Tag Archives: sports injuries

05Feb/15
Persisting sports injuries

Today’s talk at QMUL | pain in sport

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

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

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

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

23Nov/14
Persisting sports injuries

Why do Arsenal and MUFC have so many injuries?

Football injuriesArsenal 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

12Oct/14
Still on the bench?

Athletes still on the bench?

Still on the bench?

Still on the bench?

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

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

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

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

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

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

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

28Sep/14
Chronic pain and injury in football and sport

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

Chronic pain and injury in football and sportOpening 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

25Aug/14

Greatness, smoothness & injury

In response to @simonrbriggs excellent article in the Telegraph (see here) contrasting Federer and Nadal in respect of their physical longevity on the court, I wanted to agree with Simon’s subsequent tweet about the many factors involved with an injury — the line I frequently quote being: ‘no injury happens in isolation’. Whilst I am no tennis expert, I understand that these two masters have very different approaches on the court that define their games. The wicket is more familiar territory, and I would equate this observation to the games of Tendulkar versus Gilchrist. Both masters of the willow, yet styles that illustrate very different means and modes of dominating the ball. 

Sport enthusiasts and pundits alike gush with awe at the ease with which a stroke player caresses the ball. The expert appears to have all the time in the world to position themselves in perfect balance, to be able to effortlessly time the touch, and send the ball at a speed that is vastly out of proportion to the effort applied. Federer fits this mould, and whilst he undoubtedly trains to be fit and strong, he has a technique that is so efficient and so thoughtless that he can focus entirely upon the whole game as if viewing from a point up above. And to take nothing away from the skill of Nadal, his explosive force delivers excitement as he thunderously strides across the court in Zeus-like fashion. As Simon points out, if Nadal were to maintain a physical wellness, his dominance would surely prevail. Who you would most like to be conqueror would then be down to a preferred style, and we love to talk about style.

Returning to the construct of injury that is always embedded within a context and never in isolation to a range of factors that create a situation — no injury happens in isolation. The meaning of an injury is tantamount, and certainly impacts upon the intensity of pain. Cast your memory back to Messi believing that his career was over after he collided with the goalkeeper. He had merely bruised his knee yet the pain was so intense he had to be carried from the field of play in hushed silence.  A violinist who cuts his left index finger will suffer more pain than if I slice the skin on my same digit. There is a different meaning attached to his finger, even with a paper cut. 

Whilst both Federer and Nadal will be accustomed to the pain of hard training and playing, the pain of injury is different. The way we think about the pain at the time of injury sets up the on-going responses and how we chose to behave — it is not the injury itself, but the way we think that counts. Spraining an ankle usually means limping, and this is a sensible behaviour as partial weight-bearing reduces the strain through healing tissues, and is more comfortable. When we know that all is well, in other words that the injury is healing normally (and this is meant to hurt, however unpleasant or inconvenient), there is an acceptance of the necessary steps back to normal movement and activities. The early messages after an injury then, are vital to set up a positive route forward. Excessive fear, anxiety and incorrect messages at the start can set up a pathway of obstacles to recovery. 

Drawing together the smoothness of action that interweaves with other characteristics that construe the greatness of Federer: the technical self-efficacy, rehearsed movements that require no conscious processing and a baseline of fitness and mobility, all of which create a context that minimises the risk of injury. The sublime control, gliding easily across the surface and a ‘oneness’ with the occasion offers only the smallest opportunity for breakdown that most can only dream of, including Nadal whose vigorous assault upon ball and opponents opens the door for stress and strain to emerge, persist and potentially dominate.

Whilst we can swoon over the masters of any game, the vast majority of us play amateur sport. At the level of the masses, I always feel that the risks of injury are outweighed by the benefits of participation — physical fitness, the offsetting of cardiovascular disease, the cathartic outlay against stress and of course the social element (after the game: the 19th, the clubhouse, the curry house…). Equally, whilst the professionals are honing their skills and prowess, amateurs spend a great deal of time around their occupations and families to improve on the fields and courts, imagining achievements on the great meadows of Lords and Wimbledon. I too dream and envision, but returning to diminishing the risk of injury, as the principle is the same whether pro or amateur. And there is no reason why the latter should not acquire the same knowledge and receive the same principled care.

One of the first actions I take is to ensure that the injured person’s knowledge and thinking are in alignment with what we know about pain and healing, and that their choices of behaviour always take them toward and not away from recovery, no matter the start point.  My fundamental belief in our ability to change pain drives my over-arching mission to deliver pain education to all. Understanding pain will inform positive and healthy actions across the board from professional athletes to children to stakeholders (more on this in subsequent blogs). 

Recovering from an injury is straight forward. Most of the problems arise from the wrong early messages and a desire to move on faster than the healing process, thereby disrupting mechanisms that have inherent intelligence. We literally get in the way of our own recovery. We are the problem, yet the injury is blamed. Know the injury, know the pain, know the time line and know the action to take. Simple. One of the issues that Nadal may suffer, as do many professionals, is the rapid return after injury without full recovery, or a lack of time for the body to adapt. This latter problem disrupts the balance of breakdown and rebuild that is constant in the body. Tipping towards breakdown, inflammation persists and causes persistent sensitivity, even at a low level. This manifests as the on-going niggles, gradually becoming more widespread as time progresses and often without an obvious injury. Familiar? Perfectly solvable when you know how and respect the time lines of healing and recovery. Time is money some may argue, but then stepping back and thinking about the longevity of a career provides a different perspective. Deal with this bout of aches and pains completely and create the opportunity for more years of competing as opposed to the stop-start, partial recovery that affects performance and confidence, the two being utterly related. Over-thinking movement and lacking confidence both affect quality of movement — manifesting as the yips in some cases. Is Nadal smashing his way through because he fears that one day he will finally breakdown? Only he knows. Feeder on the other hand as we have seen, has a smooth style that glides him across the courts of the world. 

In summary, to look at the differing styles of play that define Federer and Nadal, it is clear that the smooth approach taken by the former has played a role in his longevity in terms of fitness (lack of injury) and success, the two being related. Simply, the more games you are able to play without a physical hinderance or even the thought that you may have a physical hinderance, for mere thinking affects the way we move, the greater the opportunity for winning titles. So surely, the planning of any athlete’s training and career must consider the ways in which maximum participation can be balanced with time required to adapt and recover. This is the same for both the professional and the amateur athlete, beginning by understanding pain and injury. 

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
Skiing - aches and pains

A quick note on… skiing — pain and injury

Skiing - aches and pains

Skiing – aches and pains

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
Murray to have back surgery

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

MurrayThe 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

17Apr/13
London Marathon 2013

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.

28Mar/13
SportEX

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