation. Even at the microscopic level, the typical white blood cells seen in acute inflammation (immune cells) are not really there. Instead, it may be more of a combination of slow tissue breakdown (without inflammation) and, most importantly, changes in our nervous system activity that makes us more likely to feel pain.
Stop taming the fire
It’s baffling... if no inflammation is present, why are RSIs still treated as if there was inflamed tissue? Applying ice on the skin will probably numb the area and make it feel better temporarily, because that’s what cold does, but it’s unlikely to have further benefits as once thought. Moreover, anti-inflammatory drugs can have negative side-effects and may actually slow down the tissue-healing processes… not what we want! So, maybe stop trying to tame the fire?
What to do at the start of an RSI
Ideally, if we recognise early-on that the pain is being caused by the repetition of a certain task or movement, a healthy dosage of resting from that particular activity may do the trick. If it is not possible to take a break, then it is useful trying to find alternative ways of using our body, so that different muscles can be engaged instead of the painful ones. For instance, you can take a break from tennis if that is what is causing your elbow to hurt, but still do some activity to keep healthy and fit. Or use an alternative mouse or keyboard setup if the traditional ones were causing you wrist pain. Though it may sound easy, using our body efficiently may be tricky at first… this is why consulting a healthcare professional may be helpful in the early stages of an RSI.
Generally, limiting the use of painkillers can be good, but if necessary, analgesics like paracetamol or topical anti-inflammatories like Voltaren or ibuprofen cream may be the better option. Engaging in gentle stretches, getting manual therapy like osteopathy (read the section on ‘osteopathy’) and understanding your condition (read the next paragraphs for a full view on RSIs) are the best options before engaging in a graded return to activity…
Graded return to activity
A lack of graded return to activity is what often may prevent complete recovery. As we get pain from an RSI, the first thing we may do is rest for a few days or weeks. The pain may more or less disappear and therefore we return to our activities in full regimen. It is not unlikely, however, that as we do this the same issue returns leaving us confused and frustrated.
What we lacked was a paced, step-by-step, return to normal activity. Because of complex changes within our nervous system (read paragraph Why does it hurt?), even after a first period of rest, our tissues are likely to be ‘sensitive’ to the loads of work that brought the RSI in the first place. In other words, too much of the particular activity too soon (ie. desk work, weight lifting, running etc) will irritate the tissues once again, meaning that we need to re-start the cycle of rest plus graded return to activity… this time with better pacing and, maybe, some professional guidance.
Lack of rest
Another major obstacle to full recovery, can be a lack of rest when needed. As initially pain may look like ‘nothing serious’, we may decide to push through it, eager to keep working, running, lifting weights or whatever it is we’re doing. Tissues don’t have enough time to recover and our nervous system grows more sensitive to this movement as time goes on, making us feel pain more frequently and intensely. What do we mean by sensitive nervous system? We explain this in the next paragraphs…
The stubborn RSI
In order to understand why certain RSIs will go on for months or even years, we need to dive deeper into an understanding of what pain is, what causes it and what tends to maintain it. Pain is complex and fascinating...
Why does it hurt?
Any movement that goes beyond a ‘safe’ range of movement or exceeds a ‘safe’ amount of load may be recorded by our nervous system as potential for damage. These ‘danger messages’ are vital to prevent real damage. So, the repetition of a seemingly innocuous movement (ie. laptop work), over and again, may trigger ‘danger messages’ recorded by our nervous system, before any real tissue damage takes place. As we keep repeating these movements, which are now labelled as a potential ‘threat’, our bodies try to protect us from it, and guess how… by making the tissue more sensitive and therefore more painful!
As time goes on and we keep repeating the now-painful motion, our nervous system grows better at protecting the area, and becomes ‘overprotective’. Whereas before we used to be able to do that particular motion for a while before feeling pain, any movement that puts stress on the sensitive tissue now hurts causing us to form adaptive behaviours (ie. being fearful of moving, moving inefficiently etc.) to avoid further potential damage. And as time goes on, simple movements that were not a problem before, may now cause pain… to a point in which even resting may hurt. All of this is happening with, potentially, hardly any tissue damage; the take-home message is that pain does not equal damage (rather, an overprotective nervous system).
Pain is weird!
As our nervous system becomes incredibly good at being protective, our brain begins to predict the onset of pain from doing a particular movement or task and therefore makes the ‘alarm bells’, aka. pain, go off even earlier, even when there’s no real threat for our tissues. Just as athletes use mental imagery to prepare for a match and improve their speed or accuracy, so too does the brain in predicting and preparing for a movement to be painful, lowering our pain threshold in anticipation of a movement This is part of a complex process that occurs with any persistent pain state, referred to as ‘central sensitisation’. For more content go here and here.
By the time we reach central sensitisation, it is likely that our tissues have mostly recovered from any initial inflammation they may have suffered. It is now a matter of reducing the sensitivity of our nervous system. This may sound simple enough but have you ever tried tricking your brain? A bit like not thinking about a pink elephant when someone shouts ‘PINK ELEPHANT”.
One of the ways we do this is by finding alternative ways of moving that our nervous system doesn’t label as ‘threatening’... it may be crucial to change the context in which we do the painful movements, for instance by changing rooms and positions during work, or changing the meaning completely, ie. doing the painful movements as a form of game. Studies have been exploring the possibility of virtual reality as a way of moving within a totally different but safe context, highlighting promising results. But, without the need for expensive virtual reality devices, there are lots of things your osteopath can do to show you exercise strategies aiming to achieve this. Safe and pain-free movements will override the feared painful ones and gradually reduce the sensitivity.
What worsens the pain
Making it more interesting, there are other factors we need to consider in order to treat pain. Our subconscious brains are very aware of our environment (ie. work, home, social, etc.) and the thoughts that may be crossing our mind, and much of its protective activity will depend on this. That’s why in healthcare we talk of a biopsychosocial model of pain. Let’s explain this further.
Research in this area has shown how chronic stress, anxiety, feelings of frustration or fear about the pain contribute to making the nervous system overprotective (more sensitive) (go here for an in-depth read). Crucially, it would be useless to address these feelings without considering the context in which they arise; you may only be stressed, and in pain, as you step into your workplace; or because of an upcoming sporting competition; or for fear of losing your job; or anxious about not knowing what is going on with your body. Feelings depend on the context and sometimes changing something within the context (ie. taking a holiday, changing job) is essential to recover from pain.
If you’re a personal trainer and your livelihood depends on working with your body, the stress resulting from this, the eagerness to get back to the gym (that may impact a graded return to activity) and frustration of not getting better may be a paramount factor in maintaining pain. Similarly, you may be working 8 hour per day at your desk, maybe with lots of pressure from your manager and hating your job. And your wrist keeps hurting, despite ergonomic chairs and keyboards provided. The mental and physical stress from the workplace and the pain may feed into each other creating a vicious cycle of stress, anxiety and more pain.
When in pain and confused about it, a hand may be everything! Health professionals, like osteopaths, are able to place some order in the ‘chaos’ we may feel within our body and map out a plan for a complete and long lasting recovery. Osteopaths use manual therapy (ie. massage, manipulations and more!) as a way of soothing pain, and improving the function of joints and muscles. This is done with a person-centred approach, understanding our patient’s unique bodies, lifestyles and needs, so that we can address all the elements playing a role in the pain.
Moreover, as you suffer from long lasting RSIs, it is likely that other related parts of your body have been compensating for the injury, compromising on their ideal function. Osteopaths can help you identify compensations and address them in the view of a fast return to ideal function. For a free telephone consultation with Core Clapton’s expert osteopaths, call 0300 561 0161.