The Bad Rap on Inflammation- Part 2: The Orthopaedic Groundhog Day

This is the big picture on inflammation, orthopedic inflammation that is.

Many, actually most orthopaedic non-trauma related inflammatory issues are mechanical problems first that create a normal inflammatory response. You might not be getting better because you are treating the wrong thing, the inflammation, and not the underlying mechanical cause which is unknown, undetected or being ignored.

Fix the mechanical problem and you fix the inflammation

This is where inflammation gets its bad name. If the inflammatory response is allowed to be recycled over and over as a result of recurring mechanical micro-trauma, then you develop an “itis”, which can result in annoying to debilitating problems and pain. These are the problems that can be elusive in diagnosis and often seem impossible to solve. They are definitely quality of life changers. This is often and generically referred to as chronic inflammation.

These are the ones that your doc or a friend or Google or Facebook groups keeps recommending treatment after different treatment and they don't work- there is no improvement. Just like in Groundhog Day, you keep waking up to the same problem day after day.

Of course there are identifiable, known abnormal types of external mechanical forces or repetitive movements that cause inflammation. We call this "overuse syndrome". This can be seen in the typist who develops carpal tunnel syndrome or the tennis player with a poor backhand stroke who develops tennis elbow or the runner logging way too many miles per week who develops knee pain. With overuse syndromes we treat the inflammation to palliate the pain and we “shut down”, or modify, the “overuse” activity (the cause) and the problem usually resolves. Then there is the inflammatory response to osteoarthritis or “wear and tear” type arthritis. This is a case where the underlying problem, the joint cartilage damage, is irreversible and the inflammation will typically get worse. Until surgery is required, treat the inflammation! What about inflammatory problems that result from mechanical imbalance issues that are subtle and not readily apparent?

The problem is your doctor

I am talking about issues like tendinitis and bursitis that just won’t go away seemingly no matter what we do. These are the problems that we doctors far too often do not know or don’t care to ask the question “what is the underlying root cause that is creating this inflammation?” Inflammation does not just appear by magic! For example, elbow problems (ulnar collateral ligament) in MLB pitchers are due to acceleration issues in pitchers attempting to retain their pitch speed. Is this all there is to it, just some dude trying to throw harder, or is it a compensation resulting from poor shoulder mechanics or even lower extremity mechanics as the source of velocity loss? Fix the real problem causing the compensation--the shoulder—and the elbow at least has a chance to fix itself or be prevented. Cause and effect! Let it go too long, treating only the elbow, and the result will be Tommy John surgery. This kind of subtle mechanical imbalance is where your physical therapist and athletic trainers are particularly valuable. Sure, they manipulate, massage, crank, and dig on our bodies to great effect, but their skill in knowing and detecting the subtle remote, seemingly unrelated mechanical imbalances is where they really shine. Determine the cause and you can effectively solve the resulting problem or the “-itis”. Really! This is where we docs can screw it up. The primary cause is not known or detected, so we “blindly” treat only the end result or inflammation. The "problem" exactly where you are pointing. And this happens all too often. We can make you feel better by treating the inflammation (with ice, rest, NSAIDS, etc), at least for a while. However, the inflammatory process rages on because the primary, root cause problem is not addressed. Now you have the orthopaedic version of Groundhog Day. Only treat the inflammation and you will usually lose. The next time you are told you have a chronic inflammatory problem, such as lower back pain, Achilles tendinitis, greater trochanteric bursitis, etc., ask yourself, ask your doctor, or, maybe best, ask your trainer or PT what the hell is really going on here. Just make sure you listen.

Maybe the problem is you

Sorry to point this out, but you are often part of the problem. Here is the thing, we might know the underlying cause, but it is not so readily apparent to you. And you might not like the answer because, after all, you’ve got a serious problem that we fail to fully comprehend, and in today’s instant gratification society you just want us to make it go away so you can move on. You coerce and beg for more. Go ahead and symptomatically treat the inflammation with NSAIDs, injections, immobilization, rest, etc, so you can feel better now. But don’t stop there, especially when you’re feeling good, because your real problem is not gone. Here is my recurring problem. The gradual, somewhat inevitable tightening of the calf is THE singular cause of greater then twenty problems in the foot and ankle, the majority of patients who come to see me. To name a few, these would include plantar fasciitis, Sever’s disease, insertional Achilles tendinosis (Haglund’s), night calf cramps, Charcot midfoot arthropathy, 2nd MTP synovitis and subsequent hammertoe formation, and posterior tibialis tendon dysfunction. Lengthen the calf by surgical means, or better yet, lengthen the calf by stretching and these problems are solved because the “unknown” mechanical problem is reversed. Stretching calves is not sexy and it takes time and effort, but it works! So, here is my point. When we tell you to stretch your calves to fix your plantar fasciitis or strengthen your core for your back pain or to strengthen you shoulder external rotators to fix your shoulder impingement, listen and do it. No matter how illogical or disconnected the exercise might appear, it might be just that simple and it might be all you need to do to solve your real problem at the source: your bad mechanics.

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