The Beyond Pain Podcast Episode 100: Do You Need to Know What's Causing Your Pain to Get Better?

DM Us! We love chatting with our audience, please feel free to do so on Instagram and say what's up!

• Joe Gambino
• Joe LaVacca

Want to work with us? Apply here!

Watch on YouTube here.

Summary

In this 100th episode of the Beyond Pain Podcast, hosts Joe Gambino and Joe LaVacca celebrate their journey and discuss the complexities of pain management. 

They explore whether it's necessary to know the source of pain for effective treatment, emphasizing the importance of understanding patient perspectives and the role of physical therapy in addressing pain without a clear diagnosis. 

The conversation highlights the significance of setting expectations and timelines for recovery, while also looking ahead to future topics and insights in pain management.

Takeaways

• This has been a blast!
• Here's to another hundred!
• Do you need to know the source of pain?
• I don't think anyone really needs to know why their pain is there.
• A client's chief complaint is rarely their chief concern.
• We can still help you without an exact tissue diagnosis.
• Exercise can target the whole person.
• What do you want to get back to?
• Pain can take months, if not years, to recover.
• We're excited for the next hundred episodes!

Transcript

Joe (00:00)
Welcome back into the Beyond Pain Podcast. I am one of your hosts, Joe Gambino. I'm here with our other host, Joe LaVacca Change of our normal intro, Joe, because today is our 100th episode. So we've made it a long way, Joe. Long way.

Joe LaVacca (00:14)
Big day.

Almost, yeah, two two

two years. and I gotta say, man, this has been a blast. I've loved doing this with you. I wanna thank the listeners for staying engaged with us and helping us grow, especially over the last few months. ⁓ thank you for that. So we just kinda keep asking, keep sharing it, keep tagging friends or family. ⁓ the more that you can put this out there to the masses, the more we'll have ideas to

Joe (00:27)
Sam's is.

Joe LaVacca (00:46)
get to help other people, but a hundred episodes, man. I I you know I didn't know where we would start or stop, but I'm here for the long run. Here's to another hundred, man. We start at zero. That's cool. That's fair. That's fair.

Joe (00:54)
We start at zero, Joe. We know where we're starting, but we don't know where we're ending. Don't know where we're ending. But

on that note, ⁓ we are doing a little bit of a giveaway for the 100th episode. So if you were to drop our podcast review, all you have to do is screenshot it to either myself or Lavaca over there. So at Joyambino DPT for myself, at Shrentinmotion underscore PT for Lavaca. ⁓ Once you do that, we will.

Joe LaVacca (01:08)
Big, big, big.

Joe (01:23)
Continue our conversation and we will send over a lovely ⁓ Beyond Paint Podcast mug. Mm-hmm. Yes. I like it.

Joe LaVacca (01:30)
Ooh, all right. Coffee mug for everybody. ⁓ make sure

you get on that because if your house is like everybody else's house, you cannot have another mug. Or you can't have too many. So please, like let us let us fit our Beyond Pain podcast mug into your life. And I hope it becomes your favorite mug. And maybe you could even l crack it out every Friday or whenever you listen to the podcast, right? And then maybe you and I get

Joe (01:41)
Yeah.

⁓ I like that.

Joe LaVacca (01:59)
Get some mugs too. So it's we're really creating a mug community.

Joe (02:02)
Yes, yes. I think either way, we deserve some some merch. So we'll we'll make it happen. Yeah.

Joe LaVacca (02:08)
I think so too. I think so too. I I

I think maybe, you know, we have summer gear, we have winter gear. ⁓ I'm I'm into this. I'm really into this. I'm really and I'm really excited. So this has been really, really cool, Joe. Thank you so much. ⁓ I'm always I always credit you as the impetus for this, kind of like pushing us to do this. So it's been a blast, man. And I've learned a lot from you over the last two years and even the guests. ⁓ I've had a blast, like just even people I'd never heard of or never knew about before. I think I've genuinely taken something.

Joe (02:30)
Mm.

Mm.

Joe LaVacca (02:37)
from every single guest. So we got a lot of other ideas for guests in the future. And I think ⁓ yeah, it'll be even more fun in next year.

Joe (02:46)
Yeah. And I think at the end of the day, ⁓ the message here of being able to, you know, get some people listening in, have a positive impact on their life and their pain and helping them move forward. because I sure do know that my journey with pain has been very long. ⁓ so ⁓ if we can give that back in any way, I'd be very happy to ⁓ brings me joy.

Joe LaVacca (03:04)
Ha ha ha.

Yeah, for sure. For sure. I definitely

echo those sentiments as well. Well, before we both start crying, ⁓ as Italian boys typically do, what ⁓ are we talking about today?

Joe (03:16)
He

We are talking about pain, obviously, but today specifically, do you need to know the source of pain? And maybe we could talk about it both from the physical therapist perspective and the client or the patient's perspective. I'll let you take the floor.

Joe LaVacca (03:40)
Yeah, I guess ⁓ I don't know, I guess we'll start from our perspective because that's probably the easiest to to speak to. I would probably say there's very few instances where I actually directly need to know the source of pain to help someone. And, you know, the things that always come to mind are trauma. Did you fall? Did you get hit by something? I probably need to know that, or we probably need to know that in order to correctly guide your care.

Joe (04:01)
Mm-hmm.

Mm-hmm.

Joe LaVacca (04:10)
Particularly I have a few patients right now where the osteoporosis or osteopenia conversation is coming up. And for them, if they fall and they're shrugging off a pain or something that's nagging them, I'd probably be a little bit more concerned about wanting to get them some imaging or something along those lines. The second one would probably be overuse. again, the thing that initially comes to mind as the weather gets nicer.

or shin splints or bone stress type injuries, right? Because I do want to be able to guide you into rest or modifying load as quickly as possible, maybe even getting into some bigger ideas on nutrition and recovery. So I think those two right there are the real big ones that stick out to me. On I want to know about these things, if they exist before we continue, whether we're in person or virtually.

Joe (05:06)
Mm-hmm.

Joe LaVacca (05:08)
Do you have other ideas off the top of your head that stick out to you?

Joe (05:15)
The probably like the first one as we were talk as you were listening to them off, like bersitus kind of like came into my mind because they just don't typically enjoy being stretched, right? So it might change the way that we might go through things. But in general, I don't really know if we need to know the exact source of pain. Because mainly, I mean we're A

I mean, in the physical therapy world, right? We don't we don't come up with the medical diagnosis. It's nice if we can get close, right? So we can make decisions. Do we need to refer out? Do they need to get imaging? Do they need stuff like that? But mainly we just need to know what areas, what movements are irritated or not, and where their movement limitations are so that we can slowly start to reintegrate, either bringing down the pain response or slowly improving that tissue's quality and resilience, right? So and I think if you can

Focus mostly on that, you can tend to to help a lot of people. And if you can't, then you're probably missing something that tells you, okay, maybe you really d do need to know the source of the pain and the imaging needs to happen to to help figure that out. ⁓

Thoughts.

Joe LaVacca (06:27)
Yeah, I think ⁓ obviously I I definitely agree with you. I think the other ⁓ sort of side of this with you know when we kind of get into more like soft tissue based things like a bursitis, a tendinitis, I I I I find that sometimes those are are hard to sometimes distinguish because I remember being at a course years and years ago and the instructor saying, you know, bursitis and tendinitis kind of go together like gin and tonic. So if you have one, you could probably assume the other.

But I think that conversation, and maybe this is the the second point about kind of maybe knowing generally where we think the the pain is coming from, just sets us up for a prognosis with someone. ⁓ if I think your pain is a little bit more tendon-based, and and this could be because of ⁓ it's irritated with activity, it's irritated with certain positions, particularly when those positions involve some compression. So, you know, around your hip, if you're sitting for a long period of time.

Joe (07:06)
Mm-hmm.

Joe LaVacca (07:26)
You compress some tendons, they don't feel great. Shoulders, you know, same thing. I'm laying on that side. People are like, I'm not even using my arm. Why can't I lay on it? And I think that goes hand in hand with what you were just saying, right? Like I have bersitus, I have tendonitis, they together like genitonic. So they're going to respond to either pressure sensitivity or load or movement-based sensitivity. But if I have that notion in mind, then I can tell people, hey, tendons take time. You're not doing anything wrong when you still have pain six months down the road.

Joe (07:51)
Mm-hmm.

Joe LaVacca (07:56)
Nine months down the road. And in fact, it is quite common or maybe even expected for you to have pain down the road. So I think when I have a general idea, not that we can always be perfectly infallible because none of our tests are really infallible. Even your MRIs and your scans and everything else, they show anatomy. They don't show a painful experience in your body. But I can at least tell people, hey, don't give up after four weeks. You know, this is going to be a long road.

Joe (08:08)
Mm-hmm.

Mm-hmm.

Joe LaVacca (08:25)
So instead, what's important to you? Whether you want to get back to some specific activity like gardening or playing with your kids, what's your baseline right now? Can you only manage gardening for five or 10 minutes? Can you only manage playing with your kids for 15 or 20 minutes? Well, let's set that as our base and slowly bring that up to a time that's desirable for you. It's the same thing with any kind of gym routine or lifting routine. A lot of clients I have with tendon base pain will see.

Joe (08:33)
Mm-hmm.

Joe LaVacca (08:54)
Their numbers go up in the gym, but then still report very similar pain for a prolonged period of time. But because we had that conversation up front and they knew that this was normal, they're not alarmed by it. So they're not going for more testing, they're not going for injections, they're not stopping, they're not going light because they can see that their goals are the things that are important to them, can sort of ⁓ or they have a path forward for that. So I mean.

Joe (08:58)
Mm-hmm.

Mm.

Mm-hmm.

Joe LaVacca (09:25)
Do you think of any other things like with timeline that could be important for like understanding like what tissue or what we think could be contributing to someone's pain?

Joe (09:31)
Yeah.

Yeah, I think to answer also like the the question at the top, right? Like from ⁓ like do the patients need to know? I mean, I don't think anyone really needs to know like why their pain is there, right? I think ⁓ to to get better. ⁓ but I think everyone likes clarity and likes to know what's going on and and like what the plan is forward. And I think that's where if you can assess and have a good idea of okay, like these are

the potential tissues that are irritated. And then obviously like with every session, right? Like we're now reassessing to make sure that our decisions are somewhat accurate and that we are improving and things like that. And do we need to modify our plan? But when you get that information, you're able to tell, hey, like this is very likely why your pain is here. That helps the buy-in, helps them have confidence what we're able to do ⁓ timelines for recovery is is important.

⁓ and then having this kind of like both us as the provider and the the client, right, working together now ⁓ moving forward. So I think that's probably where the most benefit of being able to figure out okay, it is this specific type of tissue, this is how we're gonna be working for, this is how long it's gonna take, right? And the more we can educate the client, I the more they're gonna trust us. And I also think then they're gonna

Trust the processing and kinda go with it. And if you were just gonna say, like, yeah, it's serve over here, you know, and and didn't give them too much clarity, right? I don't think anyone's gonna probably wanna come back to see you.

Joe LaVacca (11:11)
Yeah. Yeah. And I think

⁓ you know, from from a patient perspective, and obviously every patient is so different, you know, their experiences, their perspectives, their history. But, you know, you reminded me of a phrase I'll often teach about a lot is ⁓ a client's chief complaint is very rarely their chief concern. And I think that knowing the difference or trying to understand that difference when you're in that initial encounter with people is really important.

So the example, I I had one just literally this week. A lady came in and her chief complaint was knee pain. Now, as we were talking, I can tell that activity meant a lot to her. She was you know doing CrossFit and lots of other things, including running and biking, you know, you name it. You she's doing all the ings. She really identifies with movement, but my knee hurts. And as I was kind of listening to her.

I just sense a little bit of apprehension or fear with getting back into the squatting or the lunging or the biking and all these things that she enjoyed. And she kind of threw out a a very quick, like passing thought about her dad. Again, like very benign, almost kind of flew under the radar. But it prompted me to hear a little bit of this concern or fear in her voice. And I just said, Hey, did you ever have any family members by chance who

Joe (12:28)
Mm.

Joe LaVacca (12:40)
Had similar pains that were not able to go back? Or do you know any friends that had similar pains that required surgery or they couldn't get back to the things they love? And she immediately started crying. And she was like, Yeah, ⁓ it was my dad. ⁓ he had really bad knee arthritis. ⁓ it started much later for him, but it got to a point where he needed a knee replacement, and then he was never the same after that. And now I am

Joe (12:52)
Mm.

Mm-hmm.

Joe LaVacca (13:09)
concerned that this is happening to me. Right. So you know, regardless of where quote unquote the pain driver was coming from, I knew that my assessment had to kind of alleviate those concerns for her. Right. So I was very flat when I told her, I said, okay, great. Well, we can look at this, right? When you're thinking about a joint, joints need to do certain things, right? They need to flex and they need to extend at the knee. ⁓ you have bones that need to rotate. I was like, so if you had, you know,

Joe (13:09)
Mm-hmm.

Mm.

Mm-hmm.

Joe LaVacca (13:37)
Any sort of joint irritation or swelling or anything along those lines, we should be able to pick it up right here. We won't need a lot of scans or or other things like that. ⁓ so why don't we just start there? And that's all we did. And I took pictures of her range of motion side to side, and I was like, hey, look, you know, the knee that doesn't hurt, it looks like this knee does all the exact same things that your other knee does. Right. Now you're you're active, you already told me that you have a you know a genetic predisposition to maybe arthritis.

Joe (13:45)
Mm-hmm.

Joe LaVacca (14:04)
Does that mean that you're gonna definitely have arthritis like your dad? I don't know. But here's all the things that help: not drinking, not smoking, managing your weight, right? ⁓ staying active. And she was like, Yeah, you know, I don't drink, I don't smoke. ⁓ I've always been this weight that I have. Great. Okay. So now the next thing is finding activities you enjoy and sticking with them. And then as as we kind of did more and more of our assessment, it just seemed like she had maybe just more anterior knee pain or patelfemoral type pain syndrome.

Joe (14:28)
Mm.

Joe LaVacca (14:30)
And then we had a conversation on just load management. Hey, this is going to be one of those things that's irritated potentially for a while. It could take years for some people to fully ameliorate this pain. But if you're thinking about your dad and you're thinking about, you know, what makes my joint healthy, here's all the things that can do that for you. And I think that's kind of not maybe something we talked about a lot, but I do think that matters when we're talking about this conversation now of well, what's my pain driver?

Joe (14:39)
Mm.

Yeah.

Joe LaVacca (15:00)
And really how is it impacting not only my life now, but my thoughts about going into the future? And I'm sure you've had people with that same idea, right? Chief complaint, chief concern.

Joe (15:05)
Yeah.

Mm-hmm.

Yeah. And I think ⁓ what was gonna say is is, you know, why we should always be looking beyond just like what is the so called tissue that is irritated and like what are the actual movements and how is it impacting your life? Because somebody can come and it happens all the time where they have they've got the imaging, they've done all this stuff and everything is perfectly fine from an imaging perspective, right? But then they are they've been navigating pain for

Who knows how long, right? And they'd be they just keep getting, I mean, I've heard it over and over again where doctors tell them there's nothing wrong with them, other PTs and Kairos say I can't really do anything for you at this point, right? Because the the imaging is clear. And we do know that maybe, you know, sometimes you just have an elevated pain response where there's really like nothing specific going on, right? ⁓ especially if we're about like lower back pain, right? Like non-specific lower back pain is the majority of cases. And

You know, maybe you can't even like lock in on like a very specific structure that is driving it and we just need to kind of get them moving and get through fear, apprehension, and other things that might be limiting them from a from a stress ⁓ standpoint. so I think when we're really looking at things overall, like looking at the whole system, the whole body, recovery, stress, life, ⁓ becomes an important part of the

human, right, in order to help them solve ⁓ solve especially long term pain. so I think that was that was well said.

Joe LaVacca (16:42)
Yeah, and ⁓ you've touched on a couple of points now already, but I think th the the last thing I always think about is ⁓ yeah, I I maybe want to have a general idea on how your pain behaves. But I don't necessarily need to be a hundred percent accurate because like you said at the beginning of the podcast and just now, I wanna know what you want to get back to. I wanna know why you can't get back to it. And then our assessment should sort of guide us in that direction. ⁓ if you know, whether you're talking about your knee or your back, does it have sensitivity to bending or

Joe (17:06)
Mm.

Joe LaVacca (17:12)
Extending. Does it have a hard time with producing force? Does it have a hard time accepting force? And then these are all things that we can learn from the assessment and say, hey, look, I'm not a hundred percent sure what is happening or what your main pain driver is, but it seems like it's behaving this way. Here's what I can say for certain: there are no red flags, there's nothing big and scary that we found in your assessment. This is a very ⁓ common presentation of.

Joe (17:28)
Hmm.

Yeah.

Joe LaVacca (17:41)
Symptoms. We see lots of people like this day in and day out. So knowing what we want from you allows us to either design a plan, alter what you're currently doing, and then set some expectations together. So I think that all in all, do I need to know, you know, where your pain driver is to come from to help you? No, absolutely not for all the reasons that you said and that we said. I do need to generally have

Joe (17:45)
Mm-hmm.

Right.

Joe LaVacca (18:09)
maybe a bucket or idea, knowing that all these buckets sort of like overlap with one another, just so I can set expectations and timelines for you to kind of keep you motivated, to know that, hey, I'm in this for the long haul. I know it's going to take you months, if not maybe a year. And people accept that with surgery, which is always funny to me, right? You get a surgery and you automatically accept in your mind, wow, this is going to be a year or more recovery process. And then when you kind of come in without that,

Joe (18:13)
Mm-hmm.

Mm-hmm.

Joe LaVacca (18:37)
Surgical experience, you're like, well, why isn't this getting better right now? And it's like, well, hold on. We we fixed it with the surgery. Literally. That's what the surgery did. It fixed it. And it's still going to take you a year to recover. So why wouldn't you think that it would take maybe at least that long for you to really hedge everything that you want to do, create this sort of well-rounded knee tendon, back, whatever? Because if it's all good after the surgery and you can still accept that, then you know, why aren't we readjusting our

Joe (18:39)
Mm-hmm.

Mm-hmm.

Mm.

Joe LaVacca (19:07)
or field goal posts here a little bit, you know, together in rehab. So I think, you know, to sum up for me, it allows me to just rule out anything red flag, trauma, overuse. ⁓ but one thing, and maybe ⁓ maybe this is like a little breadcrumb for later on. I have tried to soften my stance with the X-rays and the MRI things just because I think I maybe went too far to the pendulum, right? Of like they really matter when I was a younger clinician and then swung all the way over to they don't matter.

Joe (19:08)
Mm-hmm.

Mm-hmm.

Mm-hmm.

Joe LaVacca (19:36)
and now I'm kind of very more in the middle. So maybe that's something else that we can talk about in the future. Like when do your scans matter or not matter? And have you changed your viewpoints on them over the years? I'd be interested to hear that conversation too with you, Joe.

Joe (19:42)
Mm-hmm.

Yeah, we could definitely

⁓ I think that'd be a good topic. I have I have some thoughts for ⁓ for sure. But I think same my take on imaging and even surgeries have probably changed over the course of time where it was like we don't really need we can do all this other stuff. And then being able to identify, okay, like this is a good time to maybe go get imaging. ⁓ or maybe it's time to start considering

Surgeries or cortisone shots and all that other stuff. ⁓ I've definitely changed my thoughts on that stuff over the course of time.

Joe LaVacca (20:25)
Yeah, for sure, for sure. So I think big picture with patients, don't worry if your PT can't give you an exact tissue diagnosis because we can still help you. And exercise and interaction target so many different things, like you, Joe, were pointing out, with a whole person. And that's what I think makes us a lot different than the cortisone injection and the pill. The cortisone injection or the pill.

Joe (20:37)
Mm-hmm.

Joe LaVacca (20:52)
Or even the surgery is targeting one very specific thing at a time. But you know, through our interactions with clients, through movement-based therapies, through graded exposure, through exercise, we can really target the whole person. So I really think that that's what is the biggest gift of physical therapy, rehab, movement, exercise, you name it.

Joe (20:55)
Mm.

Mm-hmm. Yeah, I like that. And I I was gonna say ⁓ something that I've been talking with like potential clients and even my my clients as far as how the like I've always had a really hard time of like like what's my process? You know, like how does it all work? Like, how do I like tell somebody like this is this is how it is? And this seems to have been hitting home a lot more, like trying to like it's like a very mechanical answer, which obviously rehab in our body is not.

But thinking about it from a perspective of, you know, versus just thinking like, what is the tissue that is irritated, right? Like, okay, we can we can get that answer. a lot of people think of like, you know, my glutes don't activate, or like we can become very muscle specific, right? Okay, hey, my core's not firing, my muscles aren't firing. And therefore, like then if we think about that, the the answer is well, we give exercise to that area. But if that doesn't work, then there's probably something else.

going on that's preventing you from activating or feeling like these areas are working right or bringing down your pain or whatever it is. And what we're trying to do is during this process, right? Like asking what all of your goals are, what do you want to get back to? And then figuring out where you are today and what's happening in our assessment. But once we have that, we can start I I I like to think of things as like a parts to whole method from here. Okay, well, your glutes not firing. Well what is the reason for that? Do you lack

Joe LaVacca (22:29)
Mm-hmm, mm-hmm.

Joe (22:33)
Hip rotation? Do you lack hip extension? Like, are there physical limitations that can make it harder for your body to create a

neurological connection to give you a full output there. And if there's not, it doesn't matter how many times we're activating this area, as long as these underlying things happen, we're going to continue to have to just you're going to have to do all the activation drills in the world to try to feel better. and then we can take that and layer it on as we're getting to more higher level stuff. If you wanted to play golf, but there's pain when you're bending forward, well it's going to make sense that like add impact when you're playing golf, right? Like your body's going to

Joe LaVacca (22:46)
Mm-hmm.

Joe (23:12)
probably start to hurt because you need to do all those positions there. So when we work backwards now, we can start to give your body the the tools, right, to do the things that you want to do with less pain. And that kind of description of how we get there has been very helpful of recent. So I figured I'd share that to you and the listeners.

Joe LaVacca (23:32)
I love that. I love that. And I think even like a full dive into the process could be another breadcrumb for some episodes coming up. So I think we want to get on some doctors and surgeons because like you said, I think our stance on this is maybe softened or changed over the years. So it'd be nice to maybe get a little different viewpoint there. ⁓ maybe we talk about processing, maybe we talk about imaging and all that stuff. So lots of exciting things, guys. Right. We said, I mean, if you if you enjoyed the first hundred.

Joe (23:37)
Mm, mm-hmm.

Joe LaVacca (23:59)
You don't even want to know where me and Joe are gonna go over the next hundred. So please, please keep coming back. And as a reminder, Joe, what are they the what what are they what do they get if they drop a review?

Joe (24:11)
They're gonna get a sweet mug that hasn't been fully designed yet, but maybe that's the we'll we'll get there and we'll we'll we'll share this on social media as well. ⁓ but yeah, we're gonna get a nice sweet coffee mug that will join your collection. You're gonna have to stack it on top of some other mugs in your in your cabinets because if you're like anyone that I know, you've maxed it out. You've maxed out space no matter how much space you have.

Joe LaVacca (24:34)
Exactly. Yeah. So

drop your review, screenshot it, ⁓ DM it to Mr. Joe Gambino over there at Joe Gambino DPT or myself at strengthemotion underscore PT. And we will reach out about how to get you your mug. Joe, thank you for another episode. Thank you for the last hundred episodes. Listeners, thank you for this episode and sticking with us all this time. Much love.

And don't forget to come back next week for another exciting episode of the Beyond Pain.