What causes chronic injury?
The two most important factors are not resting properly and underlying anatomical risk factors that (along with poor technique) may have predisposed you to injury which contribute ongoing stresses that enable the injury to persist. There are additional factors to inadequate rest that can make up poor rehabilitation to cause chronic injury, but I think that adequate rest is a prerequisite to correct rehab. The third factor is reinjury.
Missing the ‘healing window’.
With an overuse injury there is a window of opportunity immediately following the onset of the injury when rest is most effective. If you miss this window then you are more susceptible to a downward spiral of re-injury and secondary injury which results in a chronic injury and even osteoarthritis in joints.
Apart from persisting with overusing and misusing the part, these are some possible reasons why you may miss the healing window;
Lack of prompt access to medical expertise
You may not be aware that you have an overuse injury. This is where having access to medical expertise that can give you an accurate and quick diagnosis is important. Unfortunately this is not always or, dare I say, seldom possible. This can be due to cuts to services and increase demand on services, having a psychiatric diagnosis, and misdiagnosis by physiotherapists.
- Psychiatric diagnosis
I mention ‘psychiatric diagnosis’ as a barrier to accessing medical expertise because too often GP’s dismiss the physical complaints of people with psychiatric diagnoses and simply attribute any physical health concerns to the psychiatric diagnosis.
- GP’s (General Practitioners)
GP’s are the first port of call if you have an overuse injury and this is where things can start to go wrong. GP consultations often only last for five minutes. I have found that GP’s seem to be unaware of the existence of overuse injuries never mind how to treat and prevent them. This may be due to poor musculoskeletal training. In the UK there is something called the ‘triage system’ where your GP refers you to a physiotherapist who assesses whether you should be seen by a consultant. This further slows down the process of getting a diagnosis and knowing whether and how much you should rest. However, GP’s do support people by issuing sick notes.
Physiotherapists seem to be much better trained in treating acute than overuse injury. The basic treatment model that physiotherapists seem to adhere to is to use manual tests, rather than scans, to diagnose and then exercises to treat. These manual tests are not always accurate and correct advice is lacking in how to rest correctly and how to prevent overuse injury. In my experience they do not examine your body as a whole or take a complete history of how the problem started. In my case this has often led to a misdiagnosis or a non-diagnosis.
I have found that consultant hospital doctors are better at giving a correct diagnosis but physiotherapists, GP’s and consultant doctors rarely link up symptoms that are happening in different parts of the body and therefore miss out treating the big picture and getting to the root of the problem.
However I don’t want to generalise about GP’s or physiotherapists because I’m sure that there are plenty of excellent GP’s who are operating under difficult time constraints and also excellent physiotherapists who are also restricted by not having easy access to scanning.
Lack of awareness about overuse injuries
GP’s and physiotherapists are reflecting and perpetuating a general lack of awareness about overuse injuries within society at large. Health promotion campaigns focus on encouraging people to increase their level of activity without giving advice on safer exercise. The general message given is that the more you exercise the better and the risks are not highlighted. ‘Stop Sports Injuries’ www.stopsportsinjuries.org is a rare example of a campaign to highlight the risks, however there really needs to be a ‘Stop Exercise Injuries’ or even better ‘Stop Overuse Injuries’ campaign because many people won’t associate the exercise they undertake or the activities they undertake with sport. Public health messages are often quite simplistic and don’t want to scare people away from exercising and this is probably why currently they omit any mention of overuse injuries. However, this will change in the same way that a few years ago concussion in sport was dismissed and is now taken much more seriously.
Part of the problem may also be in the language that is used, e.g. the term ‘Repetitive Strain Injury’ is used exclusively for injuries to the upper limbs caused by computer usage even though every part of the body can experience a repetitive strain injury so therefore the term wrongly implies that you can only have an overuse injury in your upper limbs and that the injury is caused by too much computer use. As mentioned earlier in this website the term ‘Overuse injury’ is not accurate and should be replaced by ‘Misuse injury’ because overuse is only one aspect of what causes the injury.
Difficulty in taking sick leave
Sometimes it is not enough to try to rest by simply modifying one’s activities e.g. if you have injured your limbs you may need to move around much more than you realise when you are work. This is when it is essential to take sick leave.
The problem with taking sick leave arises due to pressure from employers to encourage employees to go to work when they are not well. This pressure can be harder to deal with when you do not have a prompt and accurate diagnosis that enables you to know if rest is required and to give a simple and adequate reason to your employer as to why you need to rest. An overuse injury is not something that leaves you bed ridden or in agony so it is tempting to go into work. This can mean that you do not adequately rest an injury and it becomes chronic. This can actually lead to further injuries which will probably necessitate taking much more sick leave later on as well as reducing your productivity at work.
Lack of pain
The human body is not always good at giving us information when we damage ourselves. This is particularly true for cartilage injury because cartilage has no nerve endings to transmit pain messages. So it is possible to have a severe cartilage tear and not feel much pain which will mean you will be less likely to take sufficient rest to recover from the injury.
When faced with a new injury it can be tempting to just brush it off because having to rest or seek medical treatment can be stressful and inconvenient. This can then result in an acute overuse injury developing into a chronic one.
Underlying risk factors
The underlying anatomical risk factors that (along with poor technique) may have predisposed you to injury may also contribute ongoing stresses that enable the injury to persist. This is why it is essential that you change the risk factors that you can control. Avoiding overuse and adopting the correct technique are the two things that are within your control and which together form a powerful combination. You will get a lot less benefit if you just focus on having breaks and avoiding overuse without also being vigilant about your technique and taking other steps such as using the right equipment.
If you reinjure a part of your body this be because you are repeating behaviour that makes you susceptible to re-injury or the previous injury may be connected to a vulnerability associated with a genetic vulnerability. Of course, often these 2 factors combine to create a reinjury, which in my experience is always worse second time around and can become a chronic injury.