Persistent pain and injury in football ~ better outcomes needed
We know that professional football commands an enormous amount of money. Lesser known is the huge cost of persistent pain and injury in football — the players that do not get better as expected. Whilst persistent pain only affects a small number of players, the impact can be significant: career threat, loss of place in team, the team loses a player, the cost etc.
But, pain and injury are part of playing and training. Whilst unpleasant and unwanted, suffering an injury is accepted mainly on the basis that it results in a temporary period of rehabilitation, usually well defined by a timeline. However, when the problem continues and exceeds this timeline, worry can set in, mainly for the player but also for the medical team and the club.
Players at the top end of the game will be thoroughly investigated. The club doctors, physiotherapists and coaches will typically be involved in working out what has happened. They may call upon outside specialists or the player may decide to seek an opinion from an ‘expert’.
As is the case in society, the primary model of care is biomedical, which means that there is a search for a structural issue or pathology to explain the pain and symptoms. And if you look hard enough, you will often find something, however minor. When there is an obvious injury it appears to be easier to diagnose and ‘fix’. In a sense this is true. The anterior crucial ligament for example, can be reconstructed if it is ruptured, or ankle ligaments maybe sprained or a hamstring muscle strained. There is often evidence of the injury and the healing process (e.g./ swelling, redness), and the treatment is well known.
The challenge arises when the player does not get better, or there is no obvious tissue to blame. The model runs out of explanation, which often leads to multiple consultations, a range of different treatments and attempts to solve the pain problem. In essence, much of it is guess work at this point. It may work, it may not. Meanwhile time is ticking and as hope fades and expectations slide, the risk of chronicity builds with each failed treatment.
So, why does this happen? What model should we be using?
Pain and injury are not the same
The simple fact is that pain and injury are not the same and they are poorly related. Most players will receive a full workup when they are injured, including scans and other investigations. This will determine the state of the tissues, but will not tell us anything about what it is like for the player. Piles of data and endless narratives illustrate that what is seen on a picture (scan, xray) and the lived experience (what the person says that they feel and think) are different. You cannot seen ‘funny’ by reading a joke off a page.
Over the past 10 years our knowledge of pain has moved on tremendously. Unfortunately what we really know is not being delivered in society within the standard care, meaning that the predominant model remains based on Cartesian thinking from 1633. On a basic level, it can be understood that pain is about the person, the whole person. There are no pain centres, pain signals, or pain-specific anything. Instead pain is one of the ways we protect ourselves, emerging when there is a perception of threat.
Pain is related to perception of threat, and a significant contributor is the meaning given to the situation by the person. So, it less about the situation and more about how the individual interprets the situation, including their sense of being enable and empowered versus feeling helpless. Pain can also be thought of as a need state, like hunger or thirst. Need states exist to bring our awareness to something that requires attention and motivates action to meet that need. We are meant to feel pain and we are meant to so something about it. The problem is when we do not know what to do and the fear creeps in, adding stress that in turn builds the threat and experience of pain. Classic contributors to pain include chronic stress, tiredness, and expectation of pain.
This is the experience of a thinking, feeling, emotional human being, not just a body part
How threatening is a knee or injury to a footballer? Within the culture of football there is a great fear or dread of such an encounter. The thoughts, emotions, reactions of others, the media, prior experiences, expectations, and more will all contribute to the processing of sensory information from the body as the brain makes its predictions of what it all means before it emerges as a conscious experience: what it is like.
Of course a ligament rupture, bone break or muscle tear will need some form of local treatment, perhaps even surgical. Even the persistent issue will require local attention to improve the health, mobility and strength of the ‘body part’ affected. But, without considering the whole, there will be some, perhaps just a few, who continue to suffer pain, poor performance and other problems because only a part of the problem has been addressed. This is why not only assessing the injury but the whole person is vital, enabling the clinician to understand the player’s response (biological and behaviourally) within the context of the incident.
There has been a welcome and greater focus on player welfare in recent years, in particular focusing on mental health. Fame, money, pressure can come at a cost, which means that support and mentoring are vital for young players. Kieron Dyer described his experiences bluntly in his recent book.
The reality again, is that mental health does not exist in a silo without a body. The mind is embodied, the brain needs a body and we ‘enact’ our perceptions with our whole person. There is no separation, meaning that even the term ‘mental health’ takes us down the wrong path.
Player welfare means that we listen deeply to his or her concerns, we consider the context within which the injury arose, the life circumstances, prior experiences, expectations, beliefs, cultural influences and always think about the whole person. The blend of philosophy and neuroscience has propelled our thinking with rocket-fuel-esque power with enactivism, embodied cognition and predictive coding to name three ‘branches’. It is not that we do not know, it is simply the vast gap between what we know and what is practiced in society.
We want different outcomes. We want to be able to help players with persistent pain and injury to get better. In many cases we can. For this we must use a comprehensive model of care that is based upon the whole person. The biopsychosocial model has existed for some years, yet remains a word often banded about but barely implemented. Reverting to the ‘bio’ is common, and again divvying the three elements as if separate, which they are not. The lived experience sits within the middle of them, as in a Venn Diagram. We can start by listening; the clues are in the narrative.
Persistent or chronic pain does not begin at three months as the text books say. It started a long time before, which is why we have to know the person’s story. We seek to answer the question: why is pain such a predominant feature of this person’s life? What are the needs to be met? Why is the protect state persisting? Why is this player sensitive? Sensitive means that we feel things more: bodily sensations, emotions etc. Is there something in the history that tells us? For example, prior pain problems, recurring injuries, irritable bowel syndrome, migraines, anxiety. We must know the person as much as the condition, as the great literary neurologist Oliver Sacks always said.
Knowing now that pain is related to the perception of threat, you will see the important of reducing threat by developing an understanding of the problem, and learning ways to move forward. Putting the brakes on the worry and focusing on the steps to take to meet the various needs, but always working towards a picture of success, enables and empowers the person. This is strengths based coaching, which I use together with the science of pain to create an individualised programme for people to move forward (Pain Coaching).
The problem of pain is the number one global health burden. It does not need to be. If pain is understood, then the ways forward become clear. We focus on what we want and not on what we don’t want, we practice (the many strategies, exercises, techniques, coping skills and more), we learn to roll with the ups and downs and we keep going, collecting wins along the way. This is the model of success, based on the study of what works and how we can build on it.
On we go to a better society.
RS >> see the #upandrun project from Understand Pain Social Enterprise that combines Richmond’s ultramarathons raising awareness, with Understand Pain Workshops that deliver the knowledge and skills into society