Here’s a question that’s bound to come up during a course of treatment. Why is it that sometimes I do something and it doesn’t hurt and I think I’m getting better and then I do the same thing again and it hurts. Have I re-injured myself? Am I getting worse?
In very simple terms stuff hurts because of capacity. Every structure in the body whether it is a ligament, tendon, muscle, bone or joint has a certain capacity to tolerate load. In most cases load is good for these structures, for example we need to do weight bearing exercise to maintain or improve our bone density to prevent osteoporosis. Tendons like load as it keeps them strong. Muscles respond to load and get bigger. Every structure will have a threshold at which there is a maximum load it can accept. Beyond that, the structure will start to experience stress and in response it will stimulate some pain or discomfort. Some stress stimulates the tissue as above but too great a load and that structure will fail, for example a ruptured tendon or broken bone. Now here's where the buckets come in.
Think of each structures capacity like a bucket that you fill with water. When the bucket overflows that’s when you get symptoms – pain or discomfort. Everything that works that structure is filling up the bucket with water for example lifting, sitting too long, driving etc. Everything that's good for recovery for the structure is bailing water or emptying the bucket out a bit for example a Physio session, the correct exercises, sleep, anti-inflammatories. The difficulty is that the bucket doesn’t have a 24 hour cycle. It doesn’t start off empty every day. It’s a constant process of filling up a bit and emptying it out a bit. It will fill whenever it fills up and it will empty out whenever it empties out depending on what we are doing all of the time.
This is why somedays you can do something and it doesn’t hurt but doing the same thing the next day could hurt because you’d already used up some of your capacity and therefore you started to overflow. It’s not that that thing i.e. walking/driving has made things worse it’s just that the walk on top of everything else you’d done was enough to cause you to overflow. It’s our job as physios to guide you through the process of figuring out what’s good to put into your bucket and what helps empty it out a bit. Don’t think necessarily of any one activity being good or bad, consider these as drops into the bucket and as long as you’re taking enough out you’ll be able to put more in.
Patients come to us when their bucket is full and overflowing and now they have reached capacity and stuff aches, gets painful or even fails. When a tissue is damaged such as in the case of an injury like tendinitis, arthritis, muscle tears or ligament sprain you will have a smaller bucket, reach your capacity quicker and have to do more of the recovery stuff to keep your symptoms under control. As physios our job is to help patients understand this and give them more capacity in the long run i.e. a bigger bucket!
How big a bucket you have or need depends on the extent of the injury, the rate of recovery, how fit you were to begin with, how it is managed and what you’re expectations are for the future. Every structure within your own body will have a different capacity. There is no one size fits all. The correct management when it comes to treatment, rehabilitation or training of an injured or uninjured part is all about increasing the capacity to tolerate what it is that person is expecting their body to be able to do.
Phase 3 of the 3 phases of physio thinks about the lifestyle and what the patient is putting into their bucket on a daily basis. It's easy for us to think that the only things that will fill up our bucket are physical things like exercise, manual labour, gardening etc etc but everything we do and feel has impact on the rate the bucket will fill and empty. For example a good nights sleep will empty it out a bit, a bad night sleep and you could be ready to overflow just by getting out of bed. A laugh with a friend might get rid of 10-15% of what's already in the bucket but a stressful situation and you won't have much capacity left.
Maybe wine is a better way of understanding this bit. You can have a glass of wine one day and it feels just right. The same glass of wine, same dosage, same vintage, same glass even on another day and it goes straight to your head and feels horrible. Well maybe not horrible but not quite right. That's the day you were probably tired, had a lot on your mind, hadn't slept well, were run down, exhausted, stressed, anxious, frustrated, angry. Who knows but whatever it was the same wine created a different reaction. It won't be the wine itself, it'll be how much capacity you had left to play with before you had the glass.
Pain is the same. The same dosage of activity can be absolutely fine one day and put us over the top the next day.
Like many things in life the bucket fills and empties constantly. Just think of it like drinking water. We put some in, our body uses what it needs and gets rid of the rest. If we don’t put enough in we get dehydrated, things will shrivel, we get pain because of a headache or a kidney stone. Just like our muscles if we don’t exercise them they will atrophy and we’ll have pain on normal activities. If we drink too much water we’ll be going to the toilet all the time or we could over hydrate and develop hyponatraemia – low salt and electrolytes . If we put too much load on our tissues we can develop tendonitis and we have pain for that reason.
Pain can be acting as a warning to let us know we are reaching either end of the bucket. Achy and sore because we need to get fitter and do more exercise or stiff and painful because we’ve done too much. As a physio our job is to help the patient figure all that out. It's not always easy but understanding the bucket theory can help us get our heads around the fact that if it hurts it's not because your going backwards or have re-injured things. It might just be you had too much in your bucket already on that particular occasion.
Maybe a glass of wine is what's need every now and again but not a bucket of the stuff!