The importance of triggers in injury recovery
At EVOLVE Flagstaff, one of the most important but often under-appreciated concepts that we review with every physical therapy patient is what we call “Pain Triggers.”
Pain triggers are movements, positions, or activities that place force or load on a painful or injured body structure.
Before we dive into an explanation of triggers, let’s back up and ask a fundamental question
What causes most pain or injury to arise?
Answer: Too much load or force, applied to a structure of tissue that is not able to handle it.
We’ll explore two imaginary scenarios:
Scenario 1: This concept is easy to understand with an acute injury, like a bruise or ankle sprain. Imagine that you bump your elbow, hard, against the corner of a counter top. You really smack it good. It swells up a bit, throbs, and a bruise develops. Or, imagine that you step on a rock that moves unexpectedly, you slip, and all of your bodyweight comes forcefully down on your ankle as it rolls. Ouch! These are examples of a large amounts of force, applied to the ankle or elbow quickly. The tissues cannot handle these forces, and the result is an injury.
Scenario 2: But we can also get pain or injury if we apply lower levels of force, repeatedly to a certain body structure. Let’s use the above scenario but make it less extreme. Rather than smacking your elbow really forcefully against that counter, imagine that you bump into it rather lightly, but you keep doing it, over and over. It doesn’t hurt the first time, or the second time, and maybe not even the twentieth time. But at some point, it’s reasonable to expect that if you don’t stop bumping your elbow, swelling, bruising, and pain will likely develop.
The same with your ankle: let’s imagine that for some reason you decided this morning to walk on the outside edges of your feet, rolling your ankles slightly with every step. You might imagine that at some point during the day, your ankles will start to hurt, right? Conversely, you could imagine that if you don’t stop bumping your elbow or walking on the outside of your feet, things will get increasingly more painful and sensitive, and you might risk a more significant injury. Eventually, the force that you are applying to the tissues of the ankle and elbow will exceed what they are capable of handling.
In Scenario 2, pain is caused by a lesser degree of force, applied to the elbow or ankle repeatedly over time.
This returns us to our discussion of triggers. In Scenario 2, the “trigger” is obvious: bumping your elbow against the counter, or walking on the outside edges of your feet. Stop doing that, and you would expect that your pain would resolve fairly quickly, right? Right.
While this might seem silly and simple, it is a HUGE concept for recovery in physical therapy, because the majority of pain and injuries, even if complex, are just like the second scenario, but with triggers that you are unaware of.
Flare ups of pain throughout the day are often caused by repetitive movements that are inadvertently placing repetitive force on your area of pain. They can be difficult to identify because they are often not immediately painful in the movement. They might seem innocuous, just like lightly bumping your elbow against a counter, or taking a few steps on the outsides of your feet. That doesn’t hurt at first, right? But the pain builds over time and repeated exposure. After you do it over and over and over, even the lightest tap might start to become very, very sensitive.
It is important to note that triggers typically are not inherently bad or dangerous. They often are fairly normal movements that the body can handle without much of a problem. But, we find that many patients are either unaware of their triggers, or are “stuck” in a certain way of moving that makes it initially difficult for them to modify the triggering movement. For example, rounding the lower back while bending forward is often a trigger for patients with lower back pain. We regularly find that these patients simply don’t know how to move in a different way, such as with a hip hinge, and are unaware that they are indeed rounding their back all day, every day. Rounding the back is not inherently “bad,” but it can become a trigger if you struggle to move in other ways.
While we do treat acute injuries at EVOLVE Flagstaff, the majority of our physical therapy patients come in with longer term pain, with injuries that have not healed on their own, or with injuries that have failed to heal with other treatment approaches. These are the cases where investigation of triggers is most important. We have seen instances where a patient may have tried all of the appropriate treatment strategies, but because they did not identify triggers, pain persisted.
While there are other important elements to our physical therapy process, identification of triggers is an essential step, especially early in the process. Quite simply, we need to stop bumping into the painful thing and give it some space to heal and recover. So, within the first physical therapy session, we aim to identify:
The pain generator or diagnosis – what is hurting?
Key triggers – how are you inadvertently bumping into the pain generator?
Trigger alternatives – We teach you how to move differently to avoid your pain triggers
Triggers are typically very individual to you, your daily routines and activities, and your pain generator. However, some two common themes are:
Holding the painful area under light compression for a long period of time. For example, sitting with your knees tucked under you can compress the patella tendon and be a trigger for anterior (front) knee pain.
Forcing a joint past its natural range of motion, often in an attempt to stretch. For example, the joints of the low back only have a few degrees of rotation, so repeated trying to rotate through the low back can be a trigger for many types of low back pain.
Finally, we should mention that as you progress through the physical therapy and recovery process, we want to help you to become as resilient as possible. This means that avoiding triggers, while essential, is not enough in our view. We also want to strengthen the body to be more capable of attenuating and adapting to forces placed upon it, so you are be less susceptible to your triggers in the future. If your triggers are an important or unavoidable part of your daily life, sport, or activities, we also might want to strategically re-introduce the triggers so that you can adapt to better tolerate them.
Consideration of triggers also allows us to appreciate pain for what it is: a message from our body, telling us to change something. Pain rarely comes about randomly or for no reason. Humans evolved to experience pain in order to protect our bodies from more serious injury or long term damage. Once you understand your triggers, pain can become less scary, and actually helpful, even if uncomfortable. If you understand your triggers, pain is no longer as mysterious. The pain is a message that says, “Hey, you just did your trigger again! Stop bumping into me!” This can give you an opportunity to move or act differently, and when you do that over time, these changes will start to become automatic.
If you are struggling with pain or an injury, we would love to help. We’ll help you determine an accurate diagnosis, explore your triggers, and create a plan to get you back to doing what you love.