Olympic Mountain foothills from Gardiner, WA on West Highway 101 looking toward Sequim, 

Have to vs. Want to

Have to versus want to

Often people have said to me "I have to" do something, such as go to work or water the plants.  When a body part or muscle has been overused they must rest to heal.  The only "have to" activities are eating, drinking, eliminating (pee and poo), and sleeping.   Everything else is a choice.  I am not trying to be a jerk. I simply want to educate.  When an activity is more important than healing a body part, you will likely turn the problem into a long-term chronic problem that never adequately heals.  I realize people need to work but when injured their employer should find them something to do that does not need the same muscle activity they have been doing.  Otherwise, they should ideally be off work on disability or workman's compensation, if the injury occurred at work.  It always bothers me when I am checking out at the grocery store and see a checker wearing wrist braces and still checking.  I hate having them work on me because it means I am contributing to their problem.

Many times over the years, I have worked on people who have horses or animals that have to be cared for. I agree the animals need care, I am simply saying you have to figure out a way to rest the injured body part and still give the care they need.  Ideally, this means someone else will be able to care for the animals while you are healing.

Setting priorities

As a 13-year-old I was at a church retreat where we stood on a frozen lake at night while someone drove a snowmobile pulling an inner tube around the lake.  When it was my turn I slid off of the inner tube.  The gentleman driving the snowmobile did not know I was still on the track until his headlights caught me walking back to the group.  But it was too late.  His son was riding on the inner tube that flew wide off of the course and his head slammed into my knee.  Needless to say, I broke my tibia and he got a concussion. This started me on a frustrating track of having a bum knee, to say the least.

 

When they took me to the doctor right after the injury, I don't recall an x-ray being taken but I remember standing up to take my brand new jeans off because I thought my mother would kill me.  I was told that I had a sprain and should walk on it.  I tried desperately to walk on it but it was excruciatingly painful.  I am pretty sure that was the weekend that turned me toward music therapy.  I sang "He's got a ticket to ride" by the Carpenters, every time I tried to make it to the bathroom.  The weekend was miserable and when I finally got home there was a pair of crutches in the garage that I was thrilled to use.

We did not have insurance then, and since I had already seen a doctor, my mom did not take me to another doctor.  About two weeks later, I developed horrific pain when I picked my leg up off of the pillow.  My mom took me to a doctor who did an x-ray and diagnosed me with a fracture of the tibia and thrombophlebitis which are basically blood clots in the leg.   He told my mother to meet him at the hospital with me later that evening.  I am as skeptical as can be but also have the scientific methodology on my side.  I spent the day with my mother who apparently prayed all day.  By the time we got to the hospital later, the swelling had dramatically reduced and the doctor put a cast on my leg and sent me home rather than put me in the hospital.   I still don't know what happened, but I believe that it was my miracle.  Without insurance, I am sure the hospitalization would have been devastating to my family's already-tight budget.

I was in a cast from my ankle to my groin for 8 weeks without being able to touch the ground with my foot.  We lived in Colorado at the time in the winter and I remember several times when the crutches would hit ice or a patch of melted snow/ice in school and they would slip out causing me to step on the foot.  So the healing took a long time.  I eventually got back to my usual activity level.  Throughout my teenage years, I played volleyball, basketball, softball with a church league as well as tennis, roller skating and skateboarding.  I recall being the center for basketball as the tallest girl on the team.  Often I would twist my knee and had increased pain.  I played on, however, because without me the team would surely lose.  I remember how mad my mother was when she found me jumping on the trampoline with my cast and crutches.  Needless to say, healing from any trauma is BORING!

Watching sports is a good example of overuse injuries gone awry.  When a player is injured they are often patched up and sent back out.  This is displayed every Sunday during the football season.  Sadly, I have seen my favorite players injured and yet continue to try to play.  This is never a good idea, in my opinion.

When playing the sport is more important than healing, I think the priorities are screwed up.  I am more understanding when the injury is more minor and the athlete chooses to continue playing knowing that they soon have an offseason when they can have surgery and go through proper rehab.  I can say that I did this once.  I developed a herniated disc in my back causing bad back and right leg pain.  I was scheduled for surgery in a week and I helped my brother haul a huge oil heater tank up the basement stairs at my sister's new house.  My thought was that I could do no more harm and was going to be fixed the next week anyway.  However, after the surgery, I was very careful to follow my doctor's instructions and would never have done anything like that after the procedure.  I wanted the surgery to be effective.  It always bothers me when people do not follow their doctor's advice after the surgery.  What is the point of going through the surgery if you do not want to heal properly?  I have often worked on people over the years who failed to follow directions carefully and ended up with a worse problem than they had before the surgery or the problem and pain became chronic.

Order of rehabilitation

When there are multiple problems that a "train wreck" patient has, I have to determine the best order of rehab to get them better as fast as possible.  My instructions at evaluation are always to stop whatever trauma they may be causing.  If it is overuse from chopping wood, then I tell them to stop chopping wood. They are encouraged to stop using the injured body part altogether.  We focus first on healing the acute trauma, by using RICE or rest, ice, compression, and elevation.  We also work on maintaining a joint's range of motion through passively moving the body part if the physician allows.  While resting the specific injured tissues, I focus on improving skeletal alignment by using Strain and Counter Strain or Releasing Joint Restrictions.  Then I teach them about using the pelvic floor/inner core to stabilize the skeleton while changing positions.  Once adequate healing has taken place in the injured tissues, then we work on slowly and gradually increasing strength through activities and exercises.  Finally, we work on balance training and cardiovascular conditioning.

Poor skeletal alignment leads to overuse

I find you cannot have an overuse problem unless there is a skeletal alignment problem.  Each muscle that attaches to the skeleton has a specific line of pull that allows you to pull the two bones together.  This angle has to be correct to create the greatest force.  When the angle is off, the muscle cannot get a maximal contraction and if it does try it can be the cause of the muscle fibers popping causing overuse.  When the bones of the skeleton are out of place this messes with the line of pull.  It can also cause tendons and muscles to be beaten up when pinched between two bones that should not be coming closer together.   This is very commonly the cause of shoulder problems.  When the pelvis is off, the backbones slide off, the rib cannot fit in the driveway on the backbones, the shoulder blade and collar bones cannot fit on the rib cage appropriately and then the shoulder does not fit into the socket correctly.  This is why I focus so much on treating alignment problems because they cause overuse/tendinitis problems.

 

Handout:  Overuse

 

Reformed overuser

I am a reformed overuser.  I was raised in a family where you helped those who needed it, especially those who needed it more than you.  No wonder I ended up in the medical field where I am getting paid to take care of people.  My mother would stay up all hours of the night to make sure things were done for her husband and 6 children before she ever did anything for herself.  While some would say it is admirable, I am not one of those people.  It is important to learn to take care of your own needs first and then you can spend your extra energy tokens to help others.  You are taught to put the oxygen mask on yourself first when traveling.  That way you can take a breath in to save yourself and blow the breath out to save others.   A shocking answer is "they tell you to put it on yourself first but I would put it on others first".  And my response to that answer is "that is great to save your child first, but now your dead so who will care for them"?

 

For some people, it is really hard to feel selfish by taking care of yourself first.  But if you continue to sacrifice yourself for others, there will be less of you to be able to offer them.  I recall walking on a beach with my husband's parents and I was struggling to keep up.  My conditioning was such that they were in better shape than I was and it caused an overuse in my knee.  I finally had to sit down on a log and took a rest break until they came back.  A limp was my gift for that lesson.  That was really a turning point for me, however.  I decided that I would rather walk at my pace and not be injured than try to do something I was not ready to do.

 

Later, I realized I had not learned my lesson completely.  The roof had a blockage of fir needles and cedar leaves so I had to climb up the ladder to unblock the clog.  While I had the ladder out, I decided to clean out the gutters.  I probably climbed up and down our eight-foot orchard ladder at least six times.  After putting the ladder away, while climbing the stairs into the house, I realized I was having discomfort and difficulty raising my leg to put my foot on the stair.  It was not terribly painful but I knew I was in trouble.  I immediately went into my emergency mode of not using the leg.  I actually went to bed and read or watched TV.  I used a cane to get me to the bathroom and my wonderful husband fed the dog, himself and me.  By the next day, the discomfort was gone and I had no difficulty climbing the stairs. I was careful over the next several days to build slowly and gradually back to my customary activity level.

 

Dr. Lovejoy-Evans, the hypocrite

So you would think I should have this figured out by now, wouldn't you?  I think so!  But no, it is not to be the case.  What a hypocrite I have become by not doing the things I tell other people to do.  Things like work on the pelvic floor, stand up and sit down without using hands.  Those kinds of lessons that are really worthwhile.  I have become very weak over the last couple of years while struggling with depression, but am working on trying to strengthen again.  Last week, in particular, I really started refocusing on firing my pelvic floor after writing a post about my canary in the coal mine.  I have been waking at night to use the bathroom and have been using the bathroom during the middle of the day.  I began firing my inner core in earnest.  Well, you might have guessed it, I caused an overuse.  I think I woke up 4 times during the night a few days ago and had to go 2 more times during the day than I was used to.

 

After realizing what I had done, I immediately stopped firing my inner core and rested for 2 days.  Quickly, I was back to sleeping through the night and needing to use the bathroom only 2 times during the day.  When I am well-conditioned in my pelvic floor, I typically can stay in bed for 8 hours and can work 8 hours during the day before requiring a restroom break.  Needless to say, my pelvic floor is not like the thick steak it used to be, but rather a pathetic piece of shaved ham.  I am happy to report that I recognized the problem early so I only required a few days of resting.  Now I am firing my inner core 4 times a day and will stay at that level until next week when I will add 2 more times to each day.  I will follow my own counsel!

I think of myself as a reformed, or should I say reforming overuser.   No one is perfect and I definitely make mistakes at times.  I always have overuse during the holiday season when I make my family recipe for a special pastry called Kringle.  They now call it "Christmas Crack" because it is so addictive.  I make too much of it in a very short period of time and it bothers my wrists.  This year, however, I am planning to condition my arms a few months before the holidays get here so that I will have enough energy tokens to make the pastry without having any wrist pain.

Also, I am trying to work on strengthening slowly and building gradually, those muscles that I have chosen to weaken by not using them.  I cannot get up from a seated position on the couch without using my hands.  There are some patient's houses that I have to stand in because their couch or chairs are too low for me to get out of even by using my hands.  It is pretty pathetic.  I am thrilled, however, because Friday I was able to climb 4" stairs with my left leg without difficulty and today I walked on the beach without difficulty for the first time in 2 years!  So the strengthening that I am doing is paying off quickly.  

 

Contact:  Loraine@doctorlovejoyevans.com

 

© Dr. Loraine Lovejoy-Evans, DPT