Case Study: 2 Years of Elbow Pain
A Case Study
This is a case study of a patient who had two years of biceps tendonitis, and this came on from overtraining in the gym. The physical overload of activity came through training six or seven times a week.
The patient was a fit guy and generally with no issues. Fit, healthy, and no natural history of any problems. Then he develops arm pain from training so hard that he couldn't do the thing he loved. He’d seen loads of different people and had it diagnosed as bicipital tendinitis, which is where your biceps tendon inserts in your forearm.
Popeye Muscle
If you imagine doing a biceps curl like Popeye, it’s that muscle where it inserts that can become inflamed. It’s called tendonitis or tendinopathy.
He had ultrasound scans, had a steroid injection, and he had just to manage it or maybe try a bit more physio.
I saw this gentleman, took his history, and asked him what else was going on when he started to feel the pain. He looked puzzled about that question because everyone wants to show you their pain and help them work out why it's still there.
Pain is a Result of Behaviour
Pain is the result of behavior. Although the area of the pain is relevant it is more important with persistent pain to know why the behaviour causing pain happened.
I asked him about his situation before he experienced the pain, and there was a massive amount of stress in his life at that time.
Not just for a week or two but for two years. It was practically either side of when the symptoms started.
That pain he experienced doesn't just magically manifest and persistent pain doesn’t stay without a reason. He was coping during that time by hammering a behavior that made him feel better.
Too Much of a Good Thing
Overusing a behavior that makes you feel better, which in his case was the gym, to distract himself from the emotions he felt about a situation in his life.
If you can't resolve that stressful situation or can't resolve your feelings about it, your body can't allow you to stay like that. You’ve got to escape it, and we've all got our default for that.
For example, work, chocolate, gambling, shopping, or exercise are some of the behaviors that help us quickly feel pleasure when we’re stressed.
Quick fixes never last
The minor hits of pleasure or the distraction they these things bring work in the short term, but their effect never lasts.
If there's a time in your life you have to hit them a lot harder for a lot longer, there's a chance that the behavior you use, if it's destructive, causes a problem in itself.
Then the person has lost their default down button for dealing with stress.
The more stress we feel, it releases dopamine in our brain. We would generally use the default behaviour to take us away from that anxious feeling.
If that behaviour becomes routine, it is encoded differently in the brain. More stress eventually creates a compulsion to do that behaviour without giving the same pleasure response to that person.
Vicious Cycle
You’ve got to get more of the behaviour to feel the pleasure that used to come quickly from it. More chocolate biscuits, more work, more exercise, more this, and more that all fail to reslove the anxiety from the situation creating the stress.
More destructive behavior is needed to even just feel like you can cope with what you're dealing with.
Now that means that in his case of using exercise, it became overloading. Once we identified the driving nature behind these behaviors that then created the pain, the pain can be understood as a protective mechanism. It becomes so wired to the potential of the behavior that it short circuits the behavior.
The behaviour was used to take the organism somewhere towards a sense of safety and away from the stress. But it in itself became a stressful thing that took them away from the stress.
It’s a paradox.
The Brain Plays Referee
The brain recognizes the behaviour as dangerous at that level of intensity, so it triggers pain to substitute the behaviour.
As soon as the person feels stressed, it triggers pain that creates more stress and drives the craving for the behavior that is limited by pain.
It's a loop and this guy was stuck in the loop long after the event was over.
Once you've automated the pattern, the stress around the pain becomes the driver for it, not the event.
Realisation is Key
Once he realised the drivers for his behaviour were the circumstances in his life, he understood. If the stress from that time is over it need not be represented any longer by the stress in his arm.
Reversing the behaviours is like flipping a habit, and he already had the skills to train consciously and systematically without causing injury.
He had to drop a level below the threshold of pain and commit to that. He was reassured that he would ultimately recover.
Once that reassurance is believed and the fear of two years subsides, the pain pretty much changed immediately in the room.
Change Can Be Fast
It's crazy when it happens like this. It’s liberating for the patient because you set them free of fear. Fear is the biggest driver behind the pain.
There are loads of other emotions you can link pain to, but fear is the most common driver of pain.
When you can help someone let that go, you don't have to do a lot more.
There’s physical conditioning to do. You’ve got a situation to go back to and which is like putting your head in the lion's mouth again. That's a normal response to challenge ourselves in life and build resilience to that.
We all have to deal with stuff physically, emotionally and psychologically.
Pain-Free Represents Balance
We come down from those things and get the balance again, and most people know how to do that.
If they've had pain for a long time, some people have lost that balance, but you can understand how to get it back. They may have been over resiliant or under resilient and both lead to the risk of persistent pain.
The pain is just telling you the balance isn't right in your life.
This patient did amazing and soon return to his previous level of training.
It's such a nice thing to see someone do so well.
No more biceps tendonitis.
It doesn't matter where the pain is. It doesn't matter how it originated. If it's persistent pain, you can unpick the story behind it. You can reverse it.
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