With any activity that we engage in for longer periods of time there is an increased chance of experiencing an injury. Throughout our lives it is likely that we have had several injuries or pains that have come and gone where some may have been longer lasting or more painful than others. When an injury is longer lasting or more painful we often pay more attention to this and unconsciously begin treating it according to what our body tells us. From rubbing the area (massage), stretching, or using ice/heat we are already beginning pain management strategies to help manage the injury. From time to time these injuries may resurface and this article is designed to help give you confidence in what to do when these injuries do flare up as well as how to prevent flare ups from happening as frequently or as intensely. The road to recovery is never a straight line and one of the most important things to understand is that flare-ups are a part of recovery.

Road To Recovery

With a flare up it is very important in how we manage them as this can be the difference between a short recovery (4-6 weeks) or a long-term battle (8-16 weeks).

 

Flare ups occur largely because recovering from an injury is a learning process for you as the patient. You are learning more about your body. More about how your wrist & hand muscles / tendons respond to various levels of activity. Understanding more about pain (experience of pain) and what might influence it on a day to day and weekly basis.

All of these variables can lead to situations in which we

1. Use our wrist & hands too much after we notice a larger reduction of pain
2. We happen to do something else with our wrist & hand (lifting, carrying, driving etc.) that we don’t realize also utilizes the same wrist & hand muscles
3. We might have work or life stress that can increase overall sensitivity of our pain
4. We progress our exercises too quickly

 

And…. quite a few more. During these flare-ups the pain will feel worse. It might even feel like how it was when you first began recovery. There are two paths individuals usually take in this scenario

 

Scenario 1 – Catastrophizing

“Here we go again, I’ll never escape this pain”

“I’m never going to get better” “This is a serious problem only surgery can fix” “my hands keep feeling painful even though I’m doing everything right, it must be something else going on!” “I should rest and stop using my hand, it’ll make things worse”

“Maybe this isn’t the right approach… I should go back to what my other healthcare provider mentioned”

 

In this situation the individual fears that something more nefarious might be going on and focuses heavily on the pain. As a result he or she might completely stop the exercises, aggressively rest and maintain this for an extended period of time due to fear that something else is going on.

 

In almost all cases, there is no other complicating factor and we hold ourselves back with this doubt and fear. Not only can this increase overall sensitivity (based on what we know about pain) but it also leads to less overall activity which we now know muscles & tendons need to develop its capacity.

 

This typically requires some good education from a physical therapist to guide them towards the right direction while also appropriately managing pain and beliefs around the pain. Depending on this interaction it can get the patient back on track or… continue to extend out the recovery timeline..

 

Scenario 2 – Understanding of Pain and Recovery

“I overdid it a bit with my exercises, this will probably last a couple of days… I’ll focus on just managing the pain and doing as much as I can”

“It’s normal that my pain is elevated since I have been dealing with this for awhile, it will go down if I stick to the exercises & plan”

“The pain is from my lack of sleep and when I used my hands a bit more yesterday”

“I overused it a bit yesterday since I was feeling good, it’s just a minor setback, i’ll be okay”

 

In this scenario the individual has properly attributed their pain to a specific behavior, activity, stressor, belief, and understands that the elevated pain is temporary. They remind themselves of progress that has been made with their functional capacity, rather than focus on how bad the pain is.

4-step guide on how you can manage your flare-up

Step 1: Understand flare-ups are normal

The first step is to ACTIVELY remind yourself that flare-ups are normal. When you have an increase in pain, it is an opportunity to learn more about how your lifestyle, activity and decisions may have led to some irritation. While it may seem unnecessary this mental frame is crucial to adopt as you navigate any flare-up and allows you to properly reflect on what may have led to the flare-up in the first place.

 

Step 2: Reflect and Properly Attribute

If you feel an increase in pain and limited function. There is always an underlying reason. Whether it be:

• How much exercise you did that day
• How much activity and the type of activity (high demand vs. low demand)
• How much sleep you had over the past few days
• Presence of stress and anxiety in your life
• How much you are focusing on your pain

All of these can contribute to an increase in pain and affect your function. Being able to properly attribute what behavior, environment or activity led to the increase is important. The two most common reasons for flare-ups are

1. Increase in activity

When we feel better we feel more confident about the ability to use our wrist & hands. We forget about where we are along the recovery process and jump too quickly back to a level of activity we are unable to tolerate. But sometimes we might increase our overall activity or physical stress without realizing it.

This might be adding some housework, a more demanding work sprint, long drive, game with higher actions per minute or any other activity that we don’t realize is actually of higher intensity even though the duration may be the same. Think back on the entire previous day (or two) before your flare-up to see if you might have just done “too much” with a specific activity. Make an actual note of this because it is something you will have to use in step 4

2. Exercise changes and progression

Whether you are working through an RSI on your own or with a physical therapist you may feel ready to increase the difficulty of your exercises. This can lead to situations in which you decide to increase the difficulty by adding too much weight, performing too many additional sets or reps, or add additional exercises you stumble upon online (gyroball, rice bucket, etc.).

Your exercise should not lead to any increase in pain that lasts for the rest of the day. It should also not lead to a situation in which you wake up with pain and have an altered ability to use your hands the next day. If you experience that… then you’ve likely done too much. To safely increase the difficulty of your exercises to improve your endurance do this:

• When you are able to perform 3 sets of X repetitions (lets say its 12-15) for 3-4 days in a row without difficulty, add 2-3 repetitions per set and assess your response
• Look to make this change at most 1x/week and after the first four weeks of tissue adaptations

Now that you’ve been able to reflect and think more about what might have caused your problem – feel free to track it down. Since it will be your reference point as to what you should “avoid” doing as you get back to your previous level of function or exercise programming.

Step 3: Deload and Manage Pain

During a flare-up the muscle or tendon tissue is irritated. It typically needs time to calm down and widely vary for every individual. For those who are more deconditioned and have dealt with their injury for an extended period of time flare-ups can sometimes last for 1-2 weeks. This longer duration is often influenced by some of the psychological aspects of pain.

However for most other individuals it will vary between 1-5 days and depends on what actually led to the problem in the first place. So your goal during this time is to not only reduce the amount of exercise but also activity.

The general rule is to reduce your primary aggravating activity by around 50%. It can be more aggressive if the flare-up is more severe for you (up to 75% reduction). So for example if you primarily feel your pain with typing:

• Normally you use your PC & type for around 6 hours a day. During a flare-up you might reduce the total amount to 3-4 hours (depending on how bad it is)
• If it is really painful and you feel severely limited in your hand use then reducing to a total amount of 1-2 hours may be indicated. And distributing this total time.

From there you want to focus on pain management. This could be ice, gentle massage, stretching, heat, kinesiotape and medication as necessary. Weather the storm because once it is over you can…

Step 4: Return to Programming

The last step is to get you back to your baseline as quickly as possible. You want to get back to the previous level of ACTIVITY and EXERCISE as quickly as possible.

Do not jump straight back to the same level of exercise and activity. Gradually return to what you were doing previously. Using the same example above:

If normally you type around 6 hours a day and your exercise programming was around 3×15 for all of your exercises you could start with…

• Day 1: 4-5 hours, 2 sets
• Day 2: 5-6 hours, 3 sets
• Day 3: back to baseline

Everyone is different and can likely return to baseline at differing speeds. When you are back at baseline use what you learned in step 2 to avoid progressing too quickly. You do not want to exceed what your body can currently handle so gradually test your limit as you continue to get stronger.

After doing the exercises for 2-3 weeks you might already begin to feel better (often due to nervous system changes and an improved understanding of what is going on). During this time many forget…

• Your bodies don’t magically increase in its capacity within 2-3 weeks

• All of the recent habits and lifestyle changes you’ve made to reduce your pain

From there you fall back into old habits which may lead to a flare-up. Again this is where it is important to take the path of patience and understanding.

Let these steps guide you in the right direction and remember what you learn with each flare-up. It will ultimately help you return to your baseline more quickly in the future.

What Does Progress Look Like?

For many, progress means eliminating pain and though this is a part of progress it is not the only way we should measure progress. The measure of progress should be on FUNCTION aka how much you can participate in your activity rather than how bad the pain is.

 

For example an individual with wrist pain might only be able to type for 30 minutes before feeling 3-4/10 pain. If this person takes a break, the pain will take several hours to reduce. After exercising for 4-6 weeks the individual might be able to type for 90 minutes before feeling the same 3-4/10 pain. And the pain goes back down to 0/10 quickly.

 

The pain itself might still be the same and even worse at times. But the individual can do more. Function is the measure of progress, not pain (and as we know pain is an experience which means it can vary heavily depending on certain contexts and environments).

Exercises Following A Flare-Up

Following a flare up it is best to gradually work up to more challenging exercises, but many do not know where to start. A starting point for many may simply be just moving the wrist is slow and controlled motions to begin. While these may be uncomfortable, the act of you just moving the injured area is unlikely to worsen symptoms. Be sure to listen to your body as your guide and push to some discomfort on a consistent basis (3x/day). Following this or in tandem you can also begin isometric strengthening exercises. 

 

An isometric is a muscle contraction without changing the length of the muscle. What this means is that there will be equal amounts of pressure pushing in opposite directions. There should be no movement within the exercise itself that you would see in exercises like a squat, instead an isometric for the legs would be a wall sit as it becomes a static hold to support a midrange position. Because there is no movement we can be sure that there is less strain on the tendon or joint as we’re preventing the muscle from lengthening or shortening which happens whenever movement is made. This allows us to begin working on gentle strengthening where we are in control of the intensity. 

 

Take a look at the videos below and determine which is best for you to perform based on your pain location. For each isometric exercise perform them in this fashion: 

 

1HP Protocol

Sets, Reps, Rest: 3 sets of 45 seconds holds with 30 seconds rest in between

Intensity: 30-70% effort (The amount of resistance where you DO NOT feel an increase in symptoms or pain)

 

Finger Flexor Isometric 

Helps with: Strengthening wrist and finger flexor muscles

Pain Location: Pain on palm side of the forearm, wrist, and fingers

 

Finger Extension Isometric

Helps with: Strengthening wrist/finger extensor muscles

Pain Location: Pain on back (dorsal) side of the forearm, wrist, and fingers

 

Wrist Extension Isometric

Helps with: Strengthening wrist extensor muscles

Pain Location: Pain on back (dorsal) side of the forearm, wrist, and fingers

 

Wrist Flexion Isometric

Helps with: Strengthening wrist and finger flexor muscles

Pain Location: Pain on palm side of the forearm, wrist, and fingers

 

Ulnar Deviation Isometric

Helps with: Strengthening wrist ulnar deviation muscles

Pain Location: Pain on pinky (ulnar) side of the forearm, wrist, and fingers

 

Radial Deviation Isometric

Helps with: Strengthening wrist radial deviation muscles

Pain Location: Pain on thumb (radial) side of the forearm, wrist, and fingers

Conclusion

Flare ups will very likely happen and if they do remember that this is a normal part of recovery. This article provides a strong STARTING framework for you to manage flare-ups. All of these steps should serve as a guideline, NOT RULES. This is because we are all different. We all respond to changes in activity differently. We all have different environments or contexts that may have led to the flare-up. If there are still questions then continue to explore the website full of many other blog postings or join the community we have on Discord. 

Written By: Brett Becker, OTR/L, ACE-CPT & CMES