Category Archives: Tendinopathy


Sports injuries brewing

Sports injuriesHaving seen a couple more cases of sports injuries brewing this week, it reminded me how common this issue is amongst the active population. It goes something like this…..

A minor tweak that improves somewhat, but not entirely, hanging around and occasionally reminding you that there’s something going on. Often dismissed as a pain that will get better in time if I forget about it and think about something else. It goes away for now.

Then another body part or region chimes in, sometimes replacing the first tweak, sometimes in concert. You tell someone who will listen that the pain has moved from A to B, as B now demands some attention now and again. Except now and again becomes more frequent, being more now than again, subtly creeping up on you as a more consistent pain. You may notice that your running style has changed, or that you are not concentrating so much on the activity but instead wondering if it will hurt or why it is hurting. Performance suffers.

I have described a two step story when in fact in most cases the person tells me about their pain and as we look back, there are multiple aches and pains. It is not unusual for there to be a slight change in general health, and most definitely lifestyle patterns influence the problem. This is simply because none of the issues are separate or in isolation. It is the person who lives the experience and hence they are the perceivers of their body and environment (unified) as well as the producers of that perception and the action taken.

What is happening?

Some refer to kindling, like a fire building up over time. There is an injury or inflammatory response during a time of vulnerability (e.g. perceived stress, tiredness, illness), or the person is vulnerable to experiencing an amplified protective response due to prior learning — how their protective systems have learned to interpret the possible causes of sensory input. So each time there is a protective response, the effects grow, the impact increases and all quite gradually in many cases.

How did this happen? This is frequently asked as the gradual nature means we forget about the priming or kindling events on the way to what is happening now.

This is why it is important to fully recover from injuries and illnesses so as not to carry over the effects. To do this, one must restore the normal healthy mode, re-train body sense and movement, develop confidence and technique; in essence feel yourself again, which is to say that the focus is on the performance.

Pain Coach Programme to comprehensively overcome persisting pain and sports injuries | t. 07518 445493

** Common persisting pains from sports injuries include back pain, tendon pain, knee pain, ankle pain, shoulder pain, tennis elbow, wrist pain.


Why tendons get better or not…

Why tendons get betterWhy tendons get better or not… was the question posed. Six of us were lined up to look at potential answers, the areas including isometrics, movement, injections, brain and pain. I was asked to consider brain and pain. Here are my thoughts.

To feel, to think, we need a brain but we are not just a brain. We are of course much, much more. We are a whole person and hence the brain is not the answer to the question why tendons get better, or worse. My main clinical focus is upon those that have not got better, looking at why (the back story, the primers and vulnerabilities) and then what thinking and action is needed now to change course. So most people I see are those who have got worse and in fact, we need to know as much about getting better as we do getting worse. Both are complex but then I argue, we have a greater opportunity to intervene.

The emphasis in my 10-minute talk, a format that is increasingly popular, was upon the fact that it is the person who gets better and not the tendon. What is getting better? What does this mean? I asked myself this question some time ago and followed up with asking ‘who gets better?’ for a talk at a CRPS conference. It has to be the person because it is the person who is conscious and ‘rating’ themselves as being better. The tendon cannot do this — a tendon does not know if it is better or not. Semantics you may think, but important I would say on the basis that we ‘treat’ a person.

A sense of being better results in a person being able to fully engage in their lives as they wish — meaningful living. However, much of our day to day existence is unremarkable, punctuated by situations we remember unreliably. However, we tell ourselves a story about ourselves over and over, with the ‘self’ as the main part in the film. It is strongly argued that the ‘self’ is an illusion: ask yourself where your ‘self’ exists? When you have finished pondering on that small questions, consider again getting better — ‘I’ must rate myself as getting better, meaning that I am able to focus on the task at hand and not be regularly drawn to unpleasant sensations in the space where my tendon (and other tissues) lie or be thinking about the implications of the pain — I can’t do this or I can’t do that etc. So, I concluded that the person gets better when they judge it so and hence the person being more than a brain, but certainly needs a brain, then we have to think wider.

On brain, I also briefly cleared up the seeming confusion between talking about the brain and central sensitisation. Because I argue that we need to address the person (a brain, a body, a context, an environment — unified) to address pain, and that this includes the brain, this does not mean we are saying it is central sensitisation. Without a thought that I have a tendon pain, there is no tendon pain, and hence we must address the top down processing (e.g. thoughts that are underpinned by beliefs, because of what we have been told or learned) because they impact upon the prediction as to what the sensory information means in this moment; the brain’s best guess, which is what you and I are feeling right now. Changing this prediction by minimising the prediction error by taking action is most likely how we are going about getting better.

In terms of pain, this is usually the driver that takes the person to seek help. The pain is stopping the person performing and motivating or compelling action because it hurts. The pain itself is flavoured by thoughts, sensations, thoughts about sensations as a unified experience involving many body systems that have a role in protecting us. Pain is about protection yet is part of the way we protect ourselves with other adaptations including changes in sense of self via altered body sense, altered movement, altered thinking and perception of the environment. With these adaptations occurring over and over, adapting to adaptations and onward, we need a programme that matches pain as a lived experience. What do I think and do now in this moment? The person needs to become their own coach to think and act in a way that takes them towards their vision of getting better, over and over. This means creating new habits, and that is the training programme aspect.

There is much more that can be said on this area, which has many common features with other persistent pain states. We can summarise by agreeing, as we did on the night, that there is no single answer but instead we must draw upon different areas of science and philosophy to ask the right questions and create the wisest programme that addresses pain as the unified experience that it is — physical, cognitive and emotional — but in that person with their story.




Tendon pain

40+60 Feet | Bark |

40+60 Feet | Bark |

Tendon pain has been a big topic for some years. The problem is seen commonly in the clinic and frequently poses a challenge because so often tendon pain persists. Local factors and nociception are typically blamed, yet when treatment is focused at the tissue level, the limitations are exposed. As an aside, tissue based strategies are cited, yet there is really no such thing as a tissue based treatment simply because the tissues are not separate from the person. They are the person, and of course the person knows that something is being done to them and hence emotions and thoughts are at play, affecting the outcome — consider the person who observes your hands whilst you mobilise or massage whilst remaining calm and curious versus the person who is anxious, guarded with their hand poised and ready to grasp your hand as you start treatment; the latter person demonstrating why it is vital that the threat value be diminished before starting any intervention.

Pete’s excellent blog about tendon pain acknowledges the person, perhaps for the first time in tendon literature, which is music to my ears. Having been heavily influenced by Oliver Sacks, my philosophy has always been to consider the person as much, if not more than the condition as it explains how a particular issue manifests uniquely in that person. Certainly in my mind, the ‘initial assessment’ for me is about getting to know the person, which then rolls into their own experience of pain.

I first started looking with interest at tendon pain some ten years ago as an example of a persistent condition in sport. With an interest in chronic pain, it appeared that the discussions about tendon pain remained within the boundaries of where the pain emerged, yet our understanding of pain had advanced to the higher centres and many body systems involved in the experience of pain. Even nociception was discovered as being an incomplete picture as this biological process can be afoot with or without pain. Detection of threat does not mean it has to hurt, and indeed nociception itself is not something we actually feel. However, when the brain (which is of course part of the person and not separate, although our language does sometimes suggest this) predicts the need for protection, pain emerges in the person in a location deemed under threat or potential threat. This complex activity, which includes consciousness and the mind (these are both small subjects……..), is a whole person experience that is lived moment to moment and hence a focus on what happens in the tendon is only part of the picture. There is still very little acknowledgement elsewhere within the hierarchy, so here are a few thoughts I would like to share.

Previously I have expressed the view that we treat, advise and educate a person; a whole person. The approach that I favour is one that delivers the (working) knowledge and skills for the individual so that they can overcome their pain problem and resume a meaningful life as defined by themselves. Fragmenting for convenience is common, breaking down a whole into parts, yet this can never give a full picture. Medicine and healthcare typically specialise and whilst this has value, in the case of a persisting pain that often means that people fall between the cracks. For example, a female with fibromyalgia, IBS, migraines and pelvic pain may be seeing a rheumatologist, a gastroenterologist, a neurologist and a gynaecologist, and whilst elimination of anything pathological is important, there is an understood common upstream biology. Interestingly, many of these cases also have tender tendons that can be a surprise to the person when the tendons are pressed, especially considering that they are not the primary reason for seeking help.

Nothing happens in isolation (is one of my favourite phrases), and hence the biological expressions in and around a tendon are not separate from the mechanisms that underpin how pain arises in our consciousness. We cannot explain how this happens — how do chemical reactions in our body become a lived experience? Despite the lack of an answer, it clearly involves more than the tissue or structure alone.

This is not to say that the brain and the mind alone are responsible. Where is the mind? Where is the seat of the mind? Again, we do not know. Yet surely the mind is not just in the brain, an argument put forward by supporters of embodied cognition. It is me that thinks, not my brain or my mind, but me. And I think with my whole person because I am a whole person, and indeed when I feel pain, it is me that feels pain and not the body part where I feel it. Because I am more than that body part, the experience of pain must involve the whole person in that moment in that context. It is also true to say that to be in pain, we must be thinking that we are in pain as much as experiencing the sensory qualities of pain. Thinking draws our attention to the said experience, otherwise it is subconscious and hence not occurring to me.

For tendon pain, practically speaking, we must of course consider the health of the tendon itself and surrounding tissues, but also the person’s general state (who are they, how are they), prior experiences relevant to the problem (e.g./ tendon pain, pain, general health), beliefs, expectations, vulnerabilities to developing persistent pain, their story of how the pain emerged, their movement patterns (and why they are moving in such a way; both at the planning stages of movement and actual movement), body sense and sense of self at the very minimum. This information is gathered within the first conversation, setting the scene as trust and rapport develops naturally from exploration of their story that validates and empathises.

This is a mere and brief overview of my thinking about tendon pain, which poses a significant clinical problem, often persisting for longer than is expected. Whilst the focus remains on the tendon and nociception, there will be limited results in my view as this only tells a part of the story of the person in pain. This is true for any pain, and not just tendon pain. Pain emerges in the person and all that that person means and embodies, hence we must address the person as much, if not more than the condition. As Oliver Sacks wrote on his father, a GP: ‘He knew the human, the inward side of his patients no less than their bodies and felt he could not treat one without the other’. So true and this has always been my abiding principle.

Pain Coach Programme | t. 07518 445493


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