Category Archives: Sports Injuries

08Jan/14

A quick note on… skiing — pain and injury

It is that time of year when many set off for the slopes for the joy of being on a mountain, the freedom of sliding, or bumping, down the piste and finishing the day with a favoured tipple, preferably in the sun. Sadly this is not always the case as there will be aches and pains, to be expected, and more serious injuries that require medical and surgical attention.

Firstly, the aches and pains. When we are active in a different way it usually hurts and that is normal. Waking up and trying to get out of bed with stiffness is never fun but it commonly eases off by the time a shower has been had and movement has been initiated. By and large, these aches and pains lessen as the week progresses and we are used to all the physical labours of carrying skis, poles and general clobber by the time we are heading home. I do not know how many people actively seek to improve their fitness before going skiing but many threaten to do so. If you are preparing, starting the week before will probably not do too much, but you may as well give it a go. Don’t go mad and pull a muscle. Ideally, several months before you should be undertaking exercises that in some way replicate skiing. Simple measures such as warming up and cooling down are often forgotten. Warming-up should involve easy mobilisation exercises of the whole body and cooling down in a similar way interlaced with a few stretches of the back and legs. Please note that you should always seek specific advice on exercises that are appropriate for you.

The more serious injuries involving ligaments, bones and tendons will need accurate diagnosis, good early management — that includes you knowing what has happened and everything that you should be doing physically and mentally to optimise healing; and there are many many things that you can do — pain control and a clear route forward of what needs to be done.

If you wish to prepare for your skiing trip and want to know more, or if you’ve suffered an injury that requires rehabilitation, please contact us now to find out how to go about getting back on the slopes and to normal living: 07932 689081

23Sep/13

A few thoughts on Andy Murray and his ‘minor back surgery’.

The news that Andy Murray is to have a minor back operation hit the back pages last week. It is understood that he will undergo a microdiscectomy, a technique that minimises the tissue trauma in order to access the injured disc and the nerve that is being impacted upon by this structure.

Microdiscectomy – what is it?

For the decision to be made, it is likely that a disc has been seen on a scan to be affecting the health and physiology of a nerve root (where the nerve emerges between the vertebrae). In some people this will occur without causing pain but if pain and sensitivity does arise, then it is due to a gradual change in disc health over many months. Of course, it is very possible that repeated movements and in particular rotations with force will impact under certain circumstances. In fact, with any injury that is gradual, one has to consider the combination of circumstance (‘environment’) and genetics–termed epigenetics.

It seems that Murray has been experiencing back pain for several years. Many people who I see are in a similar situation having had pain for some time, often punctuated with more acute episodes. These acute bursts of pain are highly unpleasant and can make moving, working, sleeping and functioning very difficult for a few days and sometimes longer. When it comes to sports people, we can think about the injury or pain as threatening their career, however this is the same for others who plan to return to work following a back operation. Clearly the end point is different but the preparation and early rehabilitation need not be.

Preparing for surgery – see here

I make a point of encouraging a proactive approach to pre-op preparation both physically and mentally. Where possible, you want to be fit and healthy with ‘prehabilitation’, which is a structured programme of exercises to maximise tissue function. Picking up on the rehabilitation after surgery can be far easier if this is done in an orgainsed manner.

Equally, dealing with the mindset and fears that can encroach on one’s ability to train is as important. Understanding the pain, procedure, goals of the surgery and the recovery process will go a long way to reduce the stress and anxiety of an operation – or rather, the thought of an operation prior to the procedure. Using techniques such as mindfulness and relaxed breathing can be potently effective in reducing stress that occurs as a result of negative thinking. Certainly catastrophising about pain can lead to greater inflammation and thereby affect the healing process. We are seeking to optimise healing and therefore dealing with thinking that is overly worrisome can impact upon the immune system in the right way.

Early recovery

This will vary from person to person but in the initail stages it is all about allowing the tissues to go about their healing process, orchestrated by the neuroimmune system and certainly affected by other body systems. Beyond the gradual increases in movement, and tissues certainly need this for good healing, considering factors such as adequate rest, relaxation, good nutrition and a positive outlook are all key ingredients in creating the best possible conditions for moving forward. A range of strategies and techniques can be used including simple mobilisations but alongside motor imagery,  mindfulness, movement of other body areas, the use of music and motivational techniques and cognitive tools to fortify resilience and coping to name but a few.

Rehabilitation is not just about exercising. It is about understanding, learning, motivating, creating the right context for movement with confidence and many more factors that can lead to optimised outcomes.

* Naturally, you should take the advice of your health professional when it comes to your treatment and rehabilitation.

If you are about to have an operation or are recovering, contact us now to learn about our comprehensive treatment and training programmes: 07932 689081

08Aug/13

Suffering surfer

Spending time in the West Country you cannot help but be drawn into the culture of surfing. Whether it be watching the action from the beach, taking a lesson, going shopping in one of the vast array of surf outlets or sitting in a cafe watching footage of surf champs (the most intriguing are those that illustrate the 60s and 70s surfers in sepia without the modern day equipment). So, taking in a healthy infusion of the lifestyle so removed from the metropolis, I asked a local instructor Pete from @KingsurfNewquay (King Surf, Mawgan Porth) about the types of pain and injuries that surfers suffer.

Like most outdoor adventurers, these guys and girls are robust. They don’t moan but rather get on with their pursuit and deal with aches and pains at the end of the season. Of course this may not be the best course of action, however there is a way or perhaps a code that is unwritten but known and communicated with expressions and colloquialisms such as the ‘sea ulcer’. This is not something you find on a rock but rather a breakdown of flesh that struggles to heal despite the fitness of the surfer. Simply due to the repeated friction with certain parts of the board and the hours spent in the sea water, the healing process struggles to keep up with the repeated damage.

Pete tells me that the commonest pains are in the back and knees. Another instructor Nick, adds in shoulders. Both agree that in fact you can experiences aches and pains in different places across the body that seemingly pop up randomly. Of course the reality is that these aches and pains are not random at all, but part of the body’s incredible protective device in action, responding to perceived threats.

Briefly, why would these areas predominate? The paddling action requires a great deal of shoulder use, the back is often held in extension and there is a fair amount of twisting force about the knees. That could be an explanation that would make sense to most people however, we have to ask about those who make the same actions yet feel no pain. We must also consider the fact that any sports or physical activity is accompanied by the pain of exertion that is entirely normal. Most people are familiar with the pain that follows a new exercise regime or an unaccustomed activity that lasts for a few days. This type of pain usually settles, however if you do not allow the body to adapt to the demand, you could further wind-up the sensitivity and see a more persisting pain develop.

Pain is a response to a perceived threat. Who does the perceiving? Actually it is the brain that works out the threat value of what is going on, even if we know the activity is not really dangerous. The problem is that the ‘output’ from the brain when it perceives threat to the body is pain in most cases, and this really feels like you have injured something, even if you haven’t. This is often the situation when we have a persisting problem. In an acute injury, the pain is a vital attention grabber so that we take a course of action to promote survival and healing. It hurts when we move or touch the area which is very useful and adaptive in the first days as the inflammation takes hold and kick starts the process of repair. Other responses include changes in motor control, blood flow and sometimes we are aware the we feel and think differently, more protectively. We guard and make decisions based on how the body feels. This is all entirely normal. As the healing process rolls on, the sensitivity often reduces and movement becomes easier, and we resume activities as before. Often to encourage the right conditions and to ensure that we restore normal control of movement and sense of the body, we follow a rehabilitation programme that may be accompanied by treatment. This is typically effective when we fully understand the injury, the mechanisms and our role in proactively rehabilitating the problem both physically and mentally.

In some cases, and these are the cases that I specifically see, the pain and sensitivity persist or recur. Why is this?

Scientists continue to research why people continue to suffer pain. Approximately 1:5 people have an on-going pain and although many are able to continue with their normal lives, there are those who are unable to work or play. Clearly there is a spectrum and between these ends are individuals who suffer but persevere with their activities. This often includes sportsmen and women who ‘patch’ themselves up and keep going. Admirable though this is, it may not be doing them any favours in the longer term. One major issue is that often it is these individuals who rely upon their body and an ability to be active for their income. This will clearly change the context and as regular readers will know, context in pain is a key factor for the meaning of the pain and consequently the on-going response.

What we do know is that in the early stages of an injury, if the sensitivity builds and causes changes in the central nervous system (central sensitisation) this mechanism will underpin persisting pain. This will typically occur when a nerve is injured. Nerve tissue in the periphery (body) can be damaged like any other soft tissue except that the injury causes changes in the spinal cord and higher centres manifesting as a widened area of pain, changing locations and a reduced ability of the nervous system to inhibit the sensitivity. Altered function of specific cells in the brain stem also affect both the facilitation and inhibition of the flow of danger signals thereby amplifying the sensitivity under certain circumstances. Inflammation can also cause persisting sensitivity from the periphery as the molecules bathe the nerve endings, ramping up their excitability.

The key point to remember is that pain is not an accurate indicator of tissue damage. Phantom limb pain is the classic example with their being no tissue (limb) yet the sensation of pain exists. This is because the brain perceives a threat in a limb that despite not being present, still has a representation in the brain. The body is mapped out in the brain, allowing the brain to know where sensory information is coming from with accuracy and to control precise movement. Motor and sensory function is integrated to create the ‘concrete’ sense of self that we experience. The feeling of our body is constructed by the brain as is the visual field we experience. Both vision and pain share common features in that the brain receives information and creates a reality that we feel and sense to be true. As we know from the great illusionists and many other life situations, our experience of ‘reality’ is hugely variable and often suggestible—how scary is a dark corridor after watching a horror movie? How quickly do we move after repeating a train of words pertaining to youth?

Knowing pain helps us to rationalise fears that we may have and thereby create the right conditions to move forward. To change a state of persisting pain we must be proactive but this requires the understanding of pain, the development of confidence in using the body self-sustaining tissue nourishing techniques and strategies that re-train the way in which the brain is protecting the body on the basis that the real threat is diminishing.

For the surfer who has to keep going for competition or livelihood, gathering knowledge as described above, and integrating a range of strategies into the day will be important in re-learning normal movement patterns rather than guarded postures. Pain has physical, cognitive (what we think) and emotional (how we feel) dimensions, and all must be addressed in an on-going pain state as they are entirely interdependent. For example, regular simple movements of the affected body areas that are tolerable and develop confidence as well as nourish tissues that have often become tense with a consequential poorer oxygen supply, neurodynamic movements to mobilise the nervous system and the interfacing tissues, pacing activities and mindfulness practice. With any exercise routine, it is not enough just to consider the movement itself but also the mindset, any known factors that could prime the neuroimmune system (eg/ fear of movement, stress, fatigue, previous activities) and the timing. I consider a good analogy to be taking a prescribed drug that seeks to alter physiology in the body as does exercise. Except exercise and movement when performed with confidence has a wider positive effect physically and mentally. It is the best drug we know!

Suffering persisting pain is more common than most people realise. With perhaps 20% of the population experiencing on-going pain, we need a wider shift in understanding and knowing our own pain so that we can create the right conditions for change. We are fundamentally designed to change, learn and grow with the neuroplastic characteristics of the neuroimmune system, it is just knowing how to access these mechanisms proactively and in a self-sustaining manner in order to attain the freedom we desire.

If you suffer persisting pain or injury, contact us to learn how you can creat the conditions to move forward: 07932 689081

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16Jul/13

Two excellent talks for athletes

Both talks are inspiring and demonstrate courage, perseverance and motivation in the face of the enormous challenges that were presented. In performance and rehabilitation, mindset is a key determinant and in many cases several skills must be developed, including resilience and coping strategies.

In the first video, Janine Shepherd talks about her experience of recovery following a severe injury.

In the second, Aimee Mullins talks in 1998 about her record-setting career as a runner, and about her carbon-fiber prosthetic legs.

Call us now to find out about our comprehensive treatment and training programmes to tackle persisting pain, recurring injuries and chronic pain: 07932 689081

17Apr/13

London Marathon 2013 | Dealing with the aches and pains

Most runners will have put in the hard yards by now and are set to go. Undoubtedly there have been quite a few aches and pains along the road so far. Sadly this will prevent some people from participating, say in the case of a stress fracture – click here.

It is entirely normal to experience pain as a result of exercising. We expect it after new or unaccustomed activity and recover quickly, often independently and sometimes with assistance (e.g./ physiotherapy, massage). The marathon will be no different as limbs and bodies will be sore on Sunday afternoon and evening, most likely building into Monday and Tuesday before starting to settle. This kind of sensitivity is an adaptive response to the demands placed upon the tissues and physiological systems. In essence it is the body asking for a rest, motivated by the unpleasant sensations.

If there have been more significant niggles during the training period, these may flare-up and require professional attention. For example an issue with a tendon. A diagnosis followed by a comprehensive treatment and rehabilitation programme will be needed to address such a problem or an injusy sustained on the day of the race.

For further information about post-marathon treatment and recovery please contact us on 07932 689081

Clinics in Chelsea – Harley Street – Temple – New Malden

Common running injuries include: shin splints, anterior knee pain, ITB syndrome, iliotibial band syndrome, hip pain, hamstring pain, calf strain, ankle sprain. We see the more persisting and recurring running injuries at our London clinics, delivering comprehensive treatment and rehabilitation programmes that are based on the latest neuroscience.

16Apr/13

‘Get betterers’ and ‘persisters’

Why is it that some people recover from an injury and others take longer than expected or continue to have problems beyond a normal healing time? It’s the latter group that I spend a great deal of time with, helping them to develop understanding of their pain and devising a plan of what they must do to move forward. 

The science of pain has moved on rapidly over the past 5 years with the neuroimmune system revealing some very interesting mechanisms that are fundamental to the pain experience. Groups of researchers around the World are gradually putting together the pieces of one of the most complex puzzles, that of pain, in tandem with modern thinkers who are blending science with philosophy to craft better ways of approaching the problem. This incorporates closing the gap between the individual’s narrative and the objective findings and termed first-person neuroscience.

The evolving understanding of pain as a multidimensional and multisensory experience sounds complex but in fact creates opportunity to tackle pain in different ways. Knowledge of how we prime the neuroimmune system with prior experiences, by the way we think and perceive the World, and how this blends with our genetic make-up is illuminating. There is no moment in isolation but rather a continuum. On sustaining an injury or feeling pain, this is a point in time when a certain threshold of excitability has been reached, triggering a range of protective responses including pain. The pain directs our attention to an area of the body and motivates behaviours that are congruent with healing and survival. Other responses include activation of the autonomic nervous system and changes in motor patterning. How we respond is down to what the psychoneuroimmune systems do to protect us. We feel the effects, sometimes subtly and sometimes like a tidal wave as they take hold. What happens next will depend on what has happened before, how we think and behave, our genetics, the context around the injury or when the pain starts and the state of the neuroimmune system at that point to name but a few. For simplicity I have named responders as the ’get betterers’ and the ’persisters’.

The ’get betterers’ are those who sustain injuries or develop pain (these are different constructs) and simply get better. Sometimes they seek advice and have treatment and sometimes they just modify their activities. The end result is a reduction in sensitivity and a return to normal life. Notably lacking in the early stages of the injury are any signs of catastrophising and excess vigilance to the injured area. Often these individuals have had prior injuries that have successfully resolved, have an optimistic outlook for the new injury and are not too bothered by the inconvenience. Clearly this is a simplified description of a necessarily complex interplay of physiology, behaviour, belief and character. 

The ‘persisters’ often tell a different story. The context of the injury maybe traumatic, the injury may have been poorly

managed and could have created a great deal of fear and anxiety (the latter could be pre-existing). The early focus is surrounded by catastrophic thinking in some cases, accompanied by a set of protective behaviours that although useful as an aid to healing in the acute phase, become problematic as time progresses. Often the early sensitivity and pain are intense and strong, the signals of danger bombarding the neuroimmune system and triggering changes in the properties of these neurons. Subsequent signals are amplified so that normal stimuli (touch, movement) hurt and those that would normally be painful are even more so.

A growing body of evidence suggests that at the point of injury, if the nervous system has been primed by epigenetic factors, the response could be overblown and persist due to the subsequent ‘rewiring’ in the central nervous system. Epigenetic factors are those that are as a result of the effects of the environment upon our genetic make-up. The good news regarding epigenetic effects is that they seem to be reversible if we create the right situation. This is why the thinking around the treatment of chronic or persisting pain must be different.

In a persisting pain state we are not dealing with the acute response to an injury that is unpleasant but normal and necessary. Instead we are tackling an emergent experience (the pain) from the ‘self’ (body) that is underpinned by a complex interplay between the body systems that include the neuroimmune, endocrine and autonomic. This takes a different and multidimensional approach.

How do we do this? We look at the individual and the physical-cognitive-emotional dimensions of the condition and pain. Tackling the problem requires strategies and therapies that target beliefs, behaviours, cognitions, stress, physical health (e.g. tissue mobility, strength etc), motor planning and control (i.e. normal movement), restoration of function, resilience and confidence to name a few.

Following an injury the tissues go through a healing process. Pain and other symptoms can certainly persist beyond the healing time and this is due to changes in the neuroimmune system. There can be little to see on a scan or x-ray in many cases (termed ‘medically unexplained symptoms’, i.e. no pathology or abnormality seen yet the symptoms are fully lived. However, the neuroimmune system is very plastic (neuroplasticity), a feature that allows for adaptation and learning. We can use this to our advantage and create the opportunity  to change the experience of pain and ease the symptoms concurrent with shifting our relationship with pain by changing the meaning. Reducing the threat value of pain (moving from fear/anxiety to ‘so what’) has an enormous impact upon the perception of pain, in a sense disarming the experience.

In summary, some people recover from an injury or painful condition and return to full activities at home, work and in their chosen sports whilst others have difficulty. The latter group require a very different model of care to tackle the problem of chronicity and recurrence, this model being comprehensive, addressing the physical-cognitive-emotional dimensions of pain. Naturally more complex as we must consider (in no particular order) neuroimmune development and priming, genetics, epigenetics, existing beliefs, culture, stressors, altered processing of nociceptive signals, sensory and motor cortical representation changes, altered body sense and the impact upon ‘self’ and lifestyle. Constructing a treatment programme around these factors  creates the opportunity for change, the development of wellness and the optimisation of performance.

 

13Apr/13

Tendinopathy & Tendon Pain | Guest Blog by Dr Peter Malliaras

Thanks to my friend and colleague Dr Peter Malliaras for this blog on tendinopathy – here is his bio

Painful tendon injury or tendinopathy is common and often difficult to manage. Previously this type of injury was known as tendinits, and the suffix ‘it is’ suggesting an inflammatory pathology. For over three decades now researchers have known that longstanding tendon pain may not be inflammatory, so now the popular term is tendinopathy. The pathology that is seen in laboratory studies is effectively a failed response of the tendon to adapt to forces places upon it with daily activities and sport. This is largely because tendon responds very slowly and sluggishly to changes because its infrastructure of cells and blood flow are not as extensive as some other tissues.

It is generally accepted that the key treatment for tendinopathy is exercise. Exercise is the only intervention that can restore a painful tendons ability to take the loads that it needs to in everyday function and sport. A simple formula that I use in clinical practice is to consider the loads that a patient needs to endure in their day to day function and then design an exercise program that progressively allows them to endure these loads without the tendon becoming painful. The key is to make sure that exercise is commenced at a level that will not cause the tendon to become irritable and that it is progressed at a rate that the tendon can tolerate. Every patient that I see is different and how they progress with their rehabilitation and this depends on many complex individual factors, including musculoskeletal, systemic, motivational, psychological factors, etc.

Over the last 15 years the most popular form of exercise that clinicians prescribe is eccentric exercise. This is where the muscle is loaded whilst it is lengthening (e.g. the downwards phase of a biceps curl) and is in contrast to concentric exercise where the muscle shortens whilst under load (e.g. the upwards phase of a biceps curl). An international research group I am involved with, including two physiotherapist PhD clinician-scientists (Dr Peter Malliaras, Dr Christian Barton), a Senior Human Movement Research Fellow (Dr Neil Reeves) and a Public Health Professor (Prof Henning Langberg) recently published a review questioning eccentric exercise treatment for Achilles and patellar tendon injury.

There were four studies that compared loading programs in the Achilles and six in the patellar tendon. Only two studies were rated as high quality. The most surprising finding was that very few studies have actually compared eccentric training to other forms of exercise. For example, only one study had compared eccentric training in the Achilles tendon. Overall, there was no evidence that eccentric training is better than other exercise in treating these injuries. In fact, there was equivalent (Achilles tendon) or more evidence (patellar tendon) to support exercise that involved both eccentric and concentric contractions in combination. So combined eccentric-concentric contractions may be useful in tendinopathy. Clinically, I see mainly second opinion tendinopathy cases and one of the most common reasons they have not improved with eccentric loading is that they have marked weakness of their concentric function. Due to a very well established principle of known as ‘specificity in exercise’, people will tend to get better at the type of exercise they do. So, I always give eccentric-concentric combined loading to patients with concentric weakness. Another important point is that no studies to date have investigated isometric loading in Achilles and patellar tendinopathy rehabilitation. Isometric exercise enables muscle-tendon unit load at a constant joint angle. Clinically, I use this to exercise people at a painfree joint angle that limits compression whilst still loading the tendon. Tendon compression is associated with pathology. It is very effective in the very painful or very compressive tendon presentations, and our review has highlighted that we need more research in this area.

Search for: tendon, tendon pain, tendinopathy, sports injuries tendons, tendinopathy physiotherapy, tendon injury physiotherapy, Achilles tendinopathy, patellar tendinopathy

28Mar/13

Chronic pain in sport | painphysio article in SportEX journal

In the April edition of the SportEX journal you can read my article on chronic pain in sport – click here

Chronic pain and recurring injuries in sport are a huge problem. The modern approach uses the latest neuroscience to tackle the pain and restore normal function required for the particular sport.

Call us for details on 07932 689081 or read more about our treatment programmes here

17Mar/13

All stressed out – stress fractures in marathon runners | Guest blog

 

Dr Cath Spencer-Smith writes…

Marathon season is upon us, and thousands of runners throughout the land are in the final stages of training for their big day. For some, this is also the time when they find themselves experiencing new aches and pains. Whilst we may all expect to feel discomfort and stiffness from time to time, some marathoners may literally find themselves running into trouble, when they fail to heed the warning signs of a serious injury.

Stress fractures and responses are common, and may be overlooked because of the misconception that they only occur in skinny females. Any runner is susceptible to a stress fracture, particularly if they are relatively new to the sport, have gone through a rapid increase in mileage, or have poor biomechanics or muscular conditioning. If a person with a high level of CV fitness (e.g. from road cycling or football), then decides to switch to running, they can be at increased risk as they are able to push themselves hard. A stress fracture is a literally that- a kind of fracture in the bone, which arises when the bone literally weakens when it is overstressed. It is created either through impact forces (which focally overload an area of bone –e.g.in a metatarsal), or through the forces created when muscles pull against bone (e.g. the fibula). This overload brings about an abnormal bony remodelling. A stress ‘response’ then ensues, and eventually the bone actually breaks. During this break down process, a runner will often experience increasing symptoms of pain – maybe at first at the end of a long training run, and then earlier and earlier into each successive run. Some stress responses can occur in the worst possible places, e.g. the neck of the femur. If these progress to a full facture, it can herald disaster for the hip, sadly sometimes ending in a total hip replacement in a person who may only be in their 30’s…

In additional problem we have to consider around Marathon time, is the impact of a stress fracture or stress response on the ability of a runner to be able to participate in the event, when race day comes round. This is probably the hardest part to deal with, for both the runner and the person looking after them. Sometimes, the injury is mild, and there is sufficient time to get runner recovered and robust enough to be able to race. This is sadly not often the case, and for many runners, the discussion of their diagnosis involves a conversation about pulling out of the race. The risks of participating with a high grade stress response should not be underestimated, and on the day of the London Marathon, several runners will literally try to push on through pain, and during the run, will succumb to a fracture.

When we think about the time and effort invested in training for a marathon, it’s no surprise that many runners are desperate to try to participate, particularly if they are running for a charity, or are running as part of a group. Wherever possible, we try to help runners get to the beginning of a race, provided it can be done safely. Each year I meet a runner who is determined to run, no matter what the risks, or potential fall out for him or her in the future. Some runners are cognisant of their symptoms, and yet choose to either disregard them or somehow justify that all is well. Worse still, others around them, including clinicians, can become embroiled in the process of this potentially disastrous decision making. How could, a sensible or experience coach or clinician allow this to happen?. Sometimes, the runner and his support group fall prey of two other ‘conditions’, know is ‘Groupthink’ and ‘Captainitis’.

‘Groupthink’, a term coined by a psychologist, Irving Janis, describes the process by which we can collectively, as a group, make a really, really bad decision. In essence, if we feel loyalty to our group (which might e.g. consist of the runner, their coach, a training partner, and sometimes a therapist), we want to achieve or maintain harmony. Let’s image that the runner finds him or herself in a situation, which brings about doubt – (e.g. ‘is this pain I’m experiencing a ‘tweak’ or a’ big problemo?’), or requires that an awkward decision be made (e.g. ‘is wise for me to keep training, and should I considering pulling out of the marathon?’). Imagine then, that the runner mentions his leg pain to his training partner, who is quick to dismiss it as ‘the kind of pain it’s OK to run through- just ice it’. The coach, who has seen his young prodigy blossom from couch potato to racing machine, is keen to reassure – ‘you’ll get round on the day’, and the massage therapist is quick to declare ‘look how it eases off with treatment – we’ll get you to the start line’. Outside views are purposely avoided by the group, and its members, keen to avoid upset or express concern, develop an inflated (and misguided) certainty that the right decision has been made. And then a leg breaks…

Sometimes the runner’s coach or clinician has their own malady to deal with, known as ‘captainitis’. Some of the individuals were interact with in our lives, may be very capable, and we may hold them in great esteem, or even put them up on a pedestal. We may sometimes believe that the wealth of their knowledge or experience dwarfs our own, which can bring about a strange hierarchy of opinions. When bowing to our ‘senior’ or ‘wiser’ Captain, we may literally choose suppress our own doubts and keep shtum, however personable or humble our ‘Captain’ may be. We feel we don’t want to speak out because our Captain is so capable. Surely Captain knows best? But what if the Captain has got it wrong?

In fact the more capable the Captain, the greater the risk of this. This may seem strange until we consider that the Captain in his capable, confident bubble may be unlikely to solicit the opinions and advice of others. He or she may make the decision for the group alone, not in an arrogant manner, but in a manner based upon the belief that the Captain is deemed to have the best skills to be able to make that decision.

So what advice should we give to a runner in pain, who is not sure of the cause or what to do? Firstly, it is important to own up to that there is a problem and not try to deny it. Seek help, and seek the help of experienced clinicians who are used to dealing with runners. Declare that you have a problem to your friends and family, and charge one of them with the responsibility of ensuring you do this, rather than entering into a collusion group-think situation. And how to avoid the sinking Birds Eye ship? …The answer here is to get your word in edgeways first. This means declaring that you are concerned that you might have a stress fracture, and that you believe you need to undergo some investigations. Do this rather than pausing for a response from the Captain at the point when you’ve finished discussing your symptoms. This will often be enough to trigger the Captain to reflect, and consider that you may indeed have a significant clinical problem… Never be too afraid to speak up, and remember that even if you have to sit this particular Marathon out, you only have 365 days to wait till the next one…

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A big thanks to Cath for writing this piece. For further information please see the Sport Doc website here

12Mar/13

Early messages about pain

Our immediate and early thoughts about an injury or pain that we feel can have a significant impact upon how we cope and manage the problem. It is therefore vital that we have a really good understanding of what is normal and what we can do to optimise the conditions for healing.

Within this early experience, the messages that we hear from those involved including family, friends, team mates and healthcare professionals, can have a profound influence upon our beliefs about the injury that pervade our on-going, personal approach to recovery.

The way in which we behave when we are injured, in other words the actions we choose to take, will be determined by our belief system. This system evolves from a very early age as we learn what is dangerous in life, absorb messages from significant others (parents, teachers etc) and create strategies to deal with pain and injury. Cultural memes are those passed from generation to generation, keeping the story alive. However, these can be based on erroneous information and be perpetuating an ineffective way of handling pain. On this basis, we have an obligation to pass on information that is based upon what we know about pain rather than simply taking the actions of our predecessors, ‘because that was the way they did it’.

The messages and information given to an individual about their injury and pain need to be based upon fact. Imagery provoked by language such as ‘your spine is crumbling’ and ‘your joint is worn out’ can and often do create fear of movement and sensitise our thinking. Thinking is as much neuronal activity in the brain as a movement and we can easily become sensitised to our own sensitivity via this cognitive-emotional route. How quickly can we develop a fear? In a flash.

Imagery is potent. Close your eyes and think about placing a yellow, ripe, juicy lemon segment on your lips and tongue.

The medical management of an acute injury is important: i.e./ diagnosis, investigation, RICE. All of these you would expect. But, we also need to understand and know what is NORMAL and pain is NORMAL in this situation. Unpleasant yes, normal yes. Need for control with medication? By and large yes.

Let’s make sure that we send the right signals with effective language that promotes the right thinking and consequent behaviours.