Pain and Muscle Weakness: A Smarter Approach

One common mistake I frequently observe among younger therapists and new graduates is the tendency to focus solely on strengthening when they identify muscle weakness during their objective exams. While strengthening can be an essential component of treatment, it is not always the solution. In many cases, muscle weakness is caused by pain, not by a true deficit in muscle strength. This phenomenon, known as pain inhibition, results in temporary weakness due to discomfort rather than actual weakness of the muscle group.

Understanding Pain Inhibition

Let’s consider a common example: a young, healthy, and active patient presents with anterior knee pain. They experience discomfort when ascending and descending stairs or while running, but they have no pain when walking. They’ve had to stop doing squats and lunges due to the pain. During your objective assessment, you find that their knee extension strength is 3/5, but this weakness is associated with pain.

Common but Ineffective Approach

The typical response I’ve seen from newer therapists is to recommend strengthening exercises, assuming that improving the 3/5 strength rating will alleviate the patient’s symptoms. This often includes various quad-strengthening exercises, such as squat variations, open-kinetic chain quad work, terminal knee extensions (TKEs), lunge variations, and glute abductor exercises.

While this approach seems logical, it frequently leads to worsening symptoms. The patient returns, reporting increased discomfort rather than improvement.

What Went Wrong?

The critical error in this approach is failing to address the root cause of the weakness—pain. In this case, the weakness was not due to a true strength deficit but rather pain inhibition. When a muscle is inhibited by pain, strengthening it without addressing the pain first can exacerbate the problem.

A More Effective Strategy

The correct approach is to treat the pain first. By honing your differential diagnosis skills and understanding the underlying cause of the pain, you can develop a more effective treatment plan. Once the pain is alleviated, the muscle will naturally regain its strength as the inhibition subsides.

In the example of anterior knee pain, I often focus on reducing muscle tone and tightness in the quadriceps, which can lead to increased strain on the quad and patellar tendon, causing the pain. My go-to techniques include:

• Deep soft tissue massage

• Educating the patient on self-massage techniques

• Extensive deep stretching

Recently, I treated a patient with this exact issue. After just one visit focused on pain relief, the patient reported significant improvement, demonstrating how effective this approach can be.

Key Takeaways

1. Recognize Pain Inhibition

   Always consider whether pain is causing the perceived weakness. Identifying pain inhibition can help you determine whether strengthening is appropriate or if pain management should be the priority.

   
   

2. Address the Root Cause

   Focus on treating the pain first. Use your differential diagnosis skills to pinpoint the source of the discomfort and provide targeted treatment.

   
   

3. Educate Your Patients

   Empower patients with self-care techniques, such as self-massage and stretching, to help them manage their symptoms between sessions.

   
   

4. Think Beyond Strengthening

   Strengthening is just one tool in your therapeutic arsenal. Don’t rely on it exclusively—always tailor your treatment plan to the patient’s specific needs and presentation.

   
   

Final Thoughts

I encourage all my students and mentees to develop a deep understanding of why a patient is experiencing their symptoms. Mastering the art of differential diagnosis and addressing the root cause of pain is essential for providing effective treatment and helping patients recover more quickly. By adopting this approach, you’ll not only improve patient outcomes but also build a strong reputation and grow your caseload—ultimately advancing your career.