What is “Good Pain?”

I have many rules that I personally use when attempting to help someone with a sore foot. To succeed in this, I need their cooperation in the treatment, specifically in avoiding periodic levels of increased pain. To explain, after the onset of pain, I want that pain to reduce as quickly as possible to the 0 to 2 range (on a visual analog scale – still smiling on those charts). On one end of the spectrum, one can accomplish this with complete bed rest; while others may simply just need to not run 5 miles. To start, I want patients to get that pain down and hold it down for 2 weeks.

I stress to patients that they must follow medical recommendations, but if they result in an increase in pain, they should stop those interventions and report the incident to me. Some practitioners will evaluate the situation and have the patient continue those interventions, deeming the pain “good pain.” What is good pain? To me, it is pain that does not linger for more than 2-3 days after it starts, does not cause limping, and does not come on during exercise or activity, only after.

What types of treatments do you recommend in these situations? I have some general rules, as I mentioned above, but most apply to many scenarios. I recommend at least one type of treatment from each of three categories: mechanical, inflammation, and neuropathic. Mechanical treatments can include walking casts, changing how fast the patient runs, shoe selection, insert selection, padding, taping, braces, etc. There are so many options to try that you can vary from visit to visit.

Inflammatory-related treatment, in my practice, usually is ice in some form and contrast baths. I try to avoid oral medications in general, but short periods are fine. If the patient has swelling, sudden stiffness, sore muscles or tendons, he or she should work on the inflammation daily.

Neuropathic pain can be from local nerve injury, local nerve hypersensitivity, or referred from proximal to the foot. In my experience, nerves respond well to non-painful massage, warmth, shorter ice periods no longer than 5 minutes, motion like walking, and neural flossing, but not prolonged stretching. Any injury that still exhibits significant pain after 3 months, I find will often develop nerve pain in the form of protective neural tension or just hypersensitivity. Nerve pain, in my experience, manifests more intensely than inflammatory pain, but is shorter in duration. Patients commonly describe “level 10” pain bursts for a minute or less that just shuts them down.

Therefore, when treating a painful foot problem, consider what mechanical, inflammatory and neuropathic treatments you are currently recommending. If you are missing one, add it in; or, make changes to each type of treatment if progress stalls. Good luck!

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com. 

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.