Fear and pain
This is part of an ongoing series of posts on what I have learned from an ongoing, chronic knee problem. This post describes how I injured my knee and has links to the posts I have written about other lessons I have learned.
I have lived with chronic knee pain since 2019. I thought I’d share what I’ve learned about the interplay between pain and fear, and how to overcome the fear inherent to experiencing new physical pain.
Fear
The thing I’ve realized the most through this process is how afraid I was of my body. I’m confident this is part of our broader culture, even if my upbringing amplified this fear. I remember going to chiropractors for my posture and foot doctors for feet and ankle pain. Any pain warranted an intervention and was an excuse for not doing more. I was told to use sensitive skin soap and lotions. My general takeaway is that the body was a nuisance and an inconvenience, rather than a tool or a partner.
Just the other day, I felt a new pain along my spine. I started to think about what I might be doing that caused the pain. Could it be posture? Improper cycling form? Maybe my whiplash injury from 2 years ago is flaring up?
Before my experience with chronic pain, I might have taken it easy at the gym, perhaps avoiding barbell squats. But now I know how to think about it. I knew I hadn’t injured myself; It was just some random pain. So I went to the gym and tested out a low weight barbell squat. It felt fine. I incrementally increased the weight up to my target. It still felt fine. In fact, the pain disappeared altogether at some point during the workout.
When we experience a new pain, we get worried. Some of us panic and go to a doctor immediately.
How to overcome fear
At least for me, overcoming the fear was about learning how to resolve other types of pain and how to live with chronic pain.
When I was a teenager, a doctor told me I need custom orthotics, and I used them ever since. It turns out that this was just keeping my feet and ankles weak, and consequently I would roll my ankle easily, causing pain and even mild sprains. When I used to try walking without orthotics, I would get foot, ankle, and even knee pain after walking less than a mile, and my takeaway was always “see, I need the orthotic”.
A better diagnosis is that my my feet, ankles, and knees couldn’t tolerate the load without orthotics, but that it is in fact possible to train these joints to be able to handle the load.
The most helpful concept I’ve learned from years of physical therapy is the “envelope of function”. The envelope of function is the load, intensity, and/or duration a particular musculoskeletal system can tolerate. My feet, ankles, and knees simply had a narrow envelope of function.
After 19 years of wearing orthotics, I worked with a PT to strengthen my feet and ankles, and now I can hike 20+ miles per day in off-the-shelf shoes, with no orthotics, pain-free. This was an incredibly empowering experience. Even though I’ve been out of my orthotics for several years, I am in aware of what I’m able to do now barefoot or in normal shoes.
Overcoming the fear of the chronic pain was more complicated. I had to learn the difference between tolerable pain and intolerable pain. My knee is in 2/10 and 3/10 pain every step I take - a bit worse going down steep stairs or boulders. For the first several years of chronic pain, I assumed this was unacceptable and that I needed to resolve the pain before I could get back to activities like backpacking and cycling. Now I’ve come around to a different understanding that has served me well: as long as I can do the activity and my pain level doesn’t increase, and I don’t get a spike of pain or swelling within 24 hours, the activity is fine. This is very similar to how arthritic patients are taught to think about pain.
I fully overcame fear once I started to see the body as a system that I can troubleshoot, just as I do at work with software. I expose the body to a new exercise or activity and see the result. Occasionally I seek help from a PT with a new situation, but I’m able to resolve most things myself.