How Too Much Too Soon Can Bring Back Your Pain

The below statement was a recent message taken by our receptionist indicating a level of dissatisfaction from a client of ours, Mrs K. With the intention of resolving the client's concern as soon as possible I met with the attending Physiotherapist and together we reviewed the client case notes. This particular scenario has raised an important consideration about the healing process that I would like to share in this article for the benefit of our readers.

Can you call Mrs K back please, she is not happy that after 4 sessions she is still in pain and wants to know where she goes from here?

Upon careful review of her case notes as well as discussion with her physiotherapist, we were able to determine that Mrs K’s knee had been responding very well to treatment over a three week period with a reduction in reported pain and general improvement in the function. Considering her knee pain had been present more or less persistently for 7 years, her physiotherapist was very pleased with her progress.

It had been determined on assessment that Mrs K’s pain was likely to be arising from the inner compartment of the knee joint as well as the knee cap (patellofemoral joint) and therefore much effort had been made to settle these structures using pain modulatory and strengthening exercises improving the overall function and support of the knee joint.

So what went wrong?

At Mrs K’s last treatment session she reported her knee had been aggravated by a long drive. As it was her left knee that was causing her problems, the repetitive clutch use and long period of time in a bent (flexed) position would have placed significant mechanical load on the inner knee and knee cap. This is likely to be the reason Mrs K’s pain returned, despite having been doing well in treatment previously.

This was explained by her physiotherapist and she was assured that if she modified her activity so as to reduce strain to the knee, did not panic about the pain, continued to keep the knee moving within comfortable limits and gently resumed her exercises, the knee would settle down again. As she had already received physiotherapy, the knee is likely to settle down more quickly if it is managed correctly. It was most important to reassure Mrs K that despite pain, no further damage had been done to the knee.

So why did the pain come back, even after having 4 sessions of physiotherapy?

Given that Mrs K’s knee pain and dysfunction had been present for 7 years, it is reasonable to assume that her pain and inflammation mechanisms would have become well established. As such despite a good response to treatment, the knee would still be somewhat ‘vulnerable’ to stresses and strains while the pain and inflammation mechanisms settle and start to normalise. This can take many months and will continue to settle with good self management and exercises after the course of physiotherapy has completed.

For this reason, it is essential that if pain does start to ease, any temptation to do too much too quickly is resisted. We see this very often in clinical practice and the ‘too much too soon’ problem can prove difficult to address. We do our best to advise how best to look after a joint being treated but unfortunately we cannot monitor and support our clients behaviour 24/7.

In Mrs K’s case we anticipate being able to bring her knee back on track and sometimes setbacks like these create better self awareness and can be of benefit in the long run.

Should her knee continue to become exacerbated after a course of physiotherapy treatment (usually about 6 sessions for this type of long standing problem) and after having a reasonable length of time pass then Mrs K may benefit from the opinion of an orthopaedic surgeon. However for the majority of ‘mechanical’ knee problems we find that good physiotherapy and self management is sufficient in providing long term pain management and maintaining the functional use of the knee.

by Simon.