How the Body Heals Itself Part 3: Remodeling Case 2: Remodeling Gone Wrong

“Simplicity is the highest form of sophistication” ~ Leonardo Da Vinci

There are a few common pitfalls with remodeling that I have observed. One of them is that the individual never makes it to remodeling. I see this happen when the tissues in question were subjected to countless boom and bust cycles in proliferation. Eventually the tissues do seem to pull past proliferation and an actual repair is laid. However, the repair is so tight and weak it can hardly stand any force at all. Worse yet, it has become chronically sensitized. And also, the regions around the repair have become tight, weak, and sensitive by proxy of misuse. Without proper intervention, I see individuals in this category resign themselves to “babying” the body part in question sometimes for the rest of their lives. Occasionally, they may use the area to the point of pushing it back into inflammation and then they are right back in a boom-bust. Or the inflammatory response that occurs is weak and not much happens afterwards.

This is a terrible situation, but there is a way out of this mess. And that is to start over. Through carefully executed exercise, or perhaps employing some dry needling, the effed-up tissues need to be loaded to the point of moderate damage, thus stimulating a solid inflammatory response. Read moderate damage. Large would be to the point that the person is in pain/inflammation for days. Small would be you don’t feel anything. Moderate means the person gets legitimately sore for at least a couple hours. What happens after said person gets sore is of utmost importance. They need to follow the protocol for the inflammation phase and the proliferative phase exactly. Read, no stymied inflammation and no boom-and-bust cycles! For more detail go back and read this entire series of blog posts again. The whole point of stimulating the tissues was to push them back to square one so that they have a chance to try again. The repair will never be as good as it could have been if you had done it right from the beginning but better integrity of the tissues is possible on the other side.

Another common mistake is that the individual does make it to the point of remodeling but then does not do it right or does not see it all the way through.  Maybe this person just doesn’t progressively load their tissues specific to their desired activities. Or maybe they do this for a while and then stop. This is the six-month mark in the clinic when people start coming in saying things like “well I guess this is the way it is now” or “is there surgery to fix this?” or something like that. I want them to know that there is nothing wrong with them in the least. They are just in the middle of a process.

I personally have been amazed recently with the progress of my right shoulder after suffering two glenohumeral dislocations in rapid succession about 18 months ago. I followed my own healing protocol to the letter and was clicking along with regular progress for months. I made it all the way back to my heaviest snatch weight and set a 10# personal best in the clean and jerk. My pressing strength and endurance was the best that it has ever been. I could knock out a handful of strict pull ups, some even with a weight tied around my waist. But every time I tried to do kipping pull ups, my shoulder gave me the signal that it was too much (felt unstable). I have to admit that even as the author of this blog, I thought to myself several times that I had hit a permanent ceiling. However, I kept working on pull up strength and mobility and then one day, I just felt so good I thought I should give kipping pull ups another try. So, I did. I busted out three sets of three really good ones all in row. My shoulder felt great the whole time. This is certainly not elite but it is progress. And now I have faith again. Who knows where I will be in another year.

The final pitfall that I would like to comment on is using passive modalities in lieu of the real deal. The real deal being progressive and specific forces, of course. I know that I mentioned dry needling earlier, and I fully believe that massage, cupping, needling, hot/cold therapy, et cetera has its time and place BUT these DO NOT remodel tissues. They make you feel good or attune your nervous system or potentially help stimulate an immune response but they don’t prepare to you lift heavy, go long, send it, or walk around the block (if that’s your fancy).

What does that? Good, old-fashioned exercise. The flashiest and most expensive physical therapists in town will make little money off of you. You won’t have cool kid cupping welts all over your body. And you will have to work hard and be diligent. But you will have truly healed.

How the Body Heals Itself Part 3: Remodeling, Case 1: Remodeling Gone Right

Remodeling gone right is all about progressive loads. A repairing tissue has to be exposed to a certain force or load so that it can adapt to that stimulus. This is accomplished by cells undergoing hypertrophy, aligning collagen fibers along lines of stress and depositing minerals in bone.  For example, a repaired Achilles tendon needs to be able to handle the load of standing and then walking before running and then sprinting and then maybe eventually landing a back flip on hard ground. Along the way muscles get bigger and stronger, the tendon itself gets tougher, and the bones achieve appropriate shape and density as they are “taught” to do so by progressively more difficult activity.

The art in remodeling gone right is considering every nuance of the forces applied to the healing tissue. When progressing an activity, one needs to consider how frequently it will be performed, with how much volume (duration, distance), at what intensity, and with what variability. All of these factors clearly contributing to the overall load. Typically, you make loads progressively more difficult in the same order the variables were listed above. In the case of the Achilles tendon, I generally would recommend that someone return to running three days per week (or whatever their goal is) before increasing the distance of the run. After said person has returned to their desired distances, now he can play with intensity in the form of hills and speed work. When this is sufficiently toyed with, we can consider other variables such as running on different surfaces such as increasingly difficult trails or shale. Or he can consider running with a pack or a more minimalist shoe. Et cetera.

The other part of the art in remodeling is achieving specificity. If you want to be able to do pull ups, you will not get there by pulling on cute little therapy bands below shoulder height all day. Sure, that could be where you start just to achieve a pulling motion but then that pulling needs to increase in angle and intensity until you can pull your body weight directly from an overhead position.

The most important piece of remodeling is those bolded words in the second sentence. A repairing tissue has to be exposed to a certain force or load for remodeling to occur. When a force is experienced, cells are stimulated to change. No force, no change. Progressive forces must be applied for the tissues to truly adapt. No exceptions.

So, the individual who has done remodeling right has gradually increased loads on the injured tissue in a logical fashion. He has waited until his body feels good, with no lingering soreness or pain before progressing a force. He has made the loads specific to his goals. He also saw the process all the way through to the end, achieving his desired outcome even if it took years to do. He may have plateaued a number of times, potentially for weeks or even months but he never once resigned himself to “good enough.”

How the Body Heals Itself Part 3: Remodeling

“He that can have patience can have what he will.”

~ Benjamin Franklin

This is the third and final stage in how the body heals itself. Even though someone has reached this last stage does not mean that they are on the home stretch. Indeed, this stage consumes the majority of the healing process beginning at the end of the proliferation stage (which is around week 2 or 3 after injury) and lasting up to two years in some cases. Many do not finish this stage, cutting themselves short of their true potential.  When done correctly, this stage is a beautiful showcase of all that the body is capable of and the magic that movement works on us from our cells up.

We can think of remodeling just as it sounds. When the foundation of a house is done, it is now time to put in the floors, siding and roof. Similarly, the outline of the tissue repair is complete after proliferation and now the strong collagen and other parts of the connective tissue are laid down in an organized fashion. Eventually you would remodel the inside of your home by breaking down walls to make certain rooms bigger or building additions as desired. The remodeling process works the same way as movement organizes tissues to be strong and flexible along lines of stress.

Movement is the key ingredient. The tissues only make adaptations in response to forces induced by movement. Some say “you are what you eat” and we could also quip “you are how you move”. Muscles get stronger, more efficient and bigger with use. Tendons and ligaments gain tensile strength. Even bones, which we tend to think of as being inert, change profoundly. Bones will not only change their density but will actually morph their overall shape to accommodate forces placed on them. The attachment sites of tendons to bones will get bigger as the muscles pulling on those sites get stronger.

The human body amazes me all the time but nothing is quite so awe inspiring as remodeling (in my opinion). Nothing gives me more hope than considering how adaptable the body is to its environment. We are resilient beings with a diverse array of untapped potentials. Only one of which is recovering from pain and injuries holistically. Change the environment, change the outcome. How lovely is that?

How the Body Heals Itself Part 2: Proliferation Case 2: Proliferation Gone Wrong

The one true mistake to be made in the proliferation stage is to give in to a cyle of booms and busts. For proliferation to go right, we must diligently build activity levels and carefully listen to the body’s signals for feedback on how we are doing. A boom-and-bust cycle is the exact opposite of this. When a person is not hurting or at least feels better, she thinks “I used to be able to do that activity, I want to do that right now!” Then she goes and does the thing that she is not ready for and subsequently gets super sore, painful and inflamed. Then she has to spend the next days or even week back in the inflammatory stage. When she finally feels better, she jumps for joy thinking “Oh I am really better this time!” and goes out and does something similar to last time, still without having built up to it. She gets sore and painful again and the cycle repeats indefinitely.  

As previously stated in proliferation gone right, no one appears to be completely immune to some amount of overdoing it during this stage. The difference between doing this right and succumbing to boom-and-bust cycles then is the severity of the overdoing it. The boom represents a large leap forward in activity. The subsequent bust is not just a day of being a little sore but requires that the person take days or even weeks of drastically reducing activity levels to recover.

The healing tissues consequently spend much more time in the inflammatory stage overall as they are repeatedly set back. This results in more scar tissue formation. Adjacent tissues can also be disrupted or sensitized by being exposed to the chemicals of the inflammatory milieu. When the tissues are not in the inflammatory stage, they may never get properly “trained” in flexibility and strength because they never experienced manageable loads that they can adapt to. Instead, the boom cycle that introduces unmanageable loads reinjures the tissues.

If boom and bust cycles continue long enough, the body can eventually solidify a shoddy, disorganized scar tissue riddled repair. The tissue repair in question is left sensitized, weakened, and adaptively shortened.  It’s not a great situation. However, do not despair if you are reading this and this sounds like something that you are doing right now or have done in the past. The sooner the individual can pull out of the boom-and-bust cycles the better. Also, there are ways to reboot healing and “start over” even with a disgrace of a repair.

Stay tuned.

How the Body Heals Itself Part 2: Proliferation, Case 1: Proliferation Gone Right

“Above all, do not lie to yourself. A man who lies to himself and listens to his own lie comes to a point where he does not discern any truth either in himself or anywhere around him, and thus falls towards disrespect towards himself and others. Not respecting anyone, he ceases to love, and having no love, he gives himself up to passions and course pleasures, in order to occupy and amuse himself, and in his vices reach complete bestiality, and it all comes from lying continually to others and to himself.”

~ Fyodor Dostoevsky

As previously stated, proliferation is the mort difficult stage of healing to get right. You no longer have a license for mostly rest as in the inflammatory stage. You absolutely must move to stretch and strengthen the newly laid tissue repair.  The new tissue is so delicate that it is way too easy to do too much and disturb the repair process enough to set yourself back (as in literally set yourself back into inflammation). I have never, I repeat, NEVER seen anyone through a rehabilitation process where progress was perfectly linear through this phase.

This leads us to our fundamental mindset during proliferation: mistakes are not failure, they are feedback. We must not run to a doctor every time we get sore searching for answers as to what is “wrong” asking for repeat imaging, pain medications and more diagnoses. When we pause to ask ourselves “how did we get here?” we will often find that we have re-introduced an activity or increased volume or intensity of a movement. Then it would make complete sense that the newly repaired tissue is simply sore (maybe really sore depending on how big of a jump was made) and it absolutely must take time to catch up and adapt to the new stimulus. You can think of this in a very similar way to how we would make progress in fitness. I must be able to hike five miles before I would think to hike ten. The first time I did a new, longer, or steeper hike I would expect to have some soreness in the lower body. The only difference when recovering from injury is that the soreness can quite often can be more painful than bland discomfort and potentially last longer with more symptoms of inflammation.

So, the fundamental task during proliferation is to pay attention to your body and your actions. During recovery, we can be blown away by how little we can do to set ourselves back. “All I did was work a regular day!” Sure, and that probably represents a huge increase in activity for all of your parts compared to what you were doing during the inflammatory stage. Even if you were mostly sitting, that still is a way to load your body (especially your spine). When setbacks happen, as they inevitably will, the best thing to do is revert back to your plan for inflammation. Simultaneously take mental stock of what led you to that point and then use that data to inform your decisions and activities in the coming days after the soreness/inflammation has resolved. For example, were you moving and even lifting light weights below shoulder height and then started moving your shoulder overhead when pain returned? Maybe you need to re-introduce overhead shoulder motion in a modified way where you can minimize gravity. Or maybe you simply need to start with fewer repetitions. Have you been able to walk 10 minutes on your healing foot without issue but then tried walking 30 minutes and this made you sore for two days? Well, you may need to make smaller increases (maybe even five minutes at a time), or increase frequency first (three 10-minute walks per day), or change the surface you are walking on for the time being.

This is the art of the proliferation phase. It may seem easy but it’s not. This stage also takes a lot of patience and self-restraint. You are not hurting at rest and it is easy to just do something “normal” without thinking about how or if you have meticulously built yourself up to that exact thing. In my opinion, this is why physical therapy exists as a profession. Even in incredibly healthy, capable people, this stage is difficult to navigate. Get a good guide. That’s what we are for.

The perfect proliferation phase is one where a person is consciously re-introducing movement in a graded and logical way. They start with the absolute basics. At first, they are not afraid to undershoot their activity levels. They may end a physical therapy or exercise session or day feeling like “I actually could have done more” as opposed to “I am devastated, painful and sore”. When they do overshoot, they remain calm and return to their inflammation protocol. After inflammation/soreness have subsided, they resume activity slightly below where they left off. Then they plan to take a smaller next step. They wait to make that step only after spending a few days back being active and feeling great at their current level.

This stage might feel long and frustrating. Another motto that we could use here is “go slow to go fast”. The more you pay attention and adapt as necessary, the better it will go.

How the Body Heals Itself Part 2: Proliferation

After inflammation comes proliferation. During this time, the foundation of the tissue repair is laid.  Cells surround the area of damage and make new, immature cells that become the repair. The collagen that is laid down at this time is an immature, weaker type called type III collagen.  The body is not too worried about organization and perfection at this time. Rather, the new cells and fibers are produced quickly and distributed randomly. One could even say that the cells are proliferating (get it?).

The proliferation phase is most likely to occur between days 4 and 24 following tissue injury but could take longer than this depending on the extent of the injury and whether or not the individual takes appropriate care. We will know that we have entered the proliferation stage if pain is no longer constant and the cardinal signs of inflammation such as redness, edema, and heat have greatly or completely dissipated. The hallmark of the proliferation stage is pain that is not constant but will be produced if the site of injury is subjected to any mechanical force or load that the infant tissues are not ready for yet. When the disorganized, novice tissues are loaded beyond their capacity, they will revert back to an inflammatory state in order to repair the damage that was caused. This will result in pain or soreness and possibly swelling.

I believe that the proliferation stage is the most difficult to navigate. Setbacks are common as it is easy to accidentally overload the delicate tissue repair. Leaving the healing tissues alone is no longer an option as they require mechanical loading to organize and strengthen cells and collagen fibers. We now have to walk a narrow path finding the just right amount of movement. Not too little, not too much, but just right. A target that I like to call “The Goldilocks Zone”.  A series of blogs to follow will explore how we find this zone, what can go wrong along the way, and how we eventually get to the other side of the proliferation phase.

How the Body Heals Itself Part 1: Inflammation Cases 4&5 Inflammation Gone Wrong

“If we could begin to see much illness itself not as a cruel twist of fate or some nefarious mystery but rather as an expected and therefore normal consequence of abnormal, unnatural circumstances, it would have revolutionary implications for how we approach everything health related.”

~ Dr. Gabor Mate

“He not busy being born is busy dying.”

~ Bob Dylan

Case 4: Unhealthy inflammatory response such that inflammation is much greater than what is needed

One example of this is an allergic reaction. Some relatively benign substance such as a peanut or bee venom enters the body and the body interprets it as foreign and threatening. An inflammatory process is launched and the body brings a bazooka when it really needed a tac hammer or maybe nothing at all. This is at the very least disruptive (hives, gastrointestinal upset) or, at the very most, deadly (anaphylactic shock).

Next enter autoimmune diseases. A poorly tuned or hypervigilant immune system starts a program of inflammatory shock and awe in one or more systems of the body in response to a relatively mild stressor or, apparently, no stressor at all. This immune system attack on the body’s own tissues causes damage. There is so much to say on the topic of autoimmune diseases that doing any more than touching on the subject is out of the scope of this blog. Also, I will not pretend to be the vetted expert who is worthy of writing a book on this topic. However, through my humble experience and research, I will endorse one fundamental truth that I wholeheartedly believe in. That is autoimmune diseases are absolutely curable. Ok so if your joints have become permanently deformed from rheumatoid arthritis that may not be fully reversible but, the disease process itself, I fully believe to be stoppable. If you google any autoimmune disease, webmd will surely tell you that there is no cure and that it is a lifelong illness. How fatalistic. Instead of telling people that they are destined to live a life of pain and suffering while also becoming dependent on medications they should be linking to a plethora of resources from outside-the-box thinkers who are making incredible headway with regard to autoimmune diseases. Dr. Terri Wahls is one example. She had such advanced multiple sclerosis that she had to use a power wheelchair but then returned to walking and riding a bike after completely reversing the disease with diet and lifestyle changes (you can view her TedTalk here: https://www.youtube.com/watch?v=KLjgBLwH3Wc). Or Dr. Gabor Mate who wrote a very insightful book on the cost of hidden stress and autoimmune diseases (When the Body Says No). If you believe that you can get better and you are determined to get better then it is possible. That’s all that I have to say.

One last situation where there is poorly tuned inflammation is in, oh yeah, basically every single human being living in the modern world. There is clearly a spectrum here but most everyone I see has some amount of immune dysfunction. This can show up in the form of generally achy joints, poor digestion, inability to lose stubborn belly fat, painful menstrual cycles, brain fog and etc. One symptom that I see show up repeatedly is a large, painful, hard nodule on the Achilles tendon after a moderate amount of walking and no other apparent reason. What gives immune system? Why would you overreact as such? Well, in my opinion, a dysregulated inflammatory response may be due to any of the following (although this is not an exhaustive list): eating a Standard American Diet consisting of nutrient poor and processed foods loaded with highly processed fats and carbohydrates, poor blood sugar regulation, excessive consumption of sugary/caffeinated/alcoholic drinks, poor sleep, a sedentary lifestyle, performing exercise only in the form of begrudgingly slogging out minutes on a cardio machine, never laughing or having fun, not spending enough time in natural light, not spending enough time or any time in nature, not being exposed to microorganisms necessary to form a healthy skin or gut microbiome, being overly exposed to chemicals used for cleaning/sanitizing or otherwise just on literally everything we eat off of/wear or otherwise use, literally taking hormones that alter our natural rhythms that are marketed to us as contraceptives, being lonely, not having enough physical contact with other people, not being loved as a child and/or suffering abuse as a child, or other forms of chronic stress Sound familiar?

Anyways, knowing that any of the aforementioned can result in less-than-optimal immune attunement, it really is no surprise that everyone’s inflammatory response is a bit, you know, messed up. I don’t think anyone in our culture has quite the ideal “inflammation gone right” scenario that was mentioned in the prior blog. The ideal inflammatory response is swift, precise, and concise. Essentially, gets to the right place at the right time and does the job as called for without lingering. I would say most of us don’t have this process so finely tuned. This is why inflammation has earned a reputation as “the enemy.” But now that we have really explored what inflammation actually is I hope that you agree that inflammation is not actually the problem. Our lifestyles are.

Case 5: Unhealthy inflammatory response such that inflammation is much less than what is needed

I feel like this category rarely gets mentioned but it definitely deserves its own space. I rarely see anyone who I would put in this category anymore but I did have the opportunity to observe it frequently and thus designate it as its own classification of inflammation gone wrong when I lived and worked in Eastern Washington state.  During this brief stint in my history, I often worked with people who used heroin. People who routinely use heroin are very interesting. They often times hardly eat anything, and if they do, it is total junk. Most of them hardly drink any water. They don’t sleep regularly. Most of them don’t groom or bathe at all. Many of them are incredibly entertaining storytellers. They are so intent on using heroin that they will inject themselves in an already infected wound rather than go without.  These are people who are so chronically malnourished and stressed in every way imaginable that there are simply not enough bodily resources available to get the healing process started let alone completed. Inflammation is actually a very energy intensive process and we must not take it for granted. I think that cases in this group often get chalked up to be chronic inflammation greater than what is needed (see above). However, upon second inspection, I see that the inflammatory response was always quite puny and is getting drawn out while simultaneously very little healing is actually happening.

One case I want to highlight from this category was a woman that I worked with who had a total knee replacement at a young age. After her surgery her knee never really became swollen. It was edematous and painful but that inflammation just looked like a bunch of fluid unlike what I would typically see. Her knee remained in this condition for months never moving fully into or out of the inflammation stage. I inquired about her lifestyle and learned that she subsisted on of a steady diet of coffee, Mountain Dew, cigarettes and gas station snacks. Unfortunately, she was not open to changing her lifestyle even though it was so poor that any change including accidently swallowing a bug would have been a boon to her physical body at that time. Her poor health status was so apparent to me that I was shocked when she and her doctors started to grope for any possible answer as to why she was not healing as expected. She kept saying that something had to be “wrong” with her knee replacement and indeed her doctors agreed with her which was either to placate her or because they too were oblivious as to why this was happening. We’ll never know for sure. She had more doctor’s visits and underwent extensive imaging studies. They never found anything of note. It blew my mind that it never occurred to anyone that she was just too unhealthy to heal properly. Who knows, she may have been just one well rounded meal and a good night’s sleep away from feeling so much better. So simple yet so much money and time were poured into trying to finding out what was “wrong” with her.

Maybe if everyone was required to do an internship with heroin users, they would inoculate themselves from surprise to such a degree.

How the Body Heals Itself Part 1: Inflammation Cases 2-3 Inflammation Gone Wrong

“Man is free to choose not to be conscious, but not free to escape the penalty of unconsciousness: destruction.”

~ Ayn Rand

Case 2: Healthy inflammatory response that plays out such that it results in more tissue damage.

There are some instances where the body mounts a healthy inflammatory response and it is just too much. One example of this would be compartment syndrome. I have only observed this one time my career. The person was an elite rock climber who had just spent weeks in the desert putting up new routes. She had so much inflammation in her forearms that the pressure from the swelling was causing tissues to become ischemic (essentially dying from lack of blood flow). This was clearly a problem and needed outside intervention. I think in this case she was able to control the issue with anti-inflammatories but in other instances the person may need what is called a fasciotomy where a surgeon goes in and makes cuts in the fascia that separate the different compartments of the forearm (or lower leg) to release pressure and prevent tissue death. Some may disagree but I would argue that this was a healthy inflammatory response.  The amount of inflammation was proportional to the circumstances (essentially a crush injury from so much climbing) but, given the body part affected, it became a problem.

I would also put in this category cases where people undergo a very large surgery or multiple surgeries at once. Examples of this would include someone with multiple broken bones and maybe lacerated organs after a motor vehicle accident or someone with second- or third-degree burns covering substantial body surface area. This is not an area where I spend time in my practice but I believe what happens here is that the body mounts an inflammatory response that, although proportional to the tissue damage, can be just too big to handle without outside support. Anyways these situations are important to acknowledge to better comprehend the more typical “inflammation gone right” scenario, but they will not occur with your average injury.

Case 3: Healthy inflammatory response that is chronically stymied by activity, medication or another modality.

I find cases in this category to be quite common. This is the case of an everyday tissue injury that never gets a chance to go through the motions of inflammation because the process is chronically or almost constantly interrupted with activity, anti-inflammatory medication such as Ibuprofen or use of ice or massage.

Here is a fairly common example that may sound familiar to you. Our subject is recovering from a minor knee surgery called a meniscectomy (but this really could be any other injury). She is a go getter and does not like to take down time. She takes Ibuprofen every time her knee hurts. Sometimes this really does a great job of taking away any amount of pain that she has so she will then subsequently do all kinds of work around her house, mow her lawn or even go on a hike. Then, when the Ibuprofen wears off, the flood gates of her body’s inflammatory response open with a vengeance. She has kept her body from doing its job for too long and, additionally, she created even more tissue damage doing all of that activity while the pain was masked. Now her body has to deal with that too.  She is then miserable with pain and swelling, does not sleep well, and lies awake at night wondering what is wrong with her knee. Visions of additional surgeries and long complicated diagnoses dance through her head. The next day she is exhausted and can’t comprehend tolerating another hour in pain so it’s Ibuprofen down the hatch again. Eventually, after a few days of relatively little pain, she thinks (she hopes!) that she must be better so she goes out and does a normal amount of activity for her as before. The Ibuprofen is doing its job and she is able to get through it. Then that night she is miserable and in pain. Again.

In this particular case, this cycle repeated itself for almost two months. Every time this person came in to see me, we had a similar conversation. She would drill me as to “what was wrong” and “why can’t I just get back to normal?” My answers also sounded like a broken record as I refused to deliver any more technical sounding of an explanation besides that stages of healing were being interrupted. Then I would also beg her to stop taking Ibuprofen or at least to hold herself back from doing her normal activities until she had built up to it. Just when it appeared that we would be on this hamster wheel forever, someone told her that Ibuprofen put you at greater risk for severe COVID and she finally stopped taking it (I am not saying this is true or not, I am just relaying the story). Afterwards, she did have some pain in her knee throughout the day and this resolved in just three days. She got back to mowing her lawn and doing a full day of activity about a week later.

Many do this because they don’t see the terrible bargain they are making. In an effort to return to activity as quickly as possible and to avoid discomfort, they sign up for weeks or months of recurring pain and swelling. All this when the other option was a few days of pain and resigning one’s self to being laid up. I know what I would pick having seen each side of the coin and I do put this into practice regularly. Just last night I had a splitting headache that was so bad I didn’t even want to read or eat. I had been stressed earlier this week and I calmly took this headache as a sign that my brain needed to play catch up on some routine repairs that had been neglected. So, I just laid in a dark room trying to sleep for a few hours. Was this fun or comfortable? Absolutely not. But I am perfectly fine the next day, I anticipate not having recurring headaches and I am glad to suffer for a few hours as opposed to messing with my nervous system’s ability to heal itself.

I want to discuss one caveat here. Anti-inflammatories are a powerful tool. Humans are incredibly clever beings to have invented them. Is there a time and a place to use them? Perhaps. What if you are on the last day of a ski trip and it snowed a foot overnight but your knee is hurting? You might consider taking an anti-inflammatory to help yourself through. What if you got a headache right before you were about to go to Elton John’s last concert ever? This could be why humanity created Ibuprofen and it’s your opportunity to find out. What if you are a single mom and you broke your finger when you slammed it in a car door which only happened because you were rushing because you were late to take your child to her therapy appointment and it is right before finals week and you are one term paper away from graduating and thus bettering your life immeasurably but it is too painful to type? Maybe some Ibuprofen wouldn’t be the worst thing right now. What if something far less dramatic is happening but you hurt and you just can’t handle it right now? Man, I don’t know! I firmly believe that no one can tell you what to do. You are a sovereign being with the power to weigh the consequences of augmenting your bodily functions and experiences with your present goal.  It could only be up to you if it is worth it or not. My voice is here not to tell someone what to do or not do but to be informed about it. Go ahead, take anti-inflammatories, overdue on activity, ice yourself until you can’t feel anything. Only do this with full knowledge of what you are doing. You are messing with necessary functions of your body’s immune system and it will (not might, will) catch up to you later in one way or another.

Best of luck in your decisions. 

How the Body Heals Itself Part 1: Inflammation Case 1: Inflammation Gone Right

“Nature does not hurry, yet everything is accomplished.”

~ Lao Tzu

After the last post we know that inflammation is not a mistake our body makes but is a necessary and intricate process that we can love and understand. So now let’s spend some time thinking about what to do during the inflammatory stage of healing to enhance outcomes.

First, I want to talk about the fundamental mindset. When inflammation is present the distress level can be high and it is easy to start thinking that something is very wrong. However, if we ask ourselves the question “is my body’s response to injury a mistake?” this can refocus the situation.  It is time to dig your heels in and trust your body. Also part of our fundamental mindset is how we view pain at this stage. I think of pain not as a malicious byproduct of the situation but rather as part of the exquisite design. My body needs rest and time away from certain activities while inflammation is taking place and thankfully pain is there to tell me not to do things. Without pain we would certainly overdo and disrupt inflammation at work.

With this attitude we are ready to fully embrace the situation. What can we do now?  Really there is no magic potion at this stage. Our biggest job is to not get in the way of the work that our body is trying to do. Are you picking up on a theme of acceptance here? It’s not totally out of your hands though. There are things that you can do to help yourself and I have listed them below with categorical headings.

Nutrition:  Following injury or surgery, a body’s nutritional needs, especially for protein, increase significantly. Not only does the body need fuel and building materials to repair tissues but it also needs to keep up regular bodily functions and maintain our precious lean body mass. Although we should be doing this everyday of our lives, it is especially important to focus on drinking plenty of water, consuming enough protein and micronutrients and also avoiding processed carbohydrates and fats during the inflammatory stage of healing. My estimate for protein consumption is between 0.8 and 1.35 g/lb of body weight depending on sex and how active you are. I don’t believe we need to do anything fancy with micronutrients. Just keep (or start!) eating a rainbow of fruits and vegetables.

Sleep/rest: The body needs rest right now. Sleep is when the body does its best repairs so I recommend 10 or more hours of sleep at this time. Naps are good too. If pain is really getting in the way of sleep, bedtime Is when I recommend doing some pain control either with medication or ice. Sleep is too important to let pain get in the way for long.

Movement: As above, our biggest task is to not get in the way of the healing process. Rest is king but a little movement is good to maintain some fitness and keep bodily fluids moving. I believe movement works via other mechanisms during this stage as well. I am sure that gentle movement helps our nervous system to not “forget” about the injured area and thus prevent muscle atrophy and maintain all joint mobility that is possible. Also when someone loses a limb, part of their recovery is to spend some time looking at their new stump because just looking at it and touching it helps the nervous system accept the change. I think something similar happens even with much smaller traumas.  Doing some simple movement helps the brain “accept” what is happening and, I believe, move forward with the healing process appropriately.

The movement you do at this time should be very light such as doing submaximal muscle contractions or small joint circles around the site of repair. Some exercise or movements of the joints above and below the injury may be ok. If the injury is in the lower body and it is painful to walk, using walking sticks for assistance or just outright avoidance by using a wheelchair or other device should be utilized. For inflammation following injury to the upper body, walking can be an excellent choice to keep the body moving. Although you may quickly discover that you need to keep your walks short because of how much you actually use your arms when walking and also because you are more tired than normal. Again, rest is the top priority. Even walking can wear out an arm that is doing its very best to heal.

I also recommend that you never take any kind of pain medication or other analgesic before doing movement. You need the pain signal fully intact so that you don’t accidently overdo and harm the healing tissues.

Community/relationships:  This may seem like an odd category to include but I have grown to consider this to be just as important as anything else. In just seven years practicing as a physical therapist, I have seen too many people lose their connections to work, relationships, and recreation after slipping into a negative spiral even after relatively small injuries. Recovering from an injury or surgery can be a long arduous process. It takes an incredible amount of patience, discipline and mental fortitude. Especially in this first stage of inflammation, it can be isolating and depressing. Even if you start out with the best intentions, if you have to stay away from what is meaningful to you long enough, it is easy to lose sight of why you were trying in the first place. That is why I believe it is so important to make a conscious effort to stay connected to the communities that you are a part of while you are healing. Read conscious effort because it will probably be more difficult at this time and how you interact may look different especially if your community is based around a particular kind of activity. I also think this is a great time to focus on other work and hobbies that you are able to do. You may want to take the time to make a list of all of the things that you can do so that you can refer back to this when you are feeling down about being laid up. If you have a hand injury and can no longer play guitar maybe you can read or hike. If you can’t walk, maybe it’s time to finally learn to play guitar. Challenge yourself to make this into a good thing where you are growing as a person and not wasting away in front of a screen.

If you are brave enough to take this to the next level, now is a great time to ask yourself some deeper questions.  What can you learn from this injury? Were you overtraining? Were you not resting or not eating enough? Were there signs of injury looming such as soreness or pains that you were ignoring? And, if so, why were you not paying attention them? Did you get injured doing something that you truly enjoy? How important is it to you to be able to return to that exact activity or lifestyle after healing? Are there any modifications that you would make? Throw away the attitude about fate, genetics and factors “out of your control”. Look at this as thoughtfully as you can and it will be impossible to not takeaway some new insight. You may learn there is much in your power to change in the future and this could just be the best thing that ever happened to you. Finding meaning in being swollen and painful may even make you feel better in the moment. Or not. But I would still invite you to make this experience as worthwhile a possible.

Given the above in a healthy individual, inflammation should do its job and you will be out of this stage in about one to seven days (maybe more) depending on the extent of the injury. I do want to point out that even if we do everything right, we DO NOT speed up inflammation. We can optimize the inflammatory process and we can slow it down but it will not necessarily go faster. Inflammation has to happen and it will take time. We don’t get a free pass for being super healthy and following directions. We will know that we have moved out of the inflammation stage when pain is no longer is constant and the other cardinal signs of redness, swelling and heat have greatly dissipated. Then we move into stage two which will be the subject of a future post. But first we will stop to examine what happens when inflammation doesn’t go so well.

How the Body Heals Itself. Part 1 Inflammation

“No inflammation/ no repair is a valid dictum.”

~ Carrico et al 1984

Inflammation has become a dirty word these days. Anyone who braves the internet will see much to do about “fighting inflammation” and “anti-inflammatory” products. A quick tippity-tap or two into the old search bar will lend you list upon list of action steps and products (that you can buy!) to help you get inflammation out of your life.

This might surprise you but I am not in the fight against inflammation. I consider inflammation a friend not foe because I know that without it, we would all be dead later today and, if not, then very soon after. Turns out, inflammation is absolutely necessary for healing*. So, if a cut, scrape or break doesn’t get you then you woud certainly bleed out internally in the absence of inflammation as your guts are in a constant dance of inflammation and healing (this is why ulcers and gut bleeds are a side effect of NSAID’s but more on this later).  

To understand inflammation better let’s start with an easy example. Imagine that you are quite hungry and it is still morning time so you settle on a bagel to curb this crisis. It’s an everything bagel because that just sounded more satiating. At this point there is a large bread knife in one hand and a bagel perpendicular to the counter in the other. At first you have to press pretty hard with the knife because the bagel is so thick but then, suddenly, you hit that hole in the middle and your cutting hand is still applying the same amount of pressure needed to plow through the bagel’s thickest section. The knife hand moves at alarming speed while the other hand tragically slips on a poppy seed. Knife serrations meet your index finger and the deep parts of your skin feel the air before blood bubbles to the surface of a freshly minted flesh wound. Then a wave of shame passes over you because the first thought that comes to mind is if cream cheese can cover up the rich metallic taste of blood. This being your first thought as opposed to something less barbaric like “where are the band-aides?”. This saga did begin with hunger after all. Sound familiar?

In response to the damage, the body mounts an immediate response. Initially blood vessels constrict and clotting factors work to make a seal to stop further loss of blood.  However, blood supply to the area will actually increase shortly after as a whole host of special cells and proteins are delivered to the injured area. White blood cells enter the scene to clean up dead and dying cells as well as any foreign matter that may have entered through the cut. Chemicals that are released from the site of the damage create a chemical gradient to move the white blood cells right to the heart of the action. Plasma proteins will enter into the milieu some as antibodies and clotting factors and others as the building blocks for the repair that needs to be made. The increased activity and fluid to the area results in heat, redness, and swelling. The pain comes from increased sensitivity as the area is flooded with various chemicals. In short, it is exquisitely orchestrated, purposeful, and effective as well as uncomfortable as hell.  

Acute inflammation is completely necessary for healing. Depending on the tissue that is damaged, the repair process will have varying amounts of success. In the case of many tissues, the repair is regenerating the damaged tissue in likeness to the original tissue while other tissues are only capable of being repaired with scar tissue. Tissues that are susceptible to frequent damage and thus are well suited for repair and regeneration such as the skin, the tissues lining the gut and vagina, and other epithelial tissues repair quickly and regenerate in likeness to the original. Tendons, ligaments, fascia and bone also repair in likeness but are slower to heal.  Damage that occurs to cartilage, cardiac or smooth muscle, certain organs, glands and large wounds involving multiple tissues will repair as scar tissue or at least some amount as scar tissue.

Another point I want to make about inflammation is that it does not just occur in the case of overt trauma such as a laceration, fracture, strain or burn. Inflammation can also result from repetitive or chronic overuse of a tissue in the absence of a discrete injury. Actually, inflammation can show up just from an increase in activity or when starting a new activity. That’s right kids delayed onset muscle soreness is really just inflammation trying to make repairs to those muscles and other tissues that you beat up on your first run back in a while.

Ok so the signs of inflammation have dissipated and you were able to consume that bagel albeit gingerly with the use of one hand. Are you all healed up now? No! Of course not. Inflammation was just the beginning. What comes next in the healing process will be covered in the subsequent parts of this series. Next, however, we will take a pit stop to explore what happens with inflammation in a few specific scenarios. Inflammation is a big topic after all and we will linger here to discuss more about the nature of inflammation and to reflect on how to live with it gracefully.  

A Note on the Intent and Ethics of this Blog

“All that we really need to solve the problems of our society is more people engaging in short form discourse on their behalf on the internet and social media.”

~ Said no one ever

“Come on children, you’re acting like children

Every generation thinks it’s the end of the world

All you fat followers, get fit fast

Every generation thinks it’s the last, thinks it’s the end of the world.”

~ Jeff Tweedy

I have been thinking about starting this blog for some time now but I keep starting and then stopping myself. The motivation is there but a moral question is looming. What good or, more importantly, what harm can come from publishing your thoughts on the internet for all to see? Why even bother asking this question when you are perfectly free to do it? Do I really suppose that enough people will even happen by these words that any impact could be worth consideration? Taking the pause to answer these questions could be futile but my nature does not allow me to proceed without acknowledging this dilemma. Call me overanalytical and neurotic if you must (you wouldn’t be the first) but I can’t just start any project, no matter how obscure, without thinking it through.  Words have meaning. Even letters have meaning. I can list a small chunk of the alphabet after my name and hopefully these titles represent something. I would want them to signify an unwavering commitment to truth, acquisition of knowledge and excellence for example. Indeed, everything means something until we use it so carelessly that it doesn’t anymore. And that is exactly what I intend to be conscious of here.

The idea for this blog was developed over the past three years through observations in my physical therapy practice. Unlike past work environments (you know, jobs) I am now fortunate to have supportive and competent administrative help, natural lighting, good equipment, plants everywhere and, above all, an abundance of quiet. It’s really just me in there. Me and my patients and the silence in between. With everything taken care of just so, I am free to listen and what I have heard is the best teacher of all.

There is one recurring theme of particular interest to me. I am continually amazed by what my patients already know. They come in already having tried exercises that they found on TikTok. They tell me exact details about when their tendons should be “healed” according to such and such website. They know that they want to try one type of treatment because a friend/co-worker/doctor/influencer told them that it “fixes” such and such problem. And sometimes they just know that they “have bad ankles” because their mom did too and the doctor said that is just the way it is.

There is a lot to love in this situation. I am glad that people want to be independent. I appreciate that they are self-starters who are motivated to find answers. I love that there are multiple ways to share information and that all are free to do so without censorship. The problem, as I perceive it, is that there is so much information available it’s impossible to know where to donate our attention. Should we do the back exercises in the first blog that comes up or the tenth? Or the two hundred fifty third? Or the ones that Uncle Ron said worked for him? Or the ones that Beyonce does? I know that you know what I mean. Not only is there an overwhelming amount of information available to us but the delivery is quite often too short and completely out of context. What good is a hack or tip without a foundation of knowledge to guide us in knowing where and how to implement it? Depending on the situation, the answer could very possibly be that it is of great benefit. Or it could be misleading, invalidating, confusing or just downright meaningless. It really just depends.   

I know that I am not the only one who believes that the chaotic distribution of information is one of the greatest and gravest problems of our time. And such a tremendous problem affords us with an incredible opportunity. Do we deny this problem or retreat into hermitage? Or wallow in it or even carelessly contribute to it? I hope not. I believe that what more of us need to be called to do is to take on as much responsibility as possible, to share the truth, the whole truth and then humble revisions of our truths with careful intention and clarity. So help us God.  

The intention of this blog is to shoulder some of that responsibility. I want to share with any readers what I consider to be the fundamentals on injury, healing, pain, and movement. I want to give people a framework for understanding their own bodies that takes the mystery out of deciding what to do to help themselves. I plan for this blog to be straightforward, slow, thorough, honest, unapologetically esoteric at times, and completely lacking in any desire to sell goods or services. I will focus on the topics that come up over and over again in the clinic. The stuff that is timeless enough that it will not go out of style next year or possibly ever. This could be way too much to promise but what I would really like to do is provide the background for anyone such that they never feel the need for an anxious and desperate internet search. Or at least almost never. Does that sound nice? It does to me. I will now get going on my end of the bargain.