Why Old Injuries Still Hurt!
Most people have faced the misfortune of suffering from an injury or interacting with the injured. Advances in medicine have led to the better understanding of injuries – the mechanism, the chain of events they trigger in the body and the response of the body, all of which contribute to the final outcome following the injury.
In this backdrop, the fast pace of modern life too has placed unrealistic expectations of excellent outcomes, from patients along with expectations of early, rapid and complete recovery from injuries. It is easy to comprehend that pain can be a part of the healing process. On the other hand, it is difficult to tolerate pain when satisfactory healing has occurred.
However, management of bone pain from a previous injury can be challenging, because it involves identification of the exact cause Of the pain, which may be manifold and may require multidisciplinary treatments complicated by patient factors (which range from extreme cooperation and acceptance of the situation to negativity and despair).
Stages Of Healing Injuries
Healing of injuries take place in three distinct but overlapping stages:
1. Inflammatory Stage –
This stage is from the time of the injury to few days after the injury, accompanied by pain and swelling,
2. Stage Of Regeneration –
This stage begins from six to twelve weeks in which the pain and swelling regresses,
3. Stage Of Remodelling –
This stage begins from eight to twelve weeks and persists for several months or years, during which the injured tissues are gradually sculpted back to the pre-injury state.
The duration of these phases may vary depending upon the injured tissues, age, systemic illnesses or drug intake.
The causes of pain from previous injuries may originate in the bone or the soft tissue that envelops it and the nerves and the vessels that supply them. The latter are subject to influence the brain, spinal cord and various chemical mediators.
Making the diagnosis that an injury has indeed healed in a satisfactory manner, can be difficult in many situations and the treating physician has to analyse many parameters before arriving at this decision. Also, as pain alone is an unreliable factor, other physical examination findings and imaging modalities like x-rays, scans etc. may have to be relied upon.
On many occasions, when all assessed parameters prove non-conclusive, the physician may declare that there can be no further healing possible for that injury, relying more on the time elapsed after the injury (few months to one year) than pain experienced by the patient (which can’t be the sole basis to assess healing).
Causes Of Pain After ‘Healing’
Malunion –
A fracture, uniting in improper alignment, which may require surgical correction, if unacceptable or close to a joint.
Delayed And Non Union –
It is erroneously diagnosed as healed, but detected on re-evaluation, following persistent patient symptoms. It can be treated surgically in an appropriate manner.
Infection –
It occurs, especially in patients with low immunity or who are diabetic. Imaging modalities are used to diagnose and are treated with antibiotics or surgery.
Arthritis –
The joint ‘wear out’ damage which may be post-traumatic or osteoarthritis, treated by medications, physiotherapy, braces and surgery if not relieved.
Management of bone pain from a previous injury can be challenging because it involves identification of the exact cause of the pain which may be manifold
Pain That Determines Soft Tissue Issues
Effects of Immobilisation –
It can be joint stiffness, muscle wasting and weakness, scarring and contractures. Physiotherapy, appropriate mobilisation and strengthening programmes are possible treatments.
Unhealed Ligament Tears –
It can be treated with braces or through a surgery.
Compartment Syndrome And Circulatory Problems –
Issues like swelling, skin discolouration, soreness, eczema and pigmentation.
Complex Regional Pain Syndrome –
This occurs due to sympathetic nervous overactivity and self-limiting which comprises of severe pain, swelling, skin changes, stiffness, contractures and peculiar tendency to neglect the injured part by the patient, treated by a multidisciplinary approach, robust physiotherapy and rehabilitation.
Neurogenic –
Regional causes like nerve entrapment or irritation or central nervous system issues, including psychological, workplace or compensation related issues can lead to pain and soft tissue problems.
Treatment
The key to management of bone pain from a previous injury is meticulous understanding and careful analysis of patient’s problems, rehabilitation, physiotherapy modalities, medications, braces, counselling and surgery, in selected cases with identifiable causes. Nevertheless, there can also be unexplained causes of pain which require management by activity or behavioural modifications.