Category Archives: Sports medicine

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

 

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.

24Jul/14

It’s time to bring what we know about chronic pain into sport

I recall a time when a consultant told me that chronic pain does not exist in private medicine. I was somewhat dumbfounded that an intelligent person could have such a thought. As a far as I was (and am) concerned, pain is classless. This was some years ago, however I am reminded of this when I think about the lack of recognition of chronic pain in sport.

Injury and pain are part of sport and we all know this well. Healthy people engaging in regular physical activity gain the physical and psychological benefits of exercising, but there is a risk of injury. And whilst many people who are injured will heal and recover, resuming their sport, there are a cohort who do not return to full participation and suffer on-going pain. Persisting pain affects one’s ability to perform, self-confidence, self-efficacy and in the professional case, a career. This is no different to the situation with a non-athlete with chronic pain.

There are a number of reasons why an athlete fails to recover including the context of the injury, early management, the development of fear, the understanding of the pain and injury, and the intensity of the pain at the outset. When lecturing on this subject, I tell the story of Messi who believed that his career was over because of the pain he experienced in his knee having collided with a goalkeeper. He was immediately taken for an MRI scan that revealed no injury. Recovery was swift when Messi knew he had not damaged his body. The pain he experienced on the field when he thought his footballing days were over was intense with a meaning that drove into the heart of his emotions, and that of the silenced crowd.

The reasons that pain persist are no different in the non-sporting person: the context of the injury, the state of health at the time, prior pain and injury and how they were dealt with, initial management etc. This being the case, we can bring the modern thinking about chronic pain into the sports arena for two reasons. One is to look at how injuries are dealt with in the early stages, and the other to take a broad perspective in tacking the on-going or recurring injury.

The early management of sports injuries is well known. The aspect to which I refer is the communication about injury and pain. In fact, even before an injury, providing education for players and athletes would impact upon those first vital moments that can prime and set up the recovery. At the point of injury, a whole body, all-system response kicks in, and recognising these processes in their entirety will maximise the recovery potential from the outset. All the necessary processes for recovery are in the human body. The main proponents of disruption are over-zealous treaters, fearful potential recoverers and those who ignore what the body is orchestrating. A careful explanation of the injury, pain and what will happen to aid recovery goes a long way to calming excited protective body systems.

Changing a pain state is entirely possible. Understanding that pain emerges in the body but involves the whole body is vital when considering all the factors necessary to set up recovery. When pain persists there are many habits and behaviours that become part of the problem. These need identification and re-training as much as the altered body sense, altered movement patterns, altered thinking, altered emotional state, altered immune responses, altered endocrine responses, altered autonomic responses, altered self-awareness, altered perception of the environment — we are altered in this state and it involves a host of responses, not set in stone but instead, adapting and surviving. On spraining a knee ligament, it’s not the ligament as much as how the body is responding to the detection of chemicals released by the injured tissue, the perception of threat and how the individual responds to the conscious feelings created by the whole body that drive thoughts and behaviours.

In the light of this knowledge (that has existed for many years), far more comprehensive treatment and training measures have been devised in small quarters. This approach delivers vastly improved outcomes because the problem is being addressed in a way that recognises that pain emerges from the whole. This notion was crafted from the merging of neuroscience and philosophy and is now taking our thinking forward (thanks to Mick Thacker and Lorimer Moseley for bringing this mode of thinking to physical therapy and beyond). I no longer refer to ‘pain management’ as this implies we are not trying to change pain, and I believe that we can and do change pain.

Pain is changing all the time as is every conscious experience. What patients believe is what they will achieve: “Whether you think you can, or think you can’t, you’re right”, Henry Ford. Let us draw upon the psychology of success, create a clear vision and go for it. Every action and thought can be challenged with the question, “Will this take me towards my vision?”. This is the same in sport as it is in the general population and we can use exactly the same principles, just with different end points — everyone has a different end point, hence my push for recognition that chronic pain exists in sport and remains a huge and costly problem for individuals and clubs.

How can we go about this? Initially we must create awareness of the extent of the problem, recognising that a wider approach is needed and subsequently implementing contemporary treatment and training methods that work with the whole person. Understanding the pain mechanisms, the pain influences and the context of the pain for the individual orientates thinking that creates a route forward toward the identified vision. Blending specific training (e.g./ body awareness, sensorimotor control) with techniques that boost self-efficacy and maintain motivation for the necessary steps towards recovery. The recovery is part of the vision and is determined by prioritising the programme and working consistently.

Using comprehensive measures and thinking, we can create the conditions that allow for pain to change in the whole person by allowing body systems to do their work. Our role is to facilitate this biology by what we say, do and advise. Drawing upon the contemporary way persisting pain is approached in the general population, sportsmen and women can access the same benefits, optimise their potential to return to exercise and reduce the risks of recurrence.

Richmond specialises in creating the conditions for people with chronic pain and injury to recover and move forward. When he is not seeing patients, Richmond spends his time writing and talking about pain with the aim of bringing the modern understanding of pain into the public domain for better treatment

Specialist Pain Physio Clinics, London

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

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