Tag Archives: sports injuries


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


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


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


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.


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


Early messages about pain

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

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

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

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

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

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

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



Another hamstring injury, but how serious is it?

The hamstring injury is one of football’s blights, affecting so many of our best known players. The latest is Andy Carroll who sustained the injury yesterday in his first game at West Ham – read here. The extent of the injury will be clearer following a scan. Hopefully this will be a minor insult that will be fully resolved with a rapid, yet safe return to play.

A study published this year in the BMJ looked at the use of the MRI scan as a prognostic tool for lay-off after hamstring injuries in professional footballers and the association between the MRI findings and injury circumstances. It was found that: ‘70% per cent of hamstring injuries seen in professional football are of radiological grade 0 or 1, meaning no signs of fibre disruption on MRI, but still cause the majority of absence days’. This is an interesting point as it demonstrates that significant time out of football for hamstring problems is not underpinned by serious tissue damage. We know that pain is not an accurate indicator of tissue damage and certainly I have seen many patients who experience repeated injury, yet there is no clinical evidence for an inflammatory response, the early stage of healing.

The seriousness of the injury can be measured by the impact it has upon the player’s ability to perform. This would include the time it takes to return to the field. It appears from the aforementioned study that the tissue basis for the injury does not explain the extent of the lay-off. What other factors could play a role?

The circumstances around an injury include the state of the tissues and mind in the lead up to the incident. Nothing happens in isolation. There is a background to any injury, even if it is sustained during a tackle, sprint or other seemingly unique event. The background includes general fitness, tissue health, stress, emotional state, hydration, fatigue and a previous experience of injury, particularly if it is in the same body region.

A new or recurring injury – what to do?

Therefore, when assessing a new injury, pain or recurrence, it is vital to consider these factors to establish early on the potential risks for longevity of the condition. A rapid diagnosis, reassurance and a plan certainly help. The player needs to know what has happened, what can be done and what they will need to do to get back to the field of play. This is the same for any level of participation. The immediate way in which the inury is managed and thought about by the player can have an impact upon the recovery. For example, if the injury is ridden with fear and concern, often unhelpful choices are made with regards to self-treatment. Knowledge allows for adjustment and effective management to move forwards through the healing process proactively towards the more functional stages of recovery without unneccesary anxiety.

Pain without an obvious injury or damage

Pain can often exists without any significant damage to the tissues, or any at all in some cases. A problem can present as a hamstring pull, it feels like a hamstring pull, yet there is no sign of an actual injury. Equally, a player could rupture muscle fibres and not feel the pain immediately. In most cases the pain is largely co-existent with the injury, but as we have seen, there does not have to be a huge tear. The message is that we should not use pain as the sole guide to the severity of the injury, however we must seek to treat the pain in the best way we can to reduce the risk of pathological behaviours developing-that would prolong revovery. In a less acute situation when there are no clear signs of injury, often there is sensitivity to movement in the sciatic nerve that has become excited through the mechanism or irritated by inflammatory molecules. This can be highlighted with the slump test. The sciatic nerve supplies the hamstring muscles and when sensitive can manifest pain in any of the tissues in which it innervates.


The seriousness of an injury is very individual with a hamstring injury potentially affecting the career and income of the professional player versus the inconvenience and disappointment of an amateur, part-time player, although with no-less suffering. How much damage has been sustained will also vary and cannot be assessed purely on the basis of the amount of pain. Many factors influence how an individual responds and copes with an injury, and certainly fortifying these mechanisms is key in the early stages with rapid diagnosis, reassurance and treatment.

If you are suffering recurring hamstring injuries, call us now on 07518 445493 to learn what you can do to tackle the problem and return to playing football


The hamstring | a common recurring problem

The unfortunate Thiago Motta of Italy suffered what appeared to be a hamstring injury just minutes after coming onto the pitch last night. The Euro 2012 finalists were already under severe pressure from the dominant Spanish team when he was stretchered off the field clutching the back of his thigh. The Brazilian-Italian footballer was expressing his and his nation’s agony as they eventually lost 4-0.

Hamstring injuries are common in football. Often seen as the player pulling up having been sprinting, he clutches the back of his thigh, then hopping or hitting the floor. The amount of pain can vary as in any injury as pain is not an accurate indicator of the amount of actual damage.

The hamstring group is made of three muscles situated on the back of the thigh: biceps femoris on the outside, and semimembranosus and semitendinosis on the inside. They run from the pelvis to the lower leg, bending the knee but also slowing the knee down as it straightens. It is often in this latter phase that the ‘pull’ occurs.

When the muscle is pulled it can be difficult to walk. There can be bruising and swelling in the thigh, although sometimes this is deep in the leg and therefore not immediately visible. With rupture of the muscle fibres, the blood and fluid may track down the leg, causing bruising and swelling to appear lower than the injury.

With an acute injury, ‘PRICE’ is the management strategy of choice where P is protection, R is rest, I is ice, C is compression and E is elevation. In the early stages of an injury and the healing process there is pain, redness, swelling and heat. These are all manifestations of the inflammation that starts healing. Despite the unpleasantness, the signs and symptoms are the body’s responses to injury and are normal. Seeking the advice of a health professional is advisable so that you can fully understand the problem and what you must do to facilitate the most effective recovery.

When we have recovered from the acuteness of a hamstring injury, an individualised training programme must be designed, explained and implemented by a trainer or physiotherapist. This should be followed, progressed and completed to reduce the risk of future problems in the same area. The exercises and drills become increasingly functional, rehearsing the types of movements and skills needed to perform. This routine is practiced so that the player is ready physically and mentally for the demands of the game.

It is not uncommon for a twinge or similar pain to be felt in the back of the thigh sometime after the original injury. Of course there can be a re-injury where actual muscle fibres or tissue can be damaged. However, there can equally be cases whereby it feels like the original injury but there is no actual damage. In this situation, the brain has recognised the pattern of movement, determines a potential threat and responds with a pain in the back of the thigh, more as a warning shot. This means that there is still an underlying sensitivity that may have been felt as a persisting tightness (‘my hamstrings are always tight’, I often hear) or some discomfort with running or sitting with pressure on the muscles. This low level sensitivity and tightness requires a different treatment and training approach. To determine the difference, you should see a physiotherapist or other healthcare professional who can assess your situation and advise you on a specific course of action.

If you have a recurring hamtrsing injury or pain in the back of your thigh that is stopping you return to full play, call us now: T 07518 445493


The importance of the first minutes, hours and days of an injury

Sustaining an injury is commonplace in sport. What happens in the first few minutes, hours and days can play a big part in how well we recover. The injury needs to be diagnosed and understood, for example an ankle twisting beyond the normal range of movement that results in a sprained ligament. As important is our response to the injury, what action we take and what we think about it. This blog explores these points with the aim of clarifying good practice in the first instance of an injury.

Our response to an injury includes how we protect the area, how we communicate that we are injured and the thoughts going on in our head. All are influential. How we protect a new injury is often by holding it, perhaps rubbing the area, limping, applying a bandage or using a set of crutches. This is very useful as the healing process begins immediately and the tissues need this protection to enable this activity. Communicating our pain and injury is individual. Some will cry out, use a facial expression, raise an arm to call the bench for help and others will suppress the urge to call out or use other ways of minimising body language. However, it is often difficult to do this with the acute pain of a freshly sprained ligament or strained muscle. Finally, the thoughts running through our head will vary but could include ‘What have I done?’, ‘What does this mean to my career in football?’ or ‘Not again!’. These thoughts are really important as they will be the conscious reflection of our beliefs about the situation. Our beliefs in turn, drive behaviours and consequently what we do in our injured state. In essence, what we do early on can impact upon the course of the recovery.

In the early stages, having a good understanding of what has happened, what has been injured and the extent of the injury is important from a reassurance viewpoint. Often the responses of the body to an injury are normal yet unpleasant. We need to know what is normal and what may not be normal so that the latter can be dealt with effectively. We also like to know what it is that needs to be done. For these questions to be answered we make a prompt visit to a healthcare professional. Rapid pain relief helps to take a positive stance on managing the early stages and indeed, high levels of uncontrolled pain can lead to beliefs and behaviours that are unhelpful. This is a pertinent point that I would like to emphasise. Gaining a realistic and accurate view of the situation with a good management plan promotes adaptive behaviours and responses that means you are doing everything that you should to support the healing and recovery. Developing fears of movement, catastrophising about the pain and excessively worrying about the injury usually lead to persisting problems. Clearly the former is a better scenario.

In summary, we must think about the early stages of injury management and have a clear strategy. This must include a good explanation of the problem, relevant investigations if required, a management plan that works with the healing process and monitoring of any thinking that could impact upon one’s choices.


Training for the marathon – developing pain & injury

At this time of year, as the London Marathon nears, runners reaching new levels of training can start to develop aches and pains. Usually the pains are in the legs or feet and often begin as an annoyance but develop into a problem that means training has to stop.

The tissues are constantly breaking down and rebuilding. This is a carefully orchestrated process that is impacted upon by exercise. This is how we develop muscle bulk. However, we do need a period of adaptation that can be disrupted if there is inadequate rest. The balance tips towards tissue breakdown and inflammation triggers the development of sensitivity that if ignored can progress and become amplified. A good training programme should account for both rest periods and gradual progression of intensity.

A second issue is that of control of movement. On a day to day basis we can walk around, undertake normal activities, play sports and even run for certain distances with minor motor control issues. Motor control refers to the way in which our body is controlled by the brain with a feedback-feedforward system. The tissues send information to the brain so that there is a sense of position and awareness, allowing for the next movement to be made and corrected if necessary. The problem lies in the increasing distances, often never reached before, that can highlight these usually minor issues. Compensation and extra strain upon muscles and tendons that are trying to do the job of another can lead to tissue breakdown as explained previously. The sensitivity builds and training becomes difficult.

A full assessment of the affected area, body sense and the way in which movement is controlled will reveal factors that need addressing with treatment and specific exercises. This fits alongside a likely modification in the training programme that allows for the sensitivity to reduce before progressing once more. In some cases a scan or other investigations are recommend to determine the tissue nature of the problem.

If you are starting to develop consistent twinges that are worsening, pain that is affecting training or you are concerned, you should seek advice.

For appointments at one of the clinics please call 07518 445493

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