Inflammation: Friend or Foe (From 7/22/13)

Tendonitis, arthritis, plantar fasciitis, bursitis, etc. Have you ever thought or been told that you have one of these conditions? Many people have, and undergo treatment on a daily basis. The common thread to all of these conditions is the last two syllables of the word: -ITIS. So what characterizes an ITIS condition?

The answer is inflammation. Any disease or diagnosis ending in ITIS has inflammation in the specified tissue(s). Examples:

  • Tendonitis: Inflammation of the tendon · Arthritis: Inflammation of the joint(s) · Plantar Fasciitis: Inflammation of the plantar fascia · Bursitis: Inflammation of the bursa sac · Dermatitis: Inflammation of the skin · Appendicitis: Inflammation of the appendix · Rhinitis: Inflammation of the nasal passages · Bronchitis: Inflammation of the bronchiols (within the lungs)

The list goes on. There are many different conditions characterized by inflammation, and many of them can be difficult to treat. In the realm of orthopedics and physical therapy we tend to talk more about tendonitis and arthritis and most of these conditions come from overuse or weakness. Most people will not be able to describe a single instant in which their pain began, but will have a gradual onset of symptoms. For this reason many people with have pain for weeks or months before seeking treatment. Even then, many may continue to struggle for some time with their ITIS’s for one simple reason: Inflammation has a bad reputation, for no good reason. Let me explain. When many people have pain they immediately BLAME inflammation. The reality is inflammation is just MISUNDERSTOOD. Some facts about inflammation: 1. Inflammation is the first step in the healing process, so without it, you cannot heal 2. Inflammation has five cardinal signs a. Pain b. Swelling c. Redness d. Increased tissue temperature e. Loss of function 3. If redness, swelling and increased temperature are not present, inflammation is not present 4. The inflammatory period generally lasts 48-72 hours but can be longer in some cases 5. Inflammation is almost never present beyond 7 days post injury Let’s break these facts down a little, and try to understand inflammation a little better. First, inflammation is the initial step in the healing process. When an injury occurs, chemicals are released in the tissues and into the blood stream that act as a “trail of breadcrumbs” to the injury site. This trail will lead things like white blood cells to the area, and cause an increase in blood flow. This all occurs to benefit healing. White blood cells remove damaged or dead tissue and new tissue is then able to form. Increased blood flow brings nutrients and other things needed to help rebuild the damaged area. Without inflammation, this process would not be able to occur, and the healing process would be dead in the water. It is important to remember how to recognize inflammation. Many conditions end in ITIS but may not actually have inflammation present. Many people who have tendonitis have pain and loss of function, but no redness or increased tissue temperature. Many people have a swollen joint, but no pain, loss of function or increased tissue temperature. The key point to remember is that any of the signs or symptoms of inflammation can present themselves in isolation, and do not necessarily indicate that a tissue is inflamed. With that being said, I think that the most reliable signs and symptoms of inflammation are redness and increased tissue temperature. This is for several reasons. First, swelling can be difficult to identify when present only in small quantities. Second loss of function seems to occur mostly in response to high levels of swelling, and due to pain with motion. Third, pain does not necessarily result from inflammation, and its inclusion as a cardinal sign is based on an older model of pain and nociception. The third point is a much larger topic that will be discussed in future posts, or you can learn more at our weekly pain seminars at Premier. The revised cardinal signs of inflammation that I propose are: Required Signs 1. Redness 2. Increased Tissue Temperature 3. Swelling or increased fluid volume in the area (may be present in small quantities) Secondary Signs 1. Loss of Function (secondary to swelling or pain) 2. Pain (secondary to neurologic threat appraisal) In this model of inflammation we begin to look at what must be present for inflammation to take place, and what may be present. Histamine is the primary inflammatory chemical in the body. Its primary effects are redness, increased tissue temperature, and swelling. Think about allergies and anti-histamines. In those cases, histamine causes inflammation in the nasal passages (characterized by swelling of the passages, increased fluid volume and mucus, redness of the nose and throat, and increased tissue temperature or fever), and anti-histamines prevent this inflammatory pathway. While pain and loss of function certainly still remain present in the new model, they are no longer used as the primary indicators of inflammation. This may change treatment, as we exchange the ITIS suffix (inflamed conditions) for the ALGIA suffix (painful conditions that limit function). The next key thing to remember is that the healing process is very efficient and structured. While inflammation represents the initial stage of healing, it ends rather quickly. Most inflammation will subside within 72 hours of injury, and 99% of cases will not have inflammation that persists past 7 days. This is important to remember because many cases of tendonitis and arthritis persist for weeks, months or even years. Again, it becomes important to question whether or not inflammation remains present for this long. If it did, then high concentration of white blood cells would most likely destroy excessive amounts of healthy tissue. In fact, this is the working theory behind many of these chronic conditions. I have cited a study below which reviews some of the different models of tendonitis(algia). The most modern models suggest that progressive degeneration of a tendon may lead to increased pain. Additionally, this degenerated tissue spontaneously forms new blood vessels and nerve endings. The abnormal blood flow and excess innervation have been described as other possible sources of pain in these conditions. The take home message is that many of the ITIS’s likely began with some inflammation in the tissues due to chronic overuse, but the healing processes stalled and lead to formation of new blood vessels and nerve endings and progressive degeneration of the tissue. All this means that the tissues are painful, but not inflamed. There may be several instances of inflammation during the progression of an overuse condition. The key point to remember is that these bouts will generally last only 48-72 hours, and will be characterized by swelling, redness and increased tissue temperature. The majority of the time there is no inflammation. So how does treatment change when we are not necessarily treating an inflamed tissue? While many treatment strategies have been shown to be effective, there are several which are gaining popularity. These treatments tend to rely on the positive effects of inflammation, and are geared towards restarting the healing process from the beginning. Examples include Prolo-therapy and Instrument Assisted Soft Tissue Mobilization (IASTM). Prolo-therapy will typically be done by a physician so I am going to focus on IASTM, as that is what you will receive from your physical therapist. Both of the above treatments serve to create some acute tissue irritation, and re-ignite the inflammatory process. This may seem counterintuitive, but remember, inflammation is the first step in the healing process, and conditions such as tendonalgia occur when the healing process stalls. Thus re-inflaming a tissue is like kick starting the healing process from the beginning. Once the tissue is inflamed, exercises to stretch and strengthen the tissue can be used to help repair the tissue, and correction of body mechanics can prevent future injury. A big difference here is that anti-inflammatory medications and treatments will be off-limits for the first 2-3 days of the process. This is because we want the increased blood flow and white blood cell presence to help prepare the tissue for healing. Taking anti-inflammatories or using ice could stop this process and stall healing. In general, I hope that this can help you start to take a more positive view of inflammation. It is the first step in healing, and new treatments for these chronic conditions rely on an inflammatory state to succeed. By understanding when inflammation is present, how to recognize it, what its purpose is, and why we need it, we can develop more effective treatments, and move, feel and live better. Patrick


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