Of course you do have a TMJ, ( a TemporoMandibular Joint).  If I were to say the TMJ is a ginglymoarthroidial joint, you might suspect it could cause a lot of trouble. It allows you to eat by chewing or masticating. A fantastic historical perspective on it is Richard Wrangham’s, Catching Fire: How Cooking Made Us Human . The TMJ’s functionality also influences prosody (the rhythm, stress, and intonation of speech).

Its symptoms are not always recognized but getting the right treatment is the real bugaboo. However, if you are lucky enough to be correctly diagnosed at the onset/outset, the most complicated part of TMJ pathology is simply receiving competent, efficacious treatment by a qualified specialist.

The truth is, just finding a dentist who can make and then adjust a correctly fitting appliance can be a truly toilsome assignment.

Bruxism and clenching may be part of some TMJ histories and may be reasonably easy to address if that’s the only issue. Trauma may ensue from the chronic parafunctional activity  challenging the neurological (mechano receptors and free nerve endings) and mechanical forces (lever systems) mentioned in prior blogs. Except when the teeth are touching (occluded), mandible activity and posture is entirely a function and result of the other stomatognathic structures (mouth parts , however you wish to define them, upper (maxilla) and lower (mandible) jaw, pharynx, and many other structures) involved in mastication, deglutition, and speech.  Even if you bite your cheek or tongue you may have temporary mandible dysfunction (many dentists prefer to call it TMD but for our discussion we will stick with TMJ).

The hyoid bone and its attached structures are very often over looked as “a” or “the” primary place to look for the “clue(s)” for making the accurate diagnosis.

The genome project is fast underway trying to find out WHO and WHAT we really are. But until some researcher finds the “TMJ-stomatognathic” gene comlex(es), we have to look a little more “mechanically” at a patient’s pathology. Most people think of bones as determining our posture and our physical “look”. The hyoid is one of them but probably few people know of it or its role in our physical and emotional lives.

TMJ can begin with any number of physical traumas: such as auto accident, sports, fall off a bike or over a broken sidewalk, orthodontic brace removal, but also from poor posture; some form of what I would call a compensatory forward head posture.  What’s important is to recognize that every pain you have should be diagnosable; and the diagnosis, if properly explained to you by a competent healthcare professional, should make sense to you so you believe and understand what TMJ you have.

My next blog will discuss: Posture and the TMJ headache.

Proviso: This discussion is for knee injuries

Assuming you recover uneventfully from the initial acute postoperative stage, the involved tissues will then transition to their “differentiation/ specialization” training phase. Expect the surgeon and therapist to follow a logical sequence (protocol) in the rehabilitation process. See the above link’s “discussion” portion.

To start with, the three general phases of muscle rehabilitation should be followed: Endurance, strength, and power. Generally proper stretching techniques and timing for it to begin occur during the late endurance and early strength phases but each surgical procedure and tissues involved guide the therapist’s instruction for it.

Endurance/Stamina is the least stressing and, physiologically, the best tissue “stabilizing” approach. It follows parameters based either on the number of repetitions for the exercise (50-100 reps) or a set length (5-10-20 minutes)of time to do the exercise. The exercise may at first, not only be limited by fatigue, but also by postoperative pain (and possibly some “FEAR”). Some people are afraid the wound will open or the repaired tissues will “come apart”. Some patients with total knee replacements really don’t trust the leg will hold together.

So start easy with a few “test” repetitions and then get to work doing more repetitions in a row. Where legs are concerned 3 sets of 10 just doesn’t get much happening with the mitochondria, the energy factories in all cells, especially muscle cells. Depending on whether all or part of the kinetic chain is working, 100 repetitions may be a reasonable goal to attain before pressing on to the next exercise phase: Strength.

Strength (force, weight, or resistance) training begins when the muscles are well energized by their endurance/stamina and can begin to strengthen (hypertrophy) using free weights, body weight, elastic tubing, exercise machine systems, walls, and stairs. At some point now, in this injury recovery process, there’s no need to use a formula to determine how much weight to start with, the therapist will likely decide it. Even if you are NWB on crutches, walker, or in a wheel chair, you may still be able to start the strengthening phase while waiting for the surgeon to permit FWB.

Some knee surgeries are specialized; where either the therapist will be responsible for the rehabilitation “progression” or the surgeon himself or herself will have a specifically prescribed written protocol to follow; as may be the case for ACL repairs (common for athletes) or for more complicated surgeries such as hyaline cartilage repair called mosaic plasty.

Regardless, once FWB, the therapist should always be thinking about the nerve pathway components as the endurance-strength-power program progresses. In that phase you’ll hear terms like mechanoreceptors, muscle spindles, proprioceptors, and other components. This is the time (and phase) you’ll start to feel the muscles getting stronger and your normal activities of daily living (ADL), like stairs, carrying bags and objects, driving, and shopping, resume their normal place in your household responsibilities (and life). In fact you may be able to return to employment, depending on your state’s workers’ compensation law, (workers disability pay is usually much less than regular pay) in a light duty capacity as you proceed through the ensuing weeks of rehabilitation.

The last phase of knee rehabilitation should gradually be integrated based on the physiological healing response and the physical sport or employment demands. This may be the time to begin power training:

Power (P) doesn’t begin until the nerve pathways are properly reinstated for joint tissue functions. Power is a law-of-physics term expressed as a formula (this is when some people’s eyes may “glaze” over). It simply multiplies endurance (repetitions or distance) and strength (force or weight) (known as work) while also introducing a per unit time or velocity component. The formula is P=F x d/t. Power can begin with low weight (doing work over time) and then “speed it up” as the nervous system accepts and tolerates the recovery challenge.

At some point the “insurance therapy” concludes in the early power stages for most patients but perhaps at later stages for athletes. In any event, therapy is concluded. Then athletes can see their school strength and conditioning coach, join a sport specific/sports training facility, (it seems to be a growing industry in my office referral region) or follow their own program. Finally you are ready to return to play or work.

Next Blog: You got TMJ?

Function. During surgery, the surgeon causes trauma, through invading, altering, and repairing 4 kinds of tissues: soft – skin, circulatory vessels, nerves, and muscles;  hard – bone;  rubbery – cartilaginous; and rigid – ligaments, tendons, and joint capsule tissues;

Whatever injured and traumatized tissue the surgeon addresses, afterward it will need some sort of rehabilitating (supervised or self home program), keeping the 3 F’s in mind. Soft tissues mend through a healing process of 3,generalized, somewhat distinct, but overlapping phases. In general, Wolf’s Law applies to bone healing. Cartilage is mostly an inert tissue and essentially doesn’t have a direct physiological reparative property (what’s removed stays removed, what’s left is left). The soft tissues and the rigid tissues go through the healing phases too, but absolutely require the rehabilitation mantra: Form Follows Function; keeping in mind the 3 stages of healing so various functional motions are not initiated until their appropriate physiological mending time is right.

For the knee, once an operative report is obtained, the therapist should know the path to follow with the patient, keeping in mind any extraordinary precautions the surgeon may indicate as a consequence of his/her observation during the surgery. In some instances the surgeons are also using platelet-rich plasma (PRP) in reparative or debridement procedures, which should be in the operative report. This link has a reference to Tiger Woods knee. (PRP could be another blog).

Most incisions have 2 layers of suturing for mending cuts: the bottom layer (hypodermis/subcutaneous) of the skin and the outer layer (epidermis). Most orthopedic surgeons are now often using surgical glue and/or steri strips for the external or epidermal incision (in place of ”thread like” sutures and staples), and resorbable sutures primarily for the bottom layer of skin (subcutaneous). Sometimes, 3-5 weeks post operative, a tip or part of a resorbable suture may work its way out through the skin, adjacent to the incision, and usually can be pulled out or allowed to erupt by itself. Seldom does it cause an infection problem, but for total knee arthroplasties (TKA) the therapist or surgeon should be made aware if noticeable redness or local swelling around it occurs or persists. That usually won’t interrupt your therapy. But on occasion, knee swelling from that or other unknown reasons occurs and a 2-3 out of 5 scale level of warmth develops, often slowing down the progress of attaining full extension and/or flexion range of motion of the joint (ROM). Less common is the complication of wound dehiscence, often from premature bending of the knee, such as falling on the knee with loss of balance. That requires surgeon intervention.

The surgeon has to decide if anti-inflammatories (antibiotic if infected) are indicated.  If general constant pain accompanies the swelling (described as 3-4/10 ache or throb pain), some doctors find it resolves with a short course of “pain killers”. For those patients, controlling the pain results in relief of what otherwise could evolve into a chronic healing inflammation. Rarely RSD/CRPS can occur in the knee itself and become quite disturbing and significantly inhibit good functional recovery. Infrequently, even after a “routine” arthroscopic knee surgery, swelling and pain develops. That too will be very disturbing to the patient and extend the need for supervised care (or sometimes rest).

Using ice or heat is always a question. That’s a short blog in itself because it depends on various factors and circumstances. So ask the surgeon or therapist about that.

The above, all though very much abridged to keep this blog readable, are some of the common observations I have observed over nearly 40 years. Fortunately, most knee surgeries fully recover uneventfully as long as the patient puts forth the proper effort and respects the physiological timelines in the tissue healing sequence.

My next blog will delve into the principles of the exercises (protocols) for knee rehabilitation, surgical or non-surgical.

Principles for knee rehabilitation protocols – Part II  -  Stamina, strength, power

The knee would have a hard time generating through-the-range knee power (football linemen, for example) without the patella’s unique function. It helps the quadriceps perform efficiently and at reduced energy cost. It’s a type of green energy system.

This blog isn’t meant as an in-depth arthrokinematics discussion of the P/F joint.  But understanding the joint physics helps the professional treat the painful condition more efficiently and effectively. The joint does create painful symptoms for lots of people (especially young teenage girls).  If orthopedic surgeons, physical therapists, and occupational therapists didn’t take physics, they would “come up short” when helping patients with their knee related problems. In fact, over almost 4 decades, I’ve supervised many clinical aides who were going to night school to complete prerequisite courses in order to be eligible to apply to PT school; but they ended up deciding against the profession because they couldn’t get the “hang of physics”.

So Archimedes in 3^rd century BCE defined 3 lever systems. Good for us because the knee is essentially a class one lever system (like a see-saw). The kneecap in the middle is the fulcrum, the lower leg (with or without resistance weight) is one force arm and the quadriceps muscles above the knee make up the other. One rehabilitation goal is to make the quadriceps muscle group stronger through a progressive resistance exercise (PRE’s) program. The stronger the muscle gets, the “heavier force” it can generate through the fulcrum to more strongly allow the leg to do more: tiptoe reaching a top shelf, jumping as in sports or over a puddle, or just descending stairs.

The doctor also has to understand the sheer force mechanics and the coefficient of friction which essentially means the kneecap contact should be at right angle to the femoral condyles as it goes through its motion. Otherwise it can “skid” on the femoral condyle surface and begin a degenerative process and cause pain. That means in therapy, keeping the kneecap aligned in the femoral trochlear groove; a primary job of the VMO in conjunction with some of the hip muscles. This has to be the goal for a successful recovery.

So dynamic taping (Kinesio) or static taping (McConnell, Mulligan) of the patella can assist the therapist in the acute (early) stages along with close attention to technique in the exercises. Technically, the VMO’s critical role is to provide the joint force necessary to facilitate the tibia’s morphological requirement to externally rotate on the femur as the knee joint goes into full extension (straightening). Most important, the therapist should be sure to teach you the correct hip exercises (especially abduction and adduction) so the VMO ‘s action can be facilitated with proper hip position during rehabilitation.

As an aside, and too complicated to discuss here, some total knee arthroplasties (TKA’s or knee replacements) and post ACL repairs, where these same rehabilitation principles are applicable, develop posterior knee joint pain and can not attain full knee straightening. Ask your therapist about the popliteus muscle and how to address it, if applicable. 

Here are exercises addressing this important concern.

Next blog:  A Closer Look at Rehabilitation Principles for the Knee.

In some early pain stages, a patient may not yet have been diagnosed with a chronic illness or condition and think it is an acute pain. An orthopedic surgeon may be the first to reveal to the patient that he or she has, not an orthopedic diagnosis, but an early stage of a chronic disease.

The knee is the largest joint in the human body. In the history taking, the orthopedic surgeon will want to know the circumstances because, as in most diagnoses, the history will reveal what likely structure of the knee is injured and how. The patient may even be asked to point to the painful “spot”. The knee is one of the most injured joints of the body.

The knee has many potential “culprits” causing pain and dysfunction: from internal joint problems between the femur and tibia (internal derangement knee -or IDK); in the patella-femoral joint between the knee cap bone and the end of the femur (P/F joint); and external knee structures including those starting at the hip region above the knee or those originating from the tibia below the knee and also including the joint at the top of the 2 lower leg bones (the proximal tibio-fibular joint).

So maybe the pain started for one of the reasons above and needs a “handle” or actual diagnosis. In my clinic just having a name for the pain gives some people relief.

To confirm her/his deduction from the history, the physician may (perhaps should) “take hold” of the patient’s knee and do some manual tests (there were at least 35 of them when I became a clinical specialist). The surgeon usually tries to provoke (make happen or intensify) the symptom(s) helping to confirm the diagnosis (positive finding). In other instances, the surgeon may test structures expected to be irritated but don’t hurt (negative finding). The negative finding may rule out the physician’s initial expected diagnosis. Often there are a number of different manual tests for the same structure. In general if the tests are all or mostly positive then the diagnosis is usually confirmed (positive findings). If the structures do not hurt when tested, then the surgeon has to examine further and perhaps think a little harder. The surgeon will always consider the “obvious” before suspecting something more ominous like a bone tumor.

“Expensive” tests and testing procedures should only be done if they will help determine the course of care. If the test confirms, but would not influence the course of care, there is no reason for the “expensive” test.

Therefore the next step may not be the radiographic (x-rays, cat scans, ultrasonography, MRI) pictures you are expecting. The surgeon may instead determine you need medication and or physical or occupational therapy, or just rest. If surgery is anticipated, the radiographic tests will be done for collaborative “diagnostic” evidence to confirm the doctor’s diagnosis and the course of care.

Knowing what knee structure(s) has/have been injured, changes the question of “when did your knee pain begin” to be instead “where did your knee pain begin”?

Next blog, What do you do about that CMP you have?

There’s more to the following conversation/dissertation about WHAT WENT WRONG and how you knew it, know it, and care for it. You functioned in an erroneous way. So you created a formation of pain and dysfunction needing attention. Hippocrates admonished: “First, do no harm”! He may have been speaking to physicians but it’s good advice for you also.

I have found RTC injuries or pathologies are fully explainable. They occur because of:

1) Sudden trauma as might occur in sports: tug, jam, twist

2) Inadvertent work or other daily activity trauma: resulting from the same above reasons.

3) Repetitive trauma:

a. cumulative trauma disorder:
Sports or work activities may repeatedly damage circulatory tissues of tendons (impingement syndrome).

b. repetitive strain injury (RSI):
Overworking of the RTC tissues and their environment (constant tugging/pulling); such as sports or work throwing or holding activities.

4) Some sleeping postures (a passive type of cumulative trauma).

You may remember the “3 F’s” aphorism in my blog on healing: Form Follows Function.

All joints have muscle and ligament control mechanisms but also a morphological relationship (surface shape, menisci, labrums) for determining articular (surfaces of each bone where they meet/touch) motion (referred to as accessory motion by John McMennell). The RTC is one of those muscle groups helping to control the shoulder motion activity and keeping the gleno-humeral (shoulder) joint surfaces pretty much indispensible for throwing sports.

But it’s all in the head. It may be correctly stated: “No brain, no kinetic chain”. But with a functioning brain, much can be directed to correct “what went wrong” with your RTC.

The nervous system includes the tools for establishing a muscle’s resting length, over all tone, and honing one’s coordination. The general umbrella terms may be proprioception, gamma bias, mechanoreceptors, free nerve endings, stereognosis, and others. It helps to have a normal functioning circulatory system as the shoulder ages, but even that will be notably influenced by the nervous system’s learned patterns of rest and function.

Resting posture (doing nothing) influences RTC training outcomes. It all has to do with brain interneuronal agility training and requisite engrams. If you do nothing, nothing will happen. If you train poorly, results will be poor. If you train properly…we wouldn’t be having this conversation.

In some ways we function like an oligarchy (government by the few). Most of the time mechanoreceptors reign supreme in nervous system traffic. They speak to the thalamus (a kind of president or ombudsman of the body located in the head) and provide a lot of the cabinet members who influence important (and instantaneous) decisions for the corpus (our body) to function. Washington D.C. should be so efficient.

Free nerve endings sit at the same table in the oligarchy. They know the pain you are experiencing and have the thalamus’ ear. You touch a hot stove (A delta fiber free nerve endings), your RTC won’t show much concern for the mechanoreceptors except to yank away the hand attached to the arm; but also your tongue and larynx yelp “ouch”. You have achy arthritis, delayed onset muscle soreness, or chronic RTC tendinitis, your C fibers of pain keep a low reminding tone to you to protect your functioning self (healing blog); that is: don’t make yourself worse using the pathological tissues without good reason.

You have to become an autocracy (self management), take control of your oligarchy through the abovementioned representatives. How? through proper exercise and body ergonomics instruction.

In all likelihood, after her/his examination, your orthopedic surgeon will first send you to a physical or occupational therapist:

1) To be examined for fitness to be a patient.

2) Receive supervised instruction and education with a Home Exercise Program (HEP) for RTC personal care.

3) Perhaps become a patient if #2 doesn’t work out.

4) Be offered a recurring therapist supervised exercise program predicated on Form Follows Function; as your RTC heals, repairs, and maintains its health, to hold up its proper responsibilities to the autocracy.

The next blog. When did your Knee pain begin?

It is of course easy to say prevention but maybe the better phrase is “re-injury prevention”. I know and have treated plenty of athletes over 4 decades and for the last 2 decades, enough has been known to truly prevent re-injury even if the athlete knew he/she could have taken preventive measures in their training programs from the beginning

So why not know the activities frequently causing RTC inflammation and take preventative measures to prevent them in the first place?  If you are regularly performing overhead activities: tennis serve, overhead throwing, (baseball and football), swimming, or physical overhead employment activities, you may develop the “over use/repetitive strain/impingement” symptoms of rotator cuff tendinitis. If you keep it up you may cause the body to start a tendinosis pathology (starting of chronic shoulder dysfunction and pain).

The truth is, until an athlete experiences the 10/10 pain of RTC inflammation, he/she just won’t “get it”. In professional (and most NCAA schools) sports it should be a different story because there should be a disciplined training policy (although there will always be some non-complying athletes). Current athletic department strategies will encompass many professional disciplines but this discourse is sticking to the specific RTC discussion; Hence Strength and Conditioning Coaches in the forefront, who may be licensed physical therapists with certification as athletic trainers as well.

The well-funded programs have will attending resident surgeons, nutritionists, and motion analysis physiologists or kinesiologists on staff. Diet/nutrition, sport specific weight training protocols, sport specific performance techniques, and physician supervised radiograph and ultrasound diagnostics, are essential elements of injury prevention philosophies.

Further, sports training clinics have been evolving in recent years for high school and college athletes who have the money to pay for that one-on-one, sport specific coaching and training. Personal trainers can be found in gyms and industry settings offering their version of a supervised training experience.

With that in mind you CAN prevent RTC pre or re injury. Most athletes however, do not have access to the professional, semi-professional, or various sponsored organized amateur sports musculo-skeletal wellness programs. So what do the rest of us need to do who “dabble’ in intra mural, weekend, local “pick-up” sports programs, or lay organized leagues?

If you already have shoulder pain you certainly can consult a health professional familiar with shoulder anatomy and physiology. Since we are just speaking of overhead sports for the “common man or woman”, why not KISS, keep it simple stupid.

For any joint or muscle exercise, there is an agonist / antagonist motor control relationship. One exercise may be suitable for several diagnoses and will always incorporate more muscles than just the titled muscle being referenced.

There are many online exercise program systems such as, http://www.fitnessbuilder.com/ programs like that have hundreds with still and video instructions. These videos show exercise gym machines, free weights, mat and stretching exercises, and elastic exercise bands attached to polls, door nobs, standing on it, wrapped around extremities, etc.

The following 3 exercises may suffice. If they don’t work, you either are not performing them correctly (schedule a one time appointment with a physical therapist to learn technique), you don’t have an RTC problem, or the pathology is too advanced and you will need to see an orthopedic surgeon.

Elastic exercise bands are colored to represent resistances: Yellow – Light resistance; Red – More; Green – More+; Blue – Strong; Gray – Very strong. 36in length should be sufficient.

Hold band wrapped around each hand. Keep thumbs pointing up for all three exercises to help prevent impinging the rotator cuffs attachments. Always keep band taut during exercises and not slack. Many exercises in the United States are 3 sets of 10. Odvar Holten’s diagram would be 3 sets of 30 based on resistance. In general the theory for exercises parameters is establish endurance (repetitions) then add resistance and reestablish  endurance and then add velocity component (power) by speeding up the repetition cycle.

The next blog. What went wrong with my RTC?

This is a fairly accurate rotator cuff presentation:

I suppose it would seem odd for me to say, hearing the wrong pronunciation irritates me, but it does. It just grates on my professional ear. But I got to thinking, who pronounces those words that way? Is it somehow related to me? It seems that it is: my male gender and age group. With 40 years of practice I realize I haven’t heard the young use either of those terms, just those over 60 guys.

My first car, a 1962 Ford Fairlane (same generation as the over 60 crowd) didn’t have fuel injection or a computerized anything, but it did actually have a rotor (no doubt what the over 60 men are phonetically hearing). The sounds of the engine and the physical feel of its handling when driving, were the only diagnostic tools we had. Tuning up the engine required replacing the points and the distributor rotor and aligning them with a manual timing light (we looked, listened, and felt through the tune up).  No oscilloscope or central mother board for that.

Today the surgeon does have all sorts of computerized diagnostic gear but the best way to assess the shoulder and the rotator cuff, specifically, is the same as for my ’62 Fairlane.

Look, listen, and feel:

1) Looking at the shoulder and comparing right and left (swelling, bulges, postural differences),
2) Audible patient feedback in the form of their reported history of the pain development, and
3) Physical response to the surgeon’s manual assessment tests; the feel from handling the patient’s joints, muscles, and ligaments; often comparing affected shoulder to the unaffected shoulder (tri-plane ranges of motion, warmth of tissues, and joint “end feels”).

It is something like checking the “shocks and pinions” of the Fairlane’s front end (now called rack and pinon) analogous to the “shoulders” or front wheel assemblies of the car.

Of course there are a lot of muscles to consider when someone complains of shoulder pain. The rotator cuff is specifically defined as the supraspinatus, infraspinatus, teres minor, and subscapularis. There are also teres major, 3 deltoid divisions, long and short heads of biceps, coraco- brachialis, and pectoralis minor muscles to differentiate out from pain caused by a rotator cuff injury (tendinitis, tendinosis, or tear).

A) Muscles can be palpated (physically felt by surgeons hands) for tone, contour, and temperature, B) stretched to assess muscle guarding and its affect on joint range of motion, and C) resisted contraction to identify muscle functional integrity. There may be more than 123 shoulder tests. Nothing pays for that much assessment and differential diagnosis.

Good news! Most rotator cuff tests can be quick scans (“look, listen, and feel”). Most patients usually know when and how the pain began, can point to a specific referral point of pain (the deltoid tuberosity), and automatically demonstrate the motion causing the pain. No x-ray, no MRI, no shot, no surgery, no worry. Invariably patient is referred to a physical therapist.

Can you prevent rotator cuff tendinitis?

When making a decision do you go to your PCP, a family member or friend, school trainer or infirmary, coach, the internet, or directly refer yourself to an orthopedic surgeon or physical therapist?

If it isn’t an emergency, you might search the internet before any other sources. Then search again after your professional orthopedic consultation to elaborate on the information you received.

The shoulder has three joints: gleno-humeral, acromio-clavicular, and sterno clavicular.  Sometimes the scapula thoracic is referred to as a fourth joint. The shoulder has many specialized tissues (ligament, tendon, muscle, bone, vascular, and nerves.)

Some common possibilities might include: separated shoulder, rotator cuff tendinitis or tear, TOS, bone spur, bursitis, labral tear, adhesive capsulitis, complex regional pain syndrome, …?

The surgeon may think about and ask you questions. What part of the shoulder could have gotten injured with the history of mechanism? A fall, a grab, a twist?  What domestic, sport, or work activity or maneuver? Is it a sharp, dull, achy, electric, or burning pain?  Is it referred pain (a what?) or point specific?  Can you go to work?  You may be aware of sports arenas using cameras on playing fields for use in helping to determine the mechanism of injury when one occurs. Even though the doctor has the examination skills to differentiate much of the shoulder pathologies, the x-ray, CAT scan, or MRI may reveal it isn’t broken, just roughed up.

Just because your shoulder is painful or has a pain, doesn’t mean it requires any more treatment than some rest (maybe ice, OTC medication, or heat too). Our bodies usually “tell” us when to see a doctor. Some of us are too fast inserting ourselves into the healthcare system, some too slow, but most of us “just right”.

You may recognize a traumatic injury occurring when you fall, get hurt in sports, or have a car or work accident but you may not think of surgery (iatrogenic injury) as an injury/trauma. Your brain does, however, because it is wired to respond the way it did 200,000 years ago when it is estimated we came out of trees and started spending our nights on the ground.

There are Three Stages of Healing, and they overlap.

1)Inflammation  2)Cell proliferation; 3) Remodeling:

When the body experiences an insult/trauma, usually something that results in bleeding (cuts, gun shot wound, or abrasion, like a skinned knee) or swelling where a bruise may not form (hornet sting, tic or mosquito bite, or some food allergic reaction), your body and brain considers it a trauma (or injury) demanding immediate healing attention

There are some healing response rules your body follows: stop the bleeding, call in the wound attendants (macrophages, phagocytes) through chemotaxis, and then begin nailing things down with collagen substances called fibroblasts. Mostly occurring in the first 5 days.

After that “Form follows Function” for about 4 weeks, as cell proliferation tries to differentiate (overlapping with the Inflammation and Remodeling phases) what kinds of tissues(specialized cell types) got injured and have to be replaced. Of course we have all heard of “scar tissue” and “adhesions”, part of the first responders.

Well they have to be replaced and the way that happens is following a sequence of functional movements (activities) very often with a physical or occupational therapist (and athletic trainers in some settings) to set up that pathway of functional activities which will best optimize your body’s time schedule for getting back to full function another 4 to 8 month process beginning about 4 weeks out post trauma.

For recovery it’s the Best of Times hoping to avoid The Worst of Times. Well that ole standby villain, infection (MRSA,ORSA) to name those in the news but others just as lethal to normal healing process (some great commercials depict such awful looking and mean spirited anthropomorphisms) are ever on the look out to mess up the healing process.

That’s a pathologists blog opportunity. Here’s where I can recommend Atul Gawande’s book “Better”, a must read to learn how that contrary problem gets a foothold but can be circumvented. I’ll give you a hint: Hand washing!!!

The orthopedic surgeon, physical therapist and occupational therapist have to know some chemistry, physics, physiology, psychology, and culture at the base level of recovery efforts in order to safely guide the recovering tissues, and the body in which they are healing, back to the domestic landscape (stairs, bath room, kitchen, side walk, car), the desk at work, scaffolding, crawl space, the ball field, court, pool, ring, mountain, track. Well you get the picture.

Through it all, FORM FOLLOWS FUNCTION! If your professional recovery assistant doesn’t use that phrase every day to remind you to pay attention, find another orthopedic surgeon. Sure some stuff “just gets better on its own”, but I have patients who say “it’s always been a problem, but figured I had to live with it. Cynics may flippantly say doctors and therapists “just want to make money”. True. Most of us though want to earn it.

Next blog:
What to expect when you see the orthopedic surgeon
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