YOU ARE BUILT WRONG
If you’re reading this, the chances are high that you have experienced some type of pain or injury as it relates to trauma. If you’re my sister you have dropped a dumbbell on your toe. If you’re like me you have shut your finger in a car door. You likely have even experienced pain and injury as it relates to movement and your favorite activity. If you lift weights maybe you’ve had lower back pain. If you run you likely have experienced some type of knee pain.
And when the pain lingers you ask yourself:
“Why am I hurting”
“How did I hurt myself”
Which means you want a diagnosis! If we get technical for a second a diagnosis is the determination of the cause or nature of an illness by evaluation of the signs, symptoms and supportive tests in an individual patient. Diagnostic criteria are a set of signs, symptoms, and tests for use in routine clinical care to guide the care of individual patients. (1)
You either wait it out or seek medical attention and they do their very best. As health care providers, we seek to provide the best possible care to clients who seek our counsel. To do so, we need to provide the “right treatment to the right patient at the right time. Traditionally this process has relied on some type of patho-anatomical reason for the injury and pain. We try to classify and subgroup signs and symptoms based on body region (back, hip shoulder), time (acute, subacute, chronic), irritability (low, moderate, high). It’s just that there is a disconnect between our diagnostic and treatment process when using this flawed model.
The gold standard of diagnostics is the medical image: X-ray, MRI, CT-scan. Those scans may show some type of tissue tear, disc herniation, or fracture. In typical clinical practice, however, practitioners often rely heavily on “special tests” or “pain provocation tests” to theoretically confirm the underlying presence of a tissue pathology, and that tissue’s role as a pain generator or source of the symptoms. The flaw comes in how image findings have largely and repeatedly been present in asymptomatic or non-painful populations.
- “Up to 46% of people with pathological findings of a rotator cuff tear with imaging were asymptomatic”
- “100% of asymptomatic collegiate basketball players presented with at least ONE structural abnormality on MRI, including fat pad edema, tendinopathy, meniscal tear.”
- “64.3% of adolescent athletes presented with at least one abnormality on MRI versus 32.1% in a control group who did not play any sport. Both groups were asymptomatic.”
- “43% of asymptomatic individuals greater than 40 years old presented with osteoarthritis changes.”
So we have proven the pathoanatomical model is flawed. The reason you have pain is because you are built wrong or something structurally has been compromised.
YOU MOVE WRONG
Another model is the kinesiopathological model. This model simply states that the cause of your pain and injury is because you move wrong. But this is deeply flawed as well. If you analyze any one sport: baseball, basketball, football, or even how people walk every single day. You will find a tremendous amount of variability.
- Do all baseball pitchers have the same release and look the same when throwing?
- Do all basketball players jump, land, and shift differently?
- Do all squatters and deadlifters look the same?
Just do some basic googling and you will find that one of the single best marathon runners in the world over-pronates or runs more on the inside of his foot. We could even make this comparison with you. Every time you bend down to tie your shoe you likely do the same way every single time. But for some reason this morning when you did it you had immediate onset of sharp pain in your lower back. If you move wrong why did it not hurt the prior 3,000+ times you have done the same exact movement? Why does it hurt this time?
See, it’s a very flawed model that doesn’t justify or correlate causation.
Let’s get to the goods. Stay with me, there’s great news ahead if you HAVE PAIN or INJURY!
LOAD VERSUS CAPACITY MODEL
Load vs Capacity is pretty simple: All tissues have a certain capacity and if the mechanical load applied to those tissues is greater than their capacity, there is a higher risk of pain or injury. This is likely dose dependent. If you use a cup and water we can easily depict how simple this model is. Your body and health is the empty cup or the capacity. And the water is everything applied to your body in the form of load and stressors.
Why I love this model and it makes more sense
It can be really discouraging and defeating to think the reason for your pain and injury is largely out of your control. That anatomical deviation or biomechanical flaw results in complete loss of confidence in your ability to move and perform. Patients are told to stop running, stop lifting weights, and protect the injured structure. But this does absolutely nothing to improve capacity.
The LOAD v. CAPACITY model teaches patients how to adapt. If you gradually apply load, your body adapts by increasing capacity. Reducing load (rest or overprotection) leads to reduced capacity. A better idea is to have some gradual exposure to load with appropriate monitoring of symptoms over time. This creates confidence and optimism through self-efficacy rather than one that breaks a patient’s confidence.
It can explain why someone got injured, it can help clinicians guide and patient’s progress through a rehab timeline, AND it can also help prevent future injuries by encouraging a patient to maintain a constant load, thereby possessing a higher capacity to resist injury.
Communicating with patient’s through the LOAD v. CAPACITY model simplifies. The injury occurred as a result in load such as trauma, overuse, or sudden exposure to a new environment and stimulus. It can also include situations where the load may be the same, but lowered capacity is occurring because of variables like decreased sleep, increases stress levels, or poor nutrition which lowers your capacity to adapt to normal loads.
Lastly, this model is wonderful to encourage patients to maintain some mechanical load on their body. By doing so, they can keep the capacity of the tissues higher to mitigate the risk of future injuries.
A REAL LIFE SCENARIO
47 year old businessman travels to Atlanta for five days. During his time he has poor sleep in his hotel, doesn’t have access to a kitchen so he eats low quality foods, and spends a lot of time sitting working on a big project. He doesn’t move as much as he normally does. The stress is huge because he has to finalize his project by the end of the trip. He returns home and hits the gym first thing the following morning and works his 85% of his 1RM on squats. He has 10+ years experience squatting. On the first working set when coming out of the bottom position he has sharp pain in his right glute with pins and needles radiating down his right leg. He attempts to squat his second set but the pain is unbearable and keeps getting worse.
Working with Myomuv he comes in for his initial evaluation and is seeking a diagnosis. He believes his injury was caused by his leg length discrepancy that someone told him he had a few years ago. After conversations we get to his recent lifestyle and training and uncover some lifestyle changes and other stressors and explain the load v capacity model to him. His capacity or cup came WAY DOWN and he tried to apply a normal load that he just didn’t have the capacity for. Water had to overflow from the cup.
Here is how we explain and manage his plan of care using the LOAD v. CAPACITY model.
We have two options:
1) Pour some water out
-Manage sleep, stress, recovery, nutrition, smarter programming, mindfullness, meditation, deload in training, dry needling and manual therapy interventions.
There are tons of options to calm things down before we build things back up.
2) Build a bigger cup.
Following his acute onset of pain our capacity has came way down. Instead of working with a pitcher we now have a shot glass. If we immediately throw him back to his normal training loads he will continue to disrupt tissue healing and stay in a painful state. But if we slowly pour a little water in his cup and give the cup time to adapt over time we gradually will grow into a much bigger and normal cup. This occurs through progressive loading, strength training, neuromuscular re-education, and other interventions. We can start by decreasing his normal training volume of 5 days per week to 3 days per week. Instead of working with intensities at or above 80% we drop down to 40-50%. Instead of working through full ranges of motion we use partial ranges of motion. The options are limitless. The goal is to avoid further decreasing his capacity by over-protecting but instead increasing his capacity through graded exposure.
LOAD v. CAPACITY is certainly a better explanation of pain and injury than its counterparts of pathoanatomic or kinesiopathologic models. The confidence it gives a patient to manage their injuries is invaluable. As a patient having an understanding that YOU can gradually work back to a state of health instead of blaming their function or anatomy is priceless. It highlights the the importance of maintaining your capacity to manage and prevent both current and potential future injuries you encounter. And now you don’t have to worry about your “SPINE being misaligned” from now on. WINK* WINK*
Want to work with us and improve your capacity during your current state and future state?
Aggarwal R Ringold S Khanna D, et al. Distinctions between diagnostic and classification criteria? Arthritis Care Res (Hoboken). 2015;67(7):891-897.
Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med. 2019;53(20):1268-1278.
Kaplan LD, Schurhoff MR, Selesnick H, Thorpe M, Uribe JW. Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy. 2005;21(5):557-61.
Pappas GP, Vogelsong MA, Staroswiecki E, Gold GE, Safran MR. Magnetic Resonance Imaging of Asymptomatic Knees in Collegiate Basketball Players: The Effect of One Season of Play. Clin J Sport Med. 2016;26(6):483-489.
Ludewig PM, Kamonseki DH, Staker JL, Lawrence RL, Camargo PR, Braman JP. CHANGING OUR DIAGNOSTIC PARADIGM: MOVEMENT SYSTEM DIAGNOSTIC CLASSIFICATION. Int J Sports Phys Ther. 2017;12(6):884-893.