Tag Archives: tennis injuries

09Jul/17
Andy Murray's hip

Pain and injury at Wimbledon

Why is there so much pain and injury at Wimbledon this year?

Pain and injury at Wimbledon

Seven retirements and a very painful injury on-court yesterday at Wimbledon have given the tournament a different feel. Pain and injury are part of sport, but many people have been surprised by the turn of events. Federer has called for a review of the system and several players have complained about the state of the courts. All are factors of course. The game is simply made up of the synergy of players, court and tournament. When all are ticking, we see great tennis.

The very painful moment

Bethanie Mattek-Sands was screaming out in pain this week after her knee appeared to give way. One report suggested that she could have sustained a knee cap dislocation. This can be extremely painful until relocated. Seeing the dislocation can add to the trauma. When our body does not appear as we expect, the sight can trigger feelings of aversion.

Why so much pain?

Pain is a part of the way we protect ourselves. There are many other things going on when we are in state of protect: change in movement, change in sense, altered thinking and emotion, change in perception. In other words, the world looks different and feels different as we take action in the name of survival. This is a normal shift of state in the face of a perceived threat. Pain is a lived experience when there is a perceived threat. Pain is not well related to injury. This is the common misunderstanding. Just because it hurts a lot, it does not mean that the injury is more severe. We have known this for a long time ~ see here: pain in sport, 3 key points.

When thinking about the reasons for the pain response, the context is key. In other words the situation plays a significant part in the pain experience. As well as potential tissue injury, where that possible injury occurs and what is happening is highly relevant — it always has to happen somewhere! The full picture perceived creates a learning opportunity. If this is possibly dangerous, I need to remember what happened and where so that next time I can react differently.

All of this information is processed together with sensory information from the body, based upon what is already known about injury and the situation. In essence we make a best guess about the possible causes of the sensory information on a background of our previous experiences. In effect, we weigh up the evidence: new information vs what we know, which then suggests a scenario. If this is a potentially dangerous situation, pain can then form part of the experience. The more danger perceived, the more intense the pain.

How much danger did Bethanie perceive when her knee gave way at the biggest tennis championship in the world, in front of a big crowd, when each game is career shaping?

Whatever the outcome for Bethanie, I wish her well.

Messi’s knee

In 2012 Lionel Messi was running into the box when he brushed the keeper as he came out to meet him at speed. Messi managed to get a shot away (he missed) before he hit the ground clutching his knee. He was quoted as saying that he thought his career was over because of the pain.

How dangerous was the situation to Messi? Consider: the perceived injury (he did not know about the extent of the damage at that point), the game, the crowd silent, the body part involved, how knee injuries are thought of in the culture of football, the immediate thoughts about injury and what it means and much more.

Messi was taken off the field on a cart and whisked to hospital where he was scanned. What was the injury? A bruise.

Pain and injury are not the same. The terms are often used synonymously, but this is not correct usage. A further example is phantom limb pain. The person suffers pain in a limb that no longer exists.

Pain and injury

Why have there been so many injuries?

We have seen multiple retirements during games at Wimbledon this year. Whilst some people have been frustrated, we must also consider that these players have to make choices. These are based on the culture of the sport, the system, their career, their income and their understanding of pain.

There will be a weighing up of the pros and cons, and each individual will consider different factors before deciding. We do not know what those factors are in each case, so we cannot make any specific assumptions or criticise. In life, how many assumptions are made when someone is being critical of another without knowing the full picture?

“aches and pains are part of sport

In sport, the day to day aches and pains are a well known part of the deal. Simple measures are taken to address theses responses so that the athlete can continue to perform: e.g./ physiotherapy treatment, massage, ice baths, stretching, periodisation. However, despite the level of fitness, each body needs to adapt to the demands of the training and play. Without this time, there can be a tipping of the ‘build-breakdown’ balance towards the breakdown (inflammation). A state of chronic inflammation is likely to explain a range of common problems that can become significant.

When an acute injury occurs in sport, there is pressure to resume play as soon as possible. Do players return too soon? Are they fully ready? Being ready means that the body tissue are robust to withstand the stresses and strains, movement patterns are normalised (and not guarded), body sense is acute and thought patterns focus on the game and not on the body.

“the clues are in the story

We do not know all the factors involved with each player at Wimbledon who had to retire, but the points described above are relevant and need consideration. When clinicians are assessing an injury, this is especially so. Each injury or pain moment (the two are different) occurs in a context as we have established. Nothing happens in isolation, we are on a timeline, and hence we must consider how the person may be primed by prior learning. What are the influences upon this current moment? Some will be obvious and some more hidden. This is why allowing the person to tell their story is vital. The clues lie within their narrative, so we must listen actively and be open.

This is a brief look at some of the key issues. Pain and injury are always going to feature in sport. We need to draw upon the pinnacle of our knowledge of pain and bring this into the athletic world. In other words, we need a shift in the thinking away from the biomedical model, instead looking at the wider picture: a true biopsychosocial, or sociopsychobio model. Here is a reminder of the key points:

The key points:
  • pain and injury are poorly related
  • pain is suffered by the (whole) person not a body part (e.g. tendon pain ~ the primary focus remains on the tendon rather than the person)
  • pain does change when it is understood by the person and they actively create new patterns

04Jul/17
Pain and injury

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points, but first…

What does Andy Murray have in store for fans this year?

Undoubtedly Andy Murray is resilient. He declared himself fit for Wimbledon 2017 and he has just beaten Alexander Bublik to take a step closer to the final: one game down, six to go.

There were concerns in the media about Murray suffering left hip pain during the build up to Wimbledon. Apparently this is a problem he has had for many years, however he is not going to let this stop him from giving his best. We have become used to his determined attitude, one that he has had to develop towards pain and injury in particular.

Clearly performing at the elite level has an impact upon the body, which is why the conditioning must be right to check the physical stresses. But, we are more than a physical shell. We are a ‘whole person’ and hence being resilient to life’s challenges is a key skill. This is an exciting time for Andy Murray as he embarks on his defence of the title whilst expecting a second child with wife Kim. Being able to put aside the hip pain, he could even be using this wonderful news as an inspiration.

In 2013 I wrote a blog about Andy Murray, back surgery and microdiscectomy. It still gets a fair few hits, particularly at this time of year when people are reading about him and Wimbledon. I stated that the 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”. Since then Murray has had a remarkable time, currently holding 45 titles.

“rehabilitation is not just about exercising

Murray fans now hope to enjoy (is that the right word?) the next two weeks. The pinnacle would be next Sunday watching a closely fought final with a Murray victory. Who knows? Sport these days chucks out surprises that ultimately keep us all riveted. Look at the Lions last Saturday!

Now, my blogs would not be my blogs if I didn’t somehow turn the thinking to pain. One of my favourite areas of discussion is pain in sport, in particular chronic pain in sport. Yes it exists! (Some people seem to think it may not….). Many times I have given my lecture and talks on the topic, encouraging modern thinking about pain to emerge in the sporting realm. There are some simple principles to begin with, and we can use Andy Murray to illustrate the points.

3 key points

Pain and injury are neither the same nor well related

We have known this for many years. The famous lecture and paper was in 1979! So when you see Murray in pain on the TV, this does not tell you much about the state of his hip. It does tell you that his body systems are in protect mode, compelling a range of behaviours and actions that can be seen. Pain on the other hand, cannot be seen. Pain is a lived experience. Can you see funny? Can you see hunger? All these experiences are whole person, which is my second key point.

“pain has only a weak connection to injury but a strong connection to the body state

Pat Wall (1979)

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Pain is whole person

This means when we are treating pain and overcoming pain we have to think about the whole and not reduce it to a body part or some physiology. If my knee hurts, it is ‘I’ who feel pain and not my knee. Much like thirst. It compels action by me, the agent. Think for a moment: where do you feel thirst? Some may say in my mouth or throat. Think again. That is a dry mouth, which you may interpret as a sign suggesting that you need a drink. Pain always exists in a context. The context is the person, the environment, the action, the perception, and prior experience. Of course this changes all the time, as are we, the dynamic and ‘updating’ humans that we are. This gives great hope because when we tap into our incredible ability and resource, we realise that we can chnage pain and transform our experience. And that is my third point.

Pain can and does change, beginning with truly understanding pain

This has become so important to me over the years that I have set up a social enterprise in that name: understand pain or UP. Understanding pain gives you the foundation that you need to be able to take the actions that get results. Build upon a model of success and using the tools of coaching, in particular strengths based coaching, you set out your vision. What do you want? Then you orientate your thinking and attitude towards this picture of success and do your utter best. This is the route that Andy Murray has taken and continues to pursue, just like any elite athlete or person who has achieved.

These 3 key points are fundamental and continue to feature in my talks and writings. They do so because they are vital ingredients in the clinic. There are many others, but to start with these orientates the person in the right direction. As clinicians we may think ‘treatment’ but we offer so much more. We do treat and this is important. We also coach: we coach people to coach themselves in their world and to immerse themselves in the practices that result in living as best they can. Together we create the understanding and conditions for the person to flourish and feel themselves. They live fulfilling lives with all the joys and pleasures that exist whilst developing the resilience and skills to face challenges and learn. We can do this at any age, and we should be teaching kids these skills right now in schools ~ that’s for another time.

So, good luck Andy Murray and all the others chasing the Championship! We will enjoy watching you all over the next two weeks.

RS


Pain Coach Programme ~ treatment, training and coaching to overcome pain and live life 07518 445493

 

 

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.