I used this rule everyday of my practice life. It concerns both the patient's activity level and their pain level. 80 (% overall functional and pain improvement) stands for "the injury is better enough to progress", and 20 (only 20 % improvement needed for perfection) stands for "Good Pain". This is definitely a sports medicine approach to injury. Sports Medicine is equivalent to "early motion", "early strengthening", and finding the level of activity that only produces "Good Pain". An understanding of "Good vs Bad" pain in any athlete or injured patient or post-surgical patient that no longer needs Immobilization is crucial in the Rehabilitative process. Therefore, if you want to understand the 80/20 Rule, you must understand "Good vs Bad" pain.
Answers to these questions are at the end of this post:
- Which leg (long or short) tends to have more pronation and why?
- Single heel raises are important for achilles strengthening. What are the 2 positions that they are done in?
- What are some neurological symptoms that would point towards tarsal tunnel vs posterior tibial tendonitis?
- If you have placed an injury (based on your working diagnosis) into the Immobilization Phase, and the pain gets much worse, what would you change?
- Why do we not want the width of an orthotic device to be wider than the shoe itself at its distal edge?
Constant pain all day long is never Good Pain. Good Pain early in the rehabilitative process can take 2 days to calm back down, and later on, only 24 hours. Typically, by the time you want your injured runner to run, they have no symptoms other then at the beginning of the run, and slightly after their run. By the next day, they have no residuals from the previous days run. Therefore the pain is confinded to a 24 hour period. Good pain should never get above 2 on the VAS pain scale, although an occasional stab of intense pain that instantaneously disappears is okay. "Bad Pain" always lives in the 3-7 pain level or higher, can come on during a workout, can cause limping, and can last more than 2-3 days. Weekly or biweekly conversations with your athlete, which can be via phone or email or Zoom or an office visit, is crucial initially to make sure your athlete stays in the "Good Pain" arena or a "Healing Environment".
So, as we follow our athletes and other patients, we make constant decisions on keeping them in 0-2 pain levels throughout rehabilitation. This will insure healing of their injury. We need to balance pain levels and activity allowed. We will take them through the Immobilization Phase, the Re-Strengthening Phase, and the Return to Activity Phase, although there is always blending of these phases. If we can first bring their pain level down to 0-2, and keep it there, we will have a successful rehabilitation.
Why was 80/20 so revolutionary? First came along this new way of assessing pain. 0-2 meant mild pain or discomfort, 3-4 mild to moderate pain with no limping, 5-6 moderate pain with limping, 7-8 severe pain, and 9-10 excruciating pain. Sports medicine specialists found that they could get their patients better by designing programs where the patient would live in 0-2 pain (with infrequent increases). In 0-2, there was still discomfort, aching, abnormal sensations, but the inflammatory response is minimal. Until 80/20, the goal of doctors and patients alike was to obtain 100 pain relief before activity leading to longer immobilization and more pain-relieving medications. Therefore, the 80/20 rule allowed more activity with slightly more pain (within the 0-2), allowed that activity sooner, shortening both immobilization and disuse atrophy and the length of the injury. Truly revolutionary!
The second aspect of 80/20 is the activity scale that must be used to keep a patient 0-2 pain-wise. Let's look at an activity scale.
0-2 Full immobilization with minimal walking
2-3 Limited walking with assistive aids (braces, CAM walkers, Roll-a-Bouts, Crutches)
4-5 Increasing walking without limping (braces still appropriate)
6-7 Re-Strengthening, X-training, with braces, orthoses, taping all appropriate
8-10 Begin normal activity (with the initial emphasis on "begin").
So, by this scale, when you are 80% better activity wise, you can begin normal activities. How does one decide where they fall on this scale? It depends at what level you can keep at 0-2 pain levels. If you look at the scale above related to the Phases of Rehabilitation, 0-3 Immobilization Phase, 4-7 Re-Strengthening Phase, and 8-10 Return To Activity Phase. However, there is a natural blending of all 3 phases. You can use types of Re-Strengthening right after the injury and all the way through the Rehabilitation. You can use types of Immobilization until the Rehab is done and beyond. You definitely learn how to teach appropriate cross training throughout all 3 phases.
In summary, our main goal is to keep our patients active (those that are receptive to the idea), experiment with treatments to get and keep the pain within 0-2 levels, minimize Immobilization, use mechanical and inflammatory and neuropathic treatments as needed to help this quest, and make changes when treatment plateaus when pain or activity improvement stalls.
Answers to above questions:
- Long leg due to its compensatory pronation which shortens the leg and levels the hips.
- Knee straight for gastrocnemius strength and Knee Bent for soleus strength.
- Numbness, tingling, electical, radiating, buzzing, other abnormal sensations.
- Rethink your working diagnosis first. Nerves in particular get worse with immobilization (pain wise)
- The wider orthotic shell hangs up in the shoe limiting any motion you had prescribed, but also holding the foot either too varus or too valgus.
