Category Archives: Sports Injuries

05Dec/15
40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Henderson’s heel

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Henderson’s heel has captured the front page of the Guardian sports supplement today. The article claims that he has been told to play through pain as there is no cure for plantar fasciitis–the plantar fascia is a strip of tissue spanning from the heel to the forefoot.

In the general population this problem exists and is typified by first steps soreness on getting out of bed. The pain is often noted on walking, standing and running, in some cases being sore and stiff to begin with before easing and then building again.

The usual explanation is overload, but there is more to it than that. As with any persisting problem, it is not just about the blamed tissue, but much, much more. Similar to tendon problems, when the focus is merely on the structure, the outcomes are limited as are expectations:

“…with my heel there isn’t a timescale, there isn’t really a cure….”, said Jordan Henderson, continuing to describe how he feels, “There have been times when I’ve been pretty down because we couldn’t find the answers”.

Pain problems need to be addressed in line with our modern understanding of what pain really is, a protective device in the face of a perceived threat. The point in time when something hurts is not in isolation to what has been learned or believed beforehand, the meaning, the context and prediction of what may happen. Consider the footballer who attaches great importance to the state and health of their body and their legs and feet in particular. Also think about how these problems are discussed and viewed within the culture of football; all the views and opinions and what they are based upon. An injury deemed to be chronic or long-term has great consequences for the career of a footballer and hence the meaning of this pain is different to an amateur player or someone who does not play football. Much like the violinist who cuts their finger, this is more pertinent when they are about to play a concert — we know that pain threshold is lower in violinist due to the meaning and context. There is no reason to think this is different in footballers and their legs. What is the relevance?

Our pain experience is determined by the extent of threat and not the extent of tissue damage. How threatening to the footballer is the notion of a chronic foot problem? Very. Does this impact on the experience of pain, definitely. Pain tells us little about the tissue state, but much about how the brain is predicting what the sensory input (about the body and the environment) is meaning based on what is thought and believed. Already you should be seeing how the ‘treatment’ of such a problem needs more than local interventions to change the way in which the body-brain-environment interactions are manifesting as pain, in this case in Henderson’s heel.

We are designed to change and hence pain can and does change when you understand it and take the wisest and healthiest action. This action goes upstream of where the pain is felt.

Where do we feel pain? In our body, because this is where we perceive our actions, largely created by brain networks and body systems, yet none in isolation and none predominating. All are vital to have a sense of what is happening right now. And what is happening right now? Our reality in any given moment is created by the sum of all the activity in our body and brain within a certain context. This incorporates habits and associations that create the backdrop for prediction; e.g./ Henderson arrives at the training ground, and even at the thought of running around, the systems that protect us are engaging and priming in preparation so that when he begins to run, threat is assumed based on what is known, what has been and what could be. Result, pain in the heel.

Now, of course there can be an inflammatory response as well, and this may well have been detected on various scans. However, there are different inflammatory mechanisms, the one we know well from injury: think of a sprained ankle; and then neurogenic inflammation that is a feature of on-going sensitivity, when the peripheral nerves are stimulated from on high to release inflammatory chemicals into the tissues they supply, thereby maintaining the cycle. Again, predicting that healing is required, the higher centres trigger this response, and it needs addressing, but not just locally. This is the big problem with tendon treatments currently, the focus on the periphery. There must be an interpretation of what is happening in the tissues and concurrent thinking and feeling to make the experience of pain a conscious one. There is not always central sensitisation at play, but there are always higher centres involved with a conscious sensation.

There is much more to discuss and note in relation to the points raised, but for now we can look at the principles that are important for overcoming an on-going pain problem in relation to Henderson’s heel. Considering that pain is about threat value, the over-arching aim is to reduce the perception of threat and hence the prediction of required protection. This begins with understanding pain so that the individual’s thinking is based on the working knowledge that they are safe. Safe that is, to perform specific and general exercises to nourish the body and move for health. The specific desensitising techniques are tailored to the person who feels the pain, considering the existing associations and triggers. A sensorimotor training programme works to normalise movement from the planning level to the actual execution, thereby creating a new layer of experience that forms the basis for the next prediction; the prediction of safety. Building the tolerance gradually, allowing for adaptation is key. There are a number of ways to go about this, but in essence, the programme is to be lived through the day, moment-to-moment to match the lived experience that is pain.

It is the person who feels pain, not their foot or their tendon. Their tendon or fascia is not a separate entity seeking help. They are merely the place or space in the body where the pain is felt. The biology of the whole experience sits within that that creates who we feel we are, and the richness of that experience in that moment. Hence, we must always work with the person: their body tissues, their environment, their neuroimmune system and how the sum of all of this creates their lived experience. Within each dimension, there are a number of actions that influence the whole. This is how people overcome pain — not their foot; the person. And who are these people that overcome their pain? What do they look like?

They look like you and me. They have a working knowledge of their pain that allows them to exercise and re-train on a basis of the true meaning of their pain, a feeling of safety, diminished threat, the creation of safety in situations once deemed threatening, and they match their lived experience of pain with a programme that is likewise lived, health based, strengths-based and they have a clear vision of where they are going based on their values.

Pain can and does change, beginning with understanding it.

Pain Coach Programme for persisting pain — t. 07518 445493

 

18Sep/15
Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

Sports injuries that don’t go away

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

There are many cases of sports injuries that don’t go away. They linger on and on, becoming increasingly impacting as the sensitivity builds, often accompanied with varying patterns swelling and stiffness. Understanding what is happening is the key to deciding upon the right action to change course and recover. The way that your body and you respond is determined by the circumstances of the injury, prior experiences (injured the area before? previous injuries?), beliefs about pain and injury, genetics, the immediate thoughts and messages given by others and the action taken at that point, including pain relief. Here are some of the reasons:

  • The circumstances of the injury: how healthy you are, how you are feeling at the time, where you are, how the injury happened (your fault? Someone else’s fault? An accident? In fact, it is how you perceive it that is important, not the actual reality), your first automatic thoughts, the time of the game, the importance of the game — all of these factors come together, physical-emotional to create a memory of that moment, the pain intensity determined by the perceived level of threat, and not the extent of the tissue damage (consider the player who has a break but does not realise until later). The way you and your body respond to an injury will be very different if you are stressed vs relaxed for example.
  • Previous injuries leave their mark in terms of how you think about them and the associated pain. If you have injured the area before, then there is a greater likelihood that it will hurt because the body will protect more readily. If you have had a good or a bad experience before, this affects how your body systems that heal and protect will kick in.
  • Your beliefs about pain and injury that began to be sculpted in the early days of bumps and bruises and in particular how people around you reacted — too much mollycoddling by parents/teachers is perhaps not great for how we learn to deal effectively with injury; that’s both in the way we think but also how our biological systems work. What you are thinking will impact upon the pain (‘I must get up and play on in this cup final’ vs ‘it is the end of my career’ = very different biologies), and hence the early messages given by the clinicians and therapists must be accurate and calming.
  • It seems that we can have a genetic predisposition to over-responding to injury, with inflammation kicking in as it should but more vigorously. Some people are more inflammatory that others so it seems.
  • The early actions after an injury, including the messages as mentioned above, are really important to set up healing. It is normal for an injury to hurt, however in cases of severe pain, this needs to be addressed with the right analgesia. Early high levels of pain can affect the trajectory of the problem.

For these reasons and others, some injuries appear to persist or recur, which is highly frustrating for the individual, and for the therapists. Sometimes the factors mentioned above set into place a level of sensitivity and certain protective behaviours that mean protection is vigorous — this in terms of the way the person thinks, acts and their biology plays out. This needs to be identified as quickly as possible so that the right treatment can be administered alongside working with the player to developing his or her thinking. Whatever is playing out in their minds will be affecting their biological responses, in a positive or a negative way, so we must intervene or encourage depending on the predominant thought processes.

When an individual is experiencing an on-going issue there are a range of factors to consider and address, some relating to the points above. Hearing their complete story is a vital start point, including an understanding of their perception of the events to date, as well as prior experiences that will flavour what happened then and what is happening now.

Here are some examples of the common features:

  • Often the body continues to try and heal, squirting inflammatory chemicals into the area periodically or in response to movement. This is neurogenic inflammation and sensitises just like inflammation from a fresh injury and is part of the sensitised state, but co-ordinated by higher centres
  • Rarely does the person understand their pain, which creates worry and concern. Remember that chronic stress can make us more inflammatory — also consider other life stresses as these will impact; if the body/person is in survive mode (fright-flight), then resources for healing and recovery are limited.
  • Altered movement patterns, in part from fear/lack of confidence but also as part of protect mode. These must be re-trained from the right baseline (often people start too far down the line and fail)
  • A belief that there is a re-injury when in fact it is a flare up, or an increase in sensitivity, not an actual injury

In brief, we must ensure that the individual’s thinking is right — understand pain and injury, their pain and injury — and that they are taking the right actions towards recovery (a negative thought or over-training will not take you towards recovery); but they need to be able to think clearly about this themselves, because they are with themselves all the time whereas the therapist is with them periodically. They need to become their own coach, which is why I developed the Pain Coach Programme — not only are we coaching them, but also teaching them to become their own coach. When the understanding and thinking is in place, the training and exercises are all straightforward. I use no fancy tools or kit to coach and treat, except of course the most fancy piece of kit we all possess, our brains! But let’s not be all brain-centric; we are talking whole person. It is the person who is injured, not their leg or arm; it is the person who feels pain in the context of who they believe they are and in their life, not a leg or an arm. The person feels hungry, not their stomach. Remembering this when educating, coaching and treating creates the right thinking platform.

Pain Coach 1:1 Mentoring Programme for Clinicians — see here or call us 07518 445493

05Feb/15

Today’s talk at QMUL | pain in sport

Today’s pain in sport talk at Queen Mary University of London (QMUL) for the MSc Sports & Exercise Medicine group focused on modern concepts of pain, in particular the problem of persisting pain. Using plenty of clinical examples and anecdotes, we explored a range of topics including:

  • The enormous (global) issue of pain
  • The dimensions of pain (physical – cognitive -emotional)
  • The importance of the whole person as much as the condition
  • The relevance of the meaning of pain to the individual and how this flavours the pain experience
  • The vital early messages when we talk to someone with pain, and how this can shape their thinking and actions
  • The importance of using the science of pain in dealing with sports injuries.

Richmond holds clinics for pain and chronic pain problems in Harley Street, Chelsea and New Malden

If you would like Richmond to come to your practice and talk about pain and chronic pain, please contact Jo on 07518 445493.

24Nov/14

One injury, and then another…and another….

It is a common scenario sadly, both in professional and amateur sports. One injury, then another and another, each demoralising further. It is noteworthy that the science of pain would say that expectations and other thoughts about the pain and injury will affect the pain itself, potentially increasing the overall threat value — recall from previous writings that pain is a response to threat, and not to just that of the actual injury itself. We must consider any threat to the whole person, and this includes thoughts about oneself and one’s career.

When the body is sensitised by an initial injury, despite healing this sensitivity can persist subtly. In other words, at a certain level of activity there is no problem, no defence. But reaching a new level of training may then reach the current threshold that is not yet back to normal. The threshold is the physiological point where messages are scrutinised by the neuroimmune system that is already vigilant to potential threat. There does not need to be an actual threat, just a perceived one by these vigilant body systems, which then triggers a biological defence: pain, altered planning of movement, altered thinking etc.

The continuous journey back to full fitness requires a complete integration of physical and mental preparedness. As well as tissue strength, endurance and mobility, the controlling mechanisms must switch back to normal settings rather than protect — i.e. the upstream: muscles do what they are told by the motor system that originates in the motor areas of the brain, and the motor system plans and executes movement. The planning of movement not only occurs when the ball is about to be kicked or a run begun, but also when thinking about the acts or watching another. As well as these influencing what is happening, these are also great rehabilitation tools to fully prepare the system for the rigours of the game as well as ensuring completeness of recovery: the player resumes the right thinking, decision-making, motor control as well as fitness.

 

23Nov/14

Why do Arsenal and MUFC have so many injuries?

Arsenal Football Club have apparently reported 30 injuries since August, and Manchester United 37 injuries. Why so many?

Injuries are more complex than perhaps initially thought. It is not simply that a player runs out onto the field, clatters into another player, changes direction or bursts into action. There is a huge amount of multi-system activity, both conscious and unconscious that biologically underpins every injurious situation.

For example, a seemingly ‘simple’ ankle sprain is this: a disrupted ligament releases inflammatory chemicals that excite the normally quiet danger receptors on nociceptors; nociceptors send danger signals to the spinal cord to communicate with secondary neurons that are influenced by a flow of signals coming downwards from the brain. The sum of this give and take reaches the brain. According to whether a threat is determined or not, the appropriate response is pain, drawing attention to the affected area so that the right behaviour can be assumed, promoting recovery and survival. Pain is a need state, driving and motivating action.

The danger signals, for there are no pain signals or even a pain centre in the brain, are chemical messages until given meaning by the emotional centres of the brain. This is based on the context of the situation, beliefs, immediate thoughts, previous experience and the environment to name but a few. The injury is deeply embedded within all these factors, none of which are stand alone.

To illustrate, a professional footballer who sprains his ankle could think: ‘how will this affect my career?’, ‘how long will I be out?’, ‘will this affect selection?’, ‘is this the end of my career?’, ‘what will this cost me?’ etc. The question to ask is how is this thinking likely to affect pain? Are those thought threatening? Of course they are, and hence affect the way in which the body protects. As well as promoting the right environment for healing (bottom up), one has to create the right conditions in all body systems (top down) by cultivating the right thinking and with definite action. Until thoughts and beliefs flavour nociceptive signalling, there is no meaning, and without meaning there is no pain. We need pain to survive, but we also need a logical and rational meaning.

Within the culture of football, there are certain beliefs and memes around injury. This will be the case regarding ankles, hamstrings and groins. Just listen to the pundits to hear their comments on these injuries to know this fact. How much of it is fear-based rather than being based on pain science and basic biology? Tackle this and you are more than half-way towards creating the right conditions for recovery.

Injury is incredibly complex because we are incredibly complex. Drawing upon this modern way of thinking about pain and injury and I believe we can tackle this increasing problem of recurring injuries in sport more effectively.

Persisting sports injury? Recurring injury? Football injury? Call now 07518 445493

20Oct/14

Chelsea FC – ‘long, long’ injury list

Part of the role of being a manager is to juggle the team according to injuries. The list of injured players in The Premiership at the moment is significant. Jose Mourhino described his list as ‘long, long’, hence the Chelsea manager is being forced to consider his options for the forthcoming games. With the ever-growing costs involved in football, questions about players’ availability are now a routine focus for interviews.

Diego Costa is struggling with a persisting hamstring injury. Leg injuries and pain are the scourge of footballer’s careers, but with a change in thinking, many of the on-going problems can be eradicated.

Certainly players work hard on their conditioning to make sure that their bodies are prepared for the rigour and vigour of the modern game. Time away from running and kicking allows for the body to adapt — muscles and the systems that control the muscles. Active rest is vital and should include a techniques that create calm in the body via the mind. We know only too well the potent influence of the mind upon the body and vice versa. Allowing a negative thought about pain or injury to take hold will affect movement and performance. But, there are effective ways of dealing with this and should be routine for both players and managers.

There is a difference between hamstring pain and a hamstring injury. The latter involves damaged tissue whereas the former does not. Everyone needs to understand this and know how to discriminate — by everyone, I mean players, medical staff and managers. With everyone knowing the facts about pain and injury, communication is open and free, meaning that any stress created by worry and concern is eliminated. One thing that is not good for pain is stress. Why? Because the body will be in protect mode, and this is not compatible with recovery.

Understanding pain and injury is the start point. From here, recovery can be planned and implemented, working with all the body systems involved with injury and pain — and that includes body awareness, sensorimotor function, immune function, autonomic function; all involved with protection. Protection is vital in the initial stage of an actual injury, but as healing takes hold, the biology of protection may need a helping hand to switch off.

Struggling to get back to football? Have a player who is struggling? Get in touch and we can work together to return him or her to play — 07518 445493

 

 

18Oct/14

More Premiership injury woe

Headlines today in The Guardian sport section report that Daniel Sturridge is suffering from a further strain, this time in his calf. I do not know if this is the same leg as the thigh strain from which he has recently recovered, but if so, I would not be surprised. In addition, we learn that Raheem Stirling told Roy Hodgson that his legs were sore. Anyone who plays sports will know that feeling.

A second injury or pain on the same side — why?

When we injure a muscle or ligament, inflammatory chemicals are released locally. Danger-sensing nerves (nociceptors) are activated by these chemicals when their threshold of firing is lowered. Danger signals are sent to the spinal cord, where modulation takes place with signals being sent down from the brain — these are in response to thoughts, emotions, context, perceived danger etc. The danger signals are then sent up to the brain via a second neuron, where an analysis of what is happening takes place. On concluding that there is danger, pain emerges from the body in the place where it is thought the problem lies. The body uses cortical (brain) maps to allocate the pain in the body. Put simply, the biology of pain does not reside in the injured tissues but instead involves the protective functioning of many body systems working together.

Once protection kicks in, pain draws our attention to the area, our movement changes as does our thinking amongst other things. This does not involve only the injured body region, but widespread responses of body systems that protect us from actual and potential threat. The original injury goes through a healing process — we have incredibly potent healing abilities — yet the sensitivity and protection can persist. If, for example, the thigh is strained, it is all the ‘wiring’ that involves the leg that will be on alert. Without full resolution, and this includes confidence in the body, the systems are primed and hence during this period it is easier to ‘pick up’ another injury. Sometimes there is an actual injury and damage, but often there is nothing discernible yet it hurts in the same way. Differentiating an actual injury from the sensation of an injury is important. Players and coaches understanding these mechanisms (of pain) is vital in my view, so that these problems can be tackled efficiently. It would be straight-forward to deliver a mandatory, FA backed education package — contact me for details of an education programme.

In summary, why do pains appear on the same side? Because the initial sensitivity has not fully resolved in the case when no actual injury can be found. If there is a strain or sprain detected, there is a good chance that motor control, body sense and awareness and or confidence are not complete. Of course, there is always the possibility of just plain old bad luck, however I would suggest that it is more likely that the body remains in a degree of protection mode.

Aching legs and recovery

Briefly, the body needs time to recover from the demands of exercise. This can be all out rest for a short period but also active rest that would be a lower intensity of movement and activity; a skills based session for example. There are ways of enhancing recovery that include focused movements and body awareness exercises as well as the practice of mindfulness. We have a great ability to adapt, and in fact our body systems are continually changing and adapting to our lifestyles. This is one of the reasons for chronic health problems in a society that is ‘wired’ and ‘immediate’. Put simply, our bodies are not designed in this way.

Educating players about pain, injury, recovery and health empowers them to make good decisions. With coaches and managers also understanding these principles, it creates a positive culture with clear communication about injury and pain. A player should always feel that he can talk openly about how he is feeling, physically and mentally — although I would argue that these are one and the same because we are whole person: genes, character, personality, experience, knowledge, beliefs, mind, body etc., with no single feature standing above the others.

Contact me for information about pain seminars and training at your club — 07518 445493

 

12Oct/14

Athletes still on the bench?

Chronic pain exists in sport. It is a frustrating problem for players and coaches alike, and is accompanied by an expensive price tag in professional sport. Similar to non-sporting injuries, there is initial tissue damage (e.g. a ligament sprain) that triggers inflammation, a normal part of healing, which typically hurts. This is meant to happen as a motivator to take action: to protect the injured body and to change behaviour to allow healing to progress.

The focus of treatment is usually the injured body region. Reasonable, you may think. Indeed in the early stages, it is wise to think about creating the right environment for local healing. However, there are responses that go far beyond the muscles, ligaments and joints. It is worth pointing out here that we only ‘feel’ those structures because of how our brains create the experience, this merely touching the subject on how we really ‘feel’. This in mind, it is only logical to think further than the injured tissue in order to comprehensively rehabilitate an injury.

In persisting pain states that present as an on-going injury or an inability to return to the playing field, thinking beyond the body is essential. Why is this player not recovering? The ligament has healed, the bone has healed, there is little or no inflammation on the scan etc, etc. What is going on? Going upstream of these tissues provides the answers. In fact, going upstream will explain persisting inflammation in many cases, and help to break the cycle.

Pain is multi-system, pain is emergent, pain is whole-person. A range of body systems kick-in when we injure ourselves, and sometimes they do not switch off as you may expect. There are indicators at the time of injury that suggest the route forward will be an issue. These need to be addressed rapidly.

I read and hear about treatment and rehabilitation programmes that focus on movement, proprioception, strength, core and the like. All important, but what happens when these fail to get the sports person back to play? What is the reason? The answers lie in the adaptations of the body systems and the beliefs and expectations of the healthcare professionals and the athletes.

Different thinking is needed for persisting, complex and chronic pain.

If you are struggling to return to sport or you are working with a player who is stuck, get in touch and we can work together to identify the problems and how to solve them: call now 07518 445493 

28Sep/14

Premiership football injuries — all too common, time to re-think

Opening the sports pages this morning (Saturday), the news is abound with the football injuries in the Premiership. Manchester United report nine unfit players just a few weeks into the season. Nasri is ‘out for a month’ as he is due to have surgery for a ‘serious groin injury’ — if it is a serious groin injury and requires surgery, how can Nasri be back in one month whilst allowing for healing, re-training of body sense and control, fitness and an ability to perform free of any thoughts that impact upon his play? A return without fully addressing these fundamental factors will set Nasri up for a greater risk of future problems.

Just as the thinking in pain, the largest global health burden, needs to be constantly challenged, so does the way we think about injuries in football and sport.

Clubs, managers, fans and players alike want a rapid return to the field. The financial and footballing culture demands that players are back as soon as possible. The pressure is great, but pressure is created by the way one thinks and perceives a situation. Change the thinking and a different system will emerge that allows for improved preventative strategies, full recovery and gradual return. 80% recovered is not good enough, 90% recovered is not good enough; unless of course the risk of re-ignition of pain is deemed to be acceptable. We should always aim for a full and sustainable recovery.

There are simple ways of evolving thinking, beginning with players really understanding pain and injury — for example, the poor relationship between pain and the extent of tissue damage, the many influences upon how we control movement and perform, the context around an injury and how this affects the body’s response. This education and training should equally be delivered to managers, coaches and club owners. The biggest issues are the lack of understanding of pain and the communication around the injury. With understanding of pain and clear communication from the outset, there is a strong basis for optimal recovery.

Some pains come from incidents, such as a tackle (direct trauma) or a turn of pace (hamstring strain), and others from a prior injury that has not fully recovered or emerge as a result of the body gradually protecting itself more and more. This latter scenario develops from incomplete recovery from normal training and match play, i.e. there is not enough rest and recuperation time for normal tissue breakdown-rebuild. Both of these scenarios need greater consideration to keep the players playing. And sometimes, the wisest action is that they do not play.

Drawing upon the neuroscience of pain and performance, persisting injury problems in football can be addressed in such a way as to sustainably reduce the risk of re-injury and on-going niggles. We accept that sport can hurt. But when performance is compromised by factors that we can address, for the sakes of all those involved, we can think differently and take the treatment of injuries to a new level that is all about learning and moving forwards.

If you are a player struggling to return to play or a club, call us now to start your recovery: 07932 689081

27Aug/14

Murray’s attack of the cramps

Most active people have suffered the agony of cramping. The uncontrollable vice-like spasm squeezes the blood out of the muscle, the acids build and the oxygen level drops. End result: writhing or hopping around until the tightness eases and pain gradually subsides. It is not uncommon for the effects to be felt for a day or so afterwards, much like post-exercise soreness. Usually there is one affected part of the body whilst Murray reports to have felt the cramping in his thighs, his trunk and forearms, a more widespread pattern.

Murray’s health team will monitor his electrolyte levels closely and implement a diet that optimises his needs. Widespread symptoms that are more suggestive of a systemic biological response is then, less likely to be explained by an issue of ions through dietary or liquid deficiency. However, we cannot totally eliminate this factor as the demands of any particular game are unique, both physically and psychologically — the two being inextricably linked as the whole person responding to a situation. As Murray says, you cannot really prepare for a game via practice. Practice is just that, practice. Hence the requirements are always different.

Nothing happens in isolation. The cramps did not just come on. They were the end result of a mass of biological activity in many body systems before emerging as a response by the whole body and person in an attempt to stop Murray playing at that moment. Inconvenient as this was at the time, Murray’s biology prevailed as it must, and he is subject to his biology as are we all. This biology is influenced enormously by cognition, that is, the way we are thinking, and the way we are thinking about our thoughts (metacognition), how we feel, and how we are thinking about how we are feeling. Understood? For there are chemical underpinnings to thought as much as movement, and movement is far more complicated that one may think. Our motor system is really a sensorimotor system. Actually, it is a ‘sensorimotorimmunoendocrinogastroautonomomusculoskeletal system’. That is no joke either. We are complex.

A thought, ‘I am thirsty’ initiates action in this system because the plan begins at that point — to get out of this chair, walk to the cupboard, pick out a glass etc etc. You may not even do this, but the plan is enacted. In some people with sensitivity, these thoughts and plans alone trigger pain. The system responds to watching others move as well. This is usually
below our conscious level but affects the way we move. In fact, movement is affected by where we are, who we are with, what we are thinking about doing, what we have done, how we are feeling and many other factors. Fortunately this data is scrutinised by the brain on our behalf before producing the required movement. When all is well, the systems work magnificently. When things go awry, it can range from inconvenience to catastrophic. And if it is at the inconvenient end of the spectrum, catastrophic thinking can have a dramatic effect upon the pain. I wrote about Messi’s experience of severe knee pain in 2012 when he collided with the goalkeeper. He thought his career was over because of the intensity of the pain. Examination revealed a bruise. He was playing again the next week. Pain is moulded by the situation, past experience and immediate thoughts.

Having seen huge numbers of people with chronic pain, complex pain and dystonia (a movement disorder that is characterised by unwanted and involuntary movements), one could think of a sportsman’s cramp as a transitory form. In rare cases, paroxysmal exercise-induced dystonia (PED) is diagnosed. This is a type of dystonia that is triggered by physical exertion and characterised by a sudden onset of dystonia movements: involuntary, painful spasms, torsional movements. They come and they go.

Another problem that is familiar is the yips. Arguably best known in golf, this is when a well rehearsed and automatic movement becomes conscious and falls apart. This can only happen if you are an expert. On addressing the ball, the ensuing swing is so natural, honed via thousands of rehearsals and practices, under normal circumstances. When the yips grips, this is forgotten and literally, the player does not know what to do. This is a problem of conscious thought and focus but also an issue of movement, an example of how mind-body are so integrated and bidirectional in terms of influence.

Hopefully Murray will not suffer a further bout of widespread cramping. I am sure that the medical team are looking at the footage and talking to him to establish the possible explanations and causes. It may be a one-off but thought needs to be given to why this happened and what has happened to learn and then reduce the risks of recurrence.