Keys To Pain Management In A Sports Medicine Practice

Dealing with pain in a sports medicine practice can be a very difficult, challenging and frustrating process. The patients want to get better as soon as possible. Some have high pain thresholds and some have low pain thresholds. Let us take a closer look at approaching common types of pain in these patients, dealing with good pain versus bad pain, and getting the athlete moving forward toward a complete recovery.

What are the three general types of pain that come into play in podiatry practice? These are mechanically-induced pain, inflammatory pain and neuropathic pain. Of course, there is much overlap in all three areas. When a patient presents to your office, you will need to decide what is the primary pain to deal with at that time, recognizing that it can possibly change over the next few days.

Often, the problem may have started with a mechanically-induced pain syndrome. (For example, overpronation could be causing plantar fasciitis syndrome.) However, by the time you see the patient, the inflammatory aspect has spun out of control and the neuropathic pain from limping and tweaking the low back is causing level 10 pain. Simply making orthotic devices and/or taping the foot to address the mechanics may be helpful in the long run but it should not be the initial focus. It is important to be mindful at each visit with the patient about what type of pain you are primarily dealing with right there and then.

A Closer Look At Mechanically-Induced Pain
The true uniqueness of podiatry is our understanding of mechanically-induced pain syndromes and their treatments. It is not the goal of this short article to emphasize these but I would like to summarize the most common ones presenting to “sports medicine practices.”

The six most common areas of mechanically-induced pain syndromes are:¹

1. Overpronation
2. Oversupination
3. Short leg syndrome
4. Poor shock absorption
5. Tight and weak musculature
6. Miscellaneous (like fat pad atrophy, hip degeneration, metatarsal malalignment, etc.)

Our expertise has taught us many treatments for each of the mechanically-induced pain syndromes listed above. Accordingly, we can explore many avenues if the pain remains stubborn. For example, we could consider variations in stretching routines or OTC versus custom orthotic devices, or even surgery for misaligned metatarsals.

Key to the treatment of patients is our ability to create a pain-free environment for that patient who typically has sustained pain levels of 0-2 based on the Visual Analogue Scale (VAS). We must develop skills for protected weightbearing techniques, like the use of removable boots, offloading orthotic devices and even simple gel heel pads. When the athletic patients typically first present to your office with pain, you must get them to understand the concept of good versus bad pain. Good pain is pain at the start of an activity that disappears during that activity. Good pain has little to no aftermath pain from an activity. Good pain does not cause one to limp and the pain stays in that 0-2 level on the VAS. Good pain can have an occasional sharp twinge that disappears in seconds with repeated activity.

As the patient and I try to team up to produce this pain-free environment, we initially review all three types of pain for their relativeness in the presentation. How much can only mechanical changes help the present pain (if a mechanical correlation is evident)? How much can anti-inflammatory measures help the present pain (i.e. if patients typically start on icing twice daily and contrast bathing each evening)? How much of the present pain is neuropathic? It is always good to review the concept of “double crush syndrome.”²

Deciding On The Treatment Of An Athlete With Achilles Pain
I think it is best to work through these problems two weeks at a time. At the first visit, decide how the treatment should start based on how you weigh the various types of pain as they present. Let us consider a patient presenting with severe Achilles pain (level 7-9 on the VAS) in three scenarios to work through this.

The first patient has Achilles pain, which is acute in nature, associated with a long history of back pain and no clinical signs of swelling.

The second patient has Achilles pain associated with a long history of long distance running. The pain has come on gradually and is getting worse and worse with thickening of the tendon on examination.
The third patient has Achilles pain, which is acute in nature. It occurred after stepping off a curb. There is swelling, ecchymosis and erythema.

With all three of these presentations, you have to consider the following questions.

• Do you need to order any tests?
• Are there any mechanical factors that caused or can help reduce the stress on the area? Even though heel lifts/clogs/boots typically help to reduce mechanical stress on the Achilles, and all patients with Achilles pain may benefit some from them, what presentation seems to be the most mechanical in nature? (Answer: the second presentation)
• Is there any inflammation that one can treat? Even though anti-inflammatory measures can help all three presentations, which presentation needs anti-inflammation measures the most? (Answer: the third presentation)
• Is there any nerve pain that may not respond to anti-inflammatory or mechanical treatments? What is the cause of this nerve pain? Which presentation seems neuropathic? (Answer: the first presentation)

I like employing an oral prednisone burst in situations in which the pain is high and I am not sure if the pain is inflammatory or neuropathic. Patients with neuropathic pain typically get very little relief from this eight-day course of oral prednisone and one can then direct the treatment toward more targeted agents for neuropathic pain.

In Summary
The sports medicine practitioner will be surrounded daily by patients with pain syndromes from mechanical, inflammatory and neuropathic causes. In concert with the patient recognizing good pain versus bad pain, podiatrists in busy sports medicine practices must ascertain the nature or etiology of the pain and strive to create a healing, pain-free environment. A biweekly approach to managing pain in this athletic patient population is common as the symptoms change with the recommended treatments.

Add to good treatments, remove treatments that seem useless but overall, learn what is at the root of the pain syndrome.
     
Dr. Blake is the Past President of the American Academy of Podiatric Sports Medicine. He is in private practice in San Francisco.

Editor’s note: For related articles, see “Addressing Heel Pain In Runners” in the November 2014 issue of Podiatry Today or “Conducting A Quick And Easy Functional Lower Extremity Exam Of An Athlete” in the June 2013 issue.

References
1. Donatelli RA, Hurlburt C, Conaway D, St Pierre R. Biomechanical foot orthotics: a retrospective study. J Orthop Sports Phys Ther. 1988;10(6):205-12.
2. Golovchinsky V. Double crush syndrome in the lower extremities. Electromyogr Clin Neurophysiol. 1998;38(2):115-20.