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musings on the nature of recurring chronic # site pain.
It is not uncommon to have those who had recovered fully years earlier from relatively straight forward limb #'s, particularly to the lower limbs, to complain of # area pain years later. In some cases the pain is quite specific to the old site in others more broadly identified as related, along with other signs which become useful as indicators of cause. A full examination will invariably reveal that spinal protective behaviour plays a dominant role in the chronic display. When this is so, attention paid only to relevant spinal joints will be both effective and diagnosticaly useful.
When a # occurs, the brain creates pathways and behaviour associated with assuring safety. Pain and the antalgic maneuvering and avoidance it creates will also raise the prospect of spinal protective behaviour, a common feature of post # sequelae.
Thus manual therapy aimed at turning off relevant SPB will likely restore a pain free state to the complained of limb.
My explanation to patients includes reference to the brain having already made a pain related "pathway", such that when nerves close to the spine are irritated by SPB, the brain does not bother creating a brand new one, but uses the old neural connections related to the # instead. In this way referred pain from the spine may assume characteristics identical to the # pain, well after that # has healed.
That is a different way of looking at it. I agree that referred pain is generally neurological in nature, which relates to your concept of building and rediscovering old pathways. However, I believe that once those pains have been alleviated, then the injury is basically either healed or mostly healed. And any reoccurence of old symptoms are really just a new injury or a reaggravation, not just a rediscovered neuro pathway.
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recent patient experience has been illustrative of my previous points
woman mid 50's, 5/12 post L metacarpal #, healed. at first exam ,c/o L forearm, wrist, thumb, hand pain 5/10 was unable to fist, weak grasp L, minor swelling evident to hand.
O/e spinal protective behaviour ++ L cx, upper thx >>R
RX continuous mobilisations as above, 3 sessions over two weeks. today, able to make a weak fist, swelling not evident,grip 4/5 minor thumb pain with extension only, no forearm or wrist pain further improvements likely as SPB diminishes.
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update on my patient post wrist # She is now able to fist with moderate force, minor thumb pain with extension, minor mid carpal area stiffness , no forearm pain. It is probably time for me to segue into some wrist and hand mobilisation now that the spinal related events are under good control. SPB cx/thx now mild Some infraspinatus tightness remains that most likely accounts for the thumb pain. This woman arrived with a "diagnosis"of CRPS. Cheers
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