understand the negative starting point, you may need to visit a doctor for a complete diagnosis.
I: Intervene and ice the ankle to decrease swelling and inflammation. Consider rest, ice, compression, elevation, and anti-inflammatories. Again, your doctor can help you understand the best course of intervention.
A: Assess the response of your intervention. Are you improving? If so, continue conservative treatment. If not, see a sports medicine or orthopedic physician for additional options.
P: The positive result. After your intervention, your ankle is healed and you are back to your normal activities without limitations. From this positive state, you might also have learned more about your body’s limitations, ways to prevent future sprains, and exercises to strengthen your ankle or adjust your stride.
There are no easy answers or quick fixes, but if you try to apply this “reverse the pain” model the next time you struggle with pain, it will help you become more systematic and effective about processing, recovering from, and growing from that painful experience.
How to Approach Your Pain
Apply a methodical approach to managing your pain. When science fails to give you a complete explanation for a phenomenon, rely on observation. After repeated observation, take what you see and construct a model. With the help of your doctor, you can take that model and test it to see if it holds true in practice. Together, you can study the results of your trials and use statistics to see if there truly is an effect and, if so, how powerful it is.
As Eckhart Tolle suggests in A New Earth: Awakening To Your Life’s Purpose, say to yourself, “Here is the pain, and here are my thoughts around it.” You start to put the pain in perspective.
I would encourage you to find the sources of pain in your own life experiences and learn from them. Reversing the pain can facilitate this process. We know that withdrawing reflexively from a painful situation may confer a survival advantage and is an automatic reaction. According to Isaac Newton, every action has an equal and opposite reaction. In a way, pain is a force of nature, causing you to reflexively back away from a bad stimulus in proportion to the size of that stimulus, keeping you safe. Taking this same reflex and using it to consciously channel painful experiences into something meaningful will, over time, produce an automatic reaction. This feat will require some adjustments in how you consciously (and perhaps subconsciously) process pain, but the resulting learned mechanism will contribute heavily to your survival as a human being.
For example, anterior cruciate ligament (ACL) tears are a common sports injury. The pain from an ACL injury alerts the athlete to a problem. Surgical repair is performed. Knee rehabilitation occurs post-operatively. The knee heals.
Pain is an important part of every step of this healing process. The knee hurts and reminds us we can’t go running or resume sports right away. Much like the pain of a healing ulceration or laceration, pain reminds us not to touch the area; if we get close, it hurts, and we back off. Pain protects you from the risk of an infection or increased scarring in this case. Pain is a helpful reminder not to push ourselves too early while an injury is still healing, or we can potentially worsen it or set ourselves back.
Pain, Inflammation, and Peripheral Sensitization
We now know that there is a clear link between pain and inflammation. In fact, the nervous system, including pain, and the immune system, which causes inflammation, coordinate their activities. When bacteria invade your body, they can directly cause pain when their work is detected by nociceptors, pain-sensing neurons. The immune system can also detect these invaders and respond by coordinating cells to fight them off. Both immune cells and sensory neurons lurk near the places bacteria commonly invade, ready to pounce when the nervous system sounds the alarm. The result? You guessed it: inflammation.
Peripheral sensitization occurs when the pain signal from the injury is amplified, driven by ongoing pain and inflammation. To explain this, think of an infected tooth, causing your entire jaw to hurt. The pain signal affects a larger area than just your tooth as a result of peripheral sensitization. The way this works might graphically look something like this:
Two important aspects contributing to peripheral sensitization are pain and inflammation. In particular, the two effects feed into each other, which I believe forms the circular feedback loop that drives this phenomenon. If the injury heals, then things return to normal in most cases. But in some instances, persistent pain causes wind-up, leading to central sensitization, which is how the body adjusts to the perception of ongoing pain. (For more on wind-up and central sensitization, see Chapter 1.) If your body is warning you of an ongoing injury, it will continuously sound the alarm, whether or not it is warranted. If your body senses that you will ignore the alarm, it will lower the threshold for the alarm, so with time, even the slightest pressure will elicit a painful signal. In effect, the pain alarm will become more sensitive, and you will become more sensitized to certain movements or stimuli.
To help explain wind-up and central sensitization, I will use an interesting case reported by D. W. Wheeler, et al., regarding a female patient with CIP. She became pregnant and, during childbirth, sustained multiple pelvic fractures. This meant that a C-section became necessary to prevent injury to herself or her baby. Due to injuries sustained during this fraught delivery, including injury to a nerve root in her spine, she began to experience pain for the first time in her life. Skin testing was used to determine her thresholds of sensitivity. This revealed that she was 10 times more sensitive to sensations than she had been prior to her pregnancy. Wind-up had dramatically restored the patient’s ability to feel pain.
Clearly, the nervous system is adaptive and can change. We call this trait neuroplasticity. Consider that wind-up was able to restore pain to someone previously incapable of feeling it. This should give you some sense of how excruciating wind-up can be for a person experiencing a ten-fold (or more) amplification of normal sensitivity to pain.
Inflammation can be driven by pain receptors in the skin. Pain receptors can drive the body’s inflammatory response, directly resulting in itching and discomfort. In a recent study published in Nature, scientists shut down the pain receptors in the skin of one group of mice. As a result, the mice had a lowered immune response.
This discovery fits with the observations I have made about my own patients. For example, after surgery patients often experience a stress response, similar to peripheral sensitization, with an increased level of inflammation. When we aggressively treat pain postoperatively, there is less inflammation and, in my belief, better postoperative recovery. My surgical colleagues at Mass General would routinely observe that the patients with epidurals for postoperative pain seemed to fare better after surgery, perhaps due to attenuation of the stress response and less inflammation.
Pain and inflammation are like a healthy marriage; when working well together, they are acting synergistically to maintain and protect us from outside invasion or threats. When there is an imbalance or lack of coordination, both can escalate until a pathological pain state occurs.
To interrupt the feedback loop, I treat patients with a dual approach: First, I administer steroids, which are anti-inflammatories. Then I use local anesthetics to numb the pain. This treatment approach breaks the feedback cycle at two points, more effectively than using either agent alone.
If we learn from adaptive pain, then it can serve a valuable purpose. But if we let pain spin out of control, it can become maladaptive. In that case, the feedback loop conditions a person to feel the pain in the absence of a physical cause. This poses the question: Can maladaptive
