Affirmations and Mantras for healing

Self-talk is known to be one of the most important parts of mental strength. Athletes consistently use it (often together with visualisation) to help with performance under pressure. My suggestion is that it is just as important when you are injured and facing the challenges of recovery and rehabilitation.

Are you wondering what is self-talk? I define it as the voice in your head that chatters constantly, about all kinds of things and at times can escalate to a full-on internal debate. But there is good evidence that the mind takes these messages and images very seriously, driving changes in the hormonal system and the nervous system which in turn have very significant physical impacts (as well as changing your thought patterns going forward).

Affirmations or mantras are usually short, pithy phrases to insert positive messages into the mind. I would also be remiss not to mention that in the Hindu faith and yoga mantras are chanted, with specific mantras to generate powerful sound waves that promote healing, and the relaxation from the ancient practice of gong therapy or ‘sound bathing’.

This is something that many people write about. I especially enjoyed Carole’s blog from 2014 where she talked about Dr Coue’s mantra (or autosuggestion as he called it) where in conjunction with their medical treatment, they would say over and over to themselves 20 times in the morning and 20 times in the evening ‘Every day, in every way, I am getting better and better’. Read more on this inspiring story from over 100 years ago, plus some great tips and book recommendations in Carole’s blog:

What kind of mantras help?

When I was running ultramarathons and doing Ironman triathlons, I used mantras a lot and found:

  • It needs to be positive. I had a spin teacher who used ‘mine is the power and the glory’ as a mantra, and I know that many people find these universally positive exhortations very useful– hence the Ironman slogan of ‘Impossible is Nothing’.
  • It needs to be realistic at that moment! For instance, telling myself ‘I love to run’ is true, but in the final stages of ultra-marathons or long-distance triathlons the voice on my shoulder would scream back ‘I don’t right now – I want to stop!’ so I would use simple exhortations like ‘run for home’ or ‘nice and steady’.
  • It is better when it is process-based.  There are times in a long race where the final finish line seems too far away to engage with, and so process-based mantras worked better for me. This seems a strong parallel with the uncertainty on outcomes in recovery and rehabilitation. So just as I would focus on technique points in races like ‘keep my rhythm’, ‘nice and light’, which brings the benefits to keeping good technique at a time when tiredness can reduce form. In the same way in the tough part of recovery focus on the exercises, release work, nutrition, hydration and sleep patterns can reinforce the positive habits that will make a difference.
  • It is not helpful to set specific goals that you then miss. Whilst I have spent many races setting myself a challenge for the next split time, or the person that I would overtake, these are only useful when you hit the goal and then set the next goal. Missing them really can really drag you down, as it allows the internal critic to keep saying that today is not your day and you may as well just give up.

How do I apply that to my recovery?

It is really useful to reaffirm your strengths and the resilience that you bring to this situation: from the factual such as ‘we have a good plan and next steps with the medical team’ or ‘we are focused & determined and will get to the bottom of this’, ‘I have what I need to get through this’, ‘all of this strength and conditioning will make me a better athlete’ to the more aspirational ‘we will beat this’, ‘I’ll be back’, ‘my body is amazing’ and ‘I’ve come through tough times before and I will again’.

Also to recognise all of the people on your side and rooting for you: ‘I am in great hands’, ‘I am surrounded by love and support’, ‘I stand shoulder-to-shoulder with my team’, ‘I am enveloping my body in love and kindness’.

Reaffirming the sense of progress – even when it is too small to see: ‘every day of careful nutrition and good sleep helps my body to rebuild’, ‘little by little my body is healing itself’ and ‘every step towards recovery helps me’, ‘cell by cell my body is rebuilding itself’.

Some people find perspective very useful – for example: ‘whilst this is tough, people are facing much worse than this and getting through it’.

Some inspiring quotes

This link includes some inspiring quotes for injured athletes that could be used as mantras:

https://www.theodysseyonline.com/25-quotes-inspire-injured-athletes

So why not try it?

How about choosing a favourite mantra and use it every day for a week – repeat it under your breath over and over at key points in the day, write it on a post-it and put it on the bathroom mirror or under your pillow, close your eyes and smile gently as you visualise it… the mind is a powerful thing.

Your body and mind are amazing – ‘Every day, in every way, you are getting better and better’

Do topical treatments work?

When the problems are joints and muscle cramps, there are a lot of topical treatments that are marketed at you. But should you use them?

I am not medically qualified, but I have tried a lot of them out and read a lot of labels, so here is my layperson’s view:

There are probably two underlying reasons that you are looking at topical treatments:

  1. For pain management
  2. For localised healing

These two things are linked by the need to reduce inflammation – key for the early stages of healing, and inherently linked to localised pain.

I think that there are better ways to get to pain reduction?

Many of the medicated creams and patches are delivering ibuprofen or a similar drug. These are strong drugs that can have a major impact on your organs (especially if you are not well hydrated). So my recommendation is that if you need that pharmaceutical, take it orally and monitor the dose carefully. Trying to understand the dose from cream or patch is much harder.

Some help pain relief by delivering warming, or heating component via a chemical reaction. Temperature management is a great way of helping the body with pain. But personally, I would prefer to do it with a wheat bag (for heat) or an ice pack (for cold), rather than a chemical reaction.

But massaging the scar tissue with a suitable substance seems a good plan

It is universally agreed that massaging the scar tissue is key for helping the healing of scar tissue. And massaging in nutrients that are going to help seems like a good plan. Although it should be noted that every substance can have side-effects, so you should read all of the labels and look up the potential side-effects so that you know what to look out for.

Whether these are crushed Epsom salts in olive oil (for the Magnesium – to sedate the nervous system and draw out the toxins from the muscles). Or a magnesium sulphate spray or cream for the same effects (but a more expensive price tag! Reflecting the convenience of not having to crush the salts in a polythene bag with a rolling pin and mix in the oil!).

I also realise that there are different views. I love to read the blogs from Paul Ingraham on painscience.com and this one on Epsom Salts is apparently one of his most read:  https://www.painscience.com/articles/epsom-salts.php . I think that he does accept that some things can cross the skin, but is sceptical on the impact of magnesium sulphate. You can read his blog and decide for yourself (and indeed if Epsom Salts in the bath works for you – who cares if it is a placebo effect if it works for you?)

Or maybe Aloe Vera or Arnica-based creams/patches to reduce the inflammation and support the next stage of healing. I have to admit that I prefer the creams – as the patches do not encourage the massaging, and this is really important for the benefit to the scar tissue. Additionally, with the creams you see and control the dosage a little more – which is not so clear with patches.

Probably the best option is a skincare product with vitamin D (like Bio Oil) to moisturise and care for the scar tissues when you massage them. And always make sure that you put a high factor sun cream on the area for any exposure to the sun, as the new skin is very vulnerable.

When the pain goes down the leg or arm

The challenge of a lot of the nerve-based cramping is that the pain in the muscles put into continuous cramping can be completely debilitating. Massaging in muscle-relaxing gels or creams can help to reduce this secondary issue, although obviously, it is short-lived as it does not address the nerve issue that is causing the cramping.

Oral muscle relaxants do work, and again may be a better treatment for the issues (depending on how bad the symptoms are).

Overall

So in summary, I am not sure whether the topical treatments are the best way forward, as I think that a clearly dosed oral approach may be better. But for sure you need to find the skincare product that encourages you to massage the scar tissue to keep helping it to remodel properly. And a high factor suncream to protect the tissues in the sunshine.

To go for surgery, or not to go for surgery

This is the moment of truth! Sometimes there is simply no choice and the only thing to do is try to manage the process so that your recovery can be the best that it can be (do talk about scar tissue with your surgeon!). But I have talked with people who have said that it is much harder when the case for surgery is not so clear cut, and the diagnosis or outcomes are less certain.

With the informed consent rules, it can be very difficult to get any definitive advice from the surgeon on what the likely probabilities are for different outcomes, and whether in their expert opinion it is likely to help or not.

You can feel very alone, in pain and probably having been suffering for a long time and feel that you have lost out on a lot of things. What should you do?

Many athletes have surgery and regret it

Many athletes end up saying that if they had known what it would be like in the years after surgery, they would not have had it. Don’t let that be you.

Some of the reasons may be that:

  • We are positive and believe that we can simply ‘will’ ourselves better, so when we listen to the range of outcomes and timings, we always believe that we will be in the best and fastest group – and maybe even tell ourselves that we can beat those odds too! This rarely happens. So brief the person who comes with you to listen carefully to all of the range of outcomes and probabilities.
  • We place high demands on our body, so even a slight level of dysfunction is noticeable and impacts our lives. We need to remind ourselves that almost everything has a workaround solution – you only need to watch the Paralympians to remind yourself of the power of this.
  • We may subscribe to the ‘instant-fix’ mentality of today’s modern world and forget that there is a lot of healing that takes a very long time. We are not like a bike or a machine, and will not be ready to go as soon as the mechanics are fixed – because there is too much soft tissue recovery, body trauma and system re-patterning to do.
  • We think that because we will be out of hospital in a few days, it will not take long. This is not at all true – whilst you will be home very quickly (and by the way you should plan ahead to ensure that you can cope in that difficult post-operative stage), the time for the body to heal is long. They will often cut through 9 different layers of tissue (even with keyhole) and each of these need to heal. Those with less blood supply heal slower, as they only get what they need more slowly. Whilst there are things that you can do that will make it go slower, there is little that you can do to make it go faster!

So what if you are facing the decision?

You have to find your own true-north on the right path forward… And all at a time when (for sure) your judgement is impaired as a consequence of the pain and frustration of your injury.

 Some tips that might help could be:

  • Take someone with you to the appointment to ensure that you get a well-balanced view of the probabilities of the range of outcomes. Having two of you helps to ask more questions and also listen and take notes in the appointment.
  • Ask about the surgery itself and understand the impact of the incisions and the consequences for the healing process. Often the scar tissue can be as much a factor as the ‘fix’ itself. And talking this through and understanding it can help with the decision (and indeed if you go ahead, with the choices around the exact surgical approach – for more on this read my blog on scar tissue)
  • Would you want to watch the surgery on YouTube?  Many people think that this is seriously squeamish and scary. But for others seeing it and understanding the different aspects enables an understanding of the level of trauma and recovery. And some watch it before going to see the surgeon, as it prompts different questions that they had not previously thought of. You need to think it through for yourself.
  • What is the sentiment on the internet about recovery from this surgery?  Obviously every patient is different and the internet will not tell you the answer for you. But if the prevailing sentiment is that it is a very long recovery, and not a full recovery – what are the common themes? And are there questions that you want to ask your Doctor about the specifics (without referring to the internet, as that is always how to upset Doctors!!)

What if you are not sure?

It is completely normal to come out of an appointment with the surgeon and to be really unsure of whether you want to go ahead with surgery.

If you wrote two lists on the same piece of paper – reasons, why to have the surgery and reasons why not – what would the balance of opinion suggest is the right answer? Is there any more information that would help to make it clearer? Is there anyone that you can talk over the list with to add more insight?

There are a couple of challenges to be aware of:

  • You can feel a sense of momentum that means that you feel pressure to go ahead (whether coming from the medical process, or from family & friends, or your own need to move forward). Resist it! This is a big decision and it is your body. So you need to be happy with the decision.
  • You may feel that there are no other options. This is never true.

So what are the other options?

There are a number of other options – some of which are below. Which one you go for probably depends on (i) how confident you are of the initial diagnosis of the issue, (ii) the level of improvement that you have seen (or not seen) through the current work of rehabilitating it and (iii) the levels of risk and length of predicted rehabilitation from the surgery.

  1. Get another opinion from another surgeon. You are absolutely entitled to this, and no-one should make you feel bad for asking this question.
  2. Continue rehabilitation with another physiotherapist (or whatever rehabilitation specialist you are seeing). There is a huge variation in the approaches that different people in the same profession take. And I would say that if you have been seeing them for more than a couple of months and are not making progress, then a change would be a good thing.
  3. Try a different approach. There are a lot of different therapy approaches, and when you spend a lot of time with clinicians you realise the levels of uncertainty – lots of intelligent guessing because they cannot see inside your body, and the level of variation in people. So for all that many can be very sniffy about ‘alternative’ therapies – these may be what your body will respond to.
  4. Give it some time.  This is a hard one – but can often work. So setting a time limit and truly resting and nurturing the injury by keeping away from activities that trigger it.

Good luck!

Only you can make this decision for your body – take your time and make sure that you feel  that you have explored the details and the options fully. It would be really sad to be a year or two down the line and regretting this decision.

The skinny on scar tissue

Scar tissue sounds like one of those things that you can do very little about. But actually it is a little more complex than that!

Scar tissue is laid down in the key ‘proliferative’ phase of healing and then remodels during the maturation phase of healing. If you want to read more on this, read my blog ‘How do you heal after invasive surgery?’ http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/

This image is my simple visualisation of the haphazard scar tissue on the left, and then how it settles into the correct structure after remodelling on the right. This gives a sense of why the scar tissue feels tight, solid and lacks the usual movement and elasticity of the remodelled tissue on the right.

A simple demonstration symbolising the multi-directional aspect of scar tissue on the left, and the linear nature of remodelled tissue on the right.

But not everyone lays down scar tissue in the same way!

It transpires that different people lay down scar tissue in different ways, and therefore can get more complications from the adhesions and slower remodelling.

How can you know if you are one of those people?

It is probably difficult to know, if you have never had any surgery before, but a couple of signs that would be worth looking at are:

  • Do you still have lots of scars from cuts and grazes from your childhood? Or have these faded away now?
  • When you have had cuts or grazes over the last few years, has the mark (both in texture and colouring) lingered for a year or more?
  • And if you have had surgery, did the scar fade to an almost invisible light white line within 6 months or linger on?

If you are on the longer ranges, you could be someone who lays down stickier scar tissue and takes longer for it to remodel into the usual tissue, with usual movement and function.

What can you do about this before surgery?

If you already suspect this before your surgery, do talk over with the surgeon your previous healing and the types of movement and sport that you want to be able to return to. The choices that they make can really change your scar tissue – and counterintuitively, sometimes a larger scar can mean less scar tissue.

And if you are having keyhole (or arthroscopic) surgery, so not underestimate the scar tissue. If you can imagine, it is like a sticky rope of scar tissue that goes from the point of entry to the point of surgery. And that can be quite a distance. In areas like the hop there are lots of different muscles, tendons, ligaments and bone for it to stick to and in the abdomen there are also organs.

Straight after the surgery

As soon as the surgery is complete, the surgeon and physiotherapists will often get you moving through as much of the range of movement as you can. This is to gently tear the sticky scar tissue off things that it should not be sticking to and is especially important with joint mobility.

As soon as the wound has sealed up, there are four things that you can do to help the scar tissue to start to remodel:

  1. Massage it for 5 minutes at a time, using your finger tips and moving in all directions with as much pressure as feels comfortable. Remember that the surgery will have cut through 7 different layers of tissue and they each need to remodel.
  2. Rub in some Vitamin-E based oil, such as Bio Oil to help the process
  3. Protect it with a high factor sun protection cream if you are going out in sunshine, as it will burn really easily and this will damage the healing (as well as discolouring it)
  4. Keep drinking lots of water and eating a good high protein diet, so that there is lots of collagen for the body to call on. There are mixed views on whether a collagen supplement help, or whether a diet with things like oily fish and chicken broth are sufficient.

Through the next phases of healing, gentle movement through the range of movement (with no weight or resistance) will be key in order to get the sticky fibres to only stick in the right place! If you start to get into a lot of pain, you should be:

  • Talking with your physiotherapist and surgeon about the risk of unwanted adhesions and sharing what pain you have at different parts of the range of movement.
  • Showing them your scar – especially if you feel that it is too raised up from the surface of the skin, or too indented.

Best of luck – do not be despondent if you are someone who lays down scar tissue differently. The body is an amazing thing, and it will do the remodelling. It may just take a little more time, and that may mean a longer recovery phase for you and sadly more pain for a while, plus needing to keep focusing on range of movement for a little longer before you progress back to your activities and sports.

Would a chiropractor be able to help me?

If you have been lucky enough not to have injuries in the past, you may not have any clue of who may be able to help you with your injury. One of the most common questions is what is the difference between a physiotherapist, chiropractor and osteopath? I also cover this in my previous blog www.injuredathlete.co.uk/how-do-i-know-that-i-am-going-to-a-good-physiotherapist/ 

Chiropractors generally focus on the integrity of your nervous system

The British Chiropractic Association www.chiropractic-uk.co.uk  says that chiropractors specialise in back pain, neck pain and sports aches & pains:

“Chiropractors specialise in assessing, diagnosing and managing conditions of the spine. They are highly-trained in finding the cause of pain in the spine. In the UK they undergo a minimum of four years’ full-time training. Importantly, chiropractors are regulated by law and must work within strict professional and ethical boundaries.  Before starting treatment, a chiropractor will do a full assessment. This will involve taking details about your condition, current health and medical history, and performing a physical examination. Sometimes it may be necessary to refer you for other tests, such as X-rays, MRI scans or blood tests. It is important for your chiropractor to gather as much information about your back pain as possible so that the most precise diagnosis can be made.

“Your chiropractor will then explain what is wrong, what can be done and what you can expect from chiropractic treatment.”

How do I know that it is nerve pain?

Of course, it is really hard to work out the cause of pain. Nerve pain accounts for much of the pain that goes all of the way down the leg (sciatica is a classic of this, but there are also other nerves that take different paths down the leg). The words that people usually use for nerve pain include words like prickling, tingling, burning plus sometimes stabbing, spasming and cramping. At their worst they can literally take your breath away and leave you unable to speak, stand or so anything.

Many people fear that chiropractors will be very physical and involve lots of popping

There is a range of chiropractic techniques. Some use just their hands for manipulation and other techniques use tools that can help to rebalance the tightness of muscles, tendons, ligaments etc and enable the rebalancing and correct alignment of the spine and therefore the body, both at rest and in movement.

The short, sharp movement with popping for spinal alignment is just one technique, and if this is not what you want, then talk with your chiropractor. For more advice, this link is worth a read:

https://www.spine-health.com/treatment/chiropractic/questions-ask-about-chiropractic-techniques

When you are in pain, there is lots of compensating

The bad news about compensating behaviours is that you can start to get pain in parts of your body that were not involved in the injury. For example, most injuries are more on one side than the other. This means that you are not evenly balanced across the two sides, but the brain does not tolerate the eyes not being level at all times. So the top of the spine often takes a compensating role, and this can lead to issues in your head and neck, as well as the site of the injury.

More runners’ injuries are related to nervous system issues than you might think

Joe Uhan has written a series of very useful posts on how often ongoing injuries in runners are related to nervous system issues. You could start by reading his blog on the I Run Far website for trail running and ultra-running https://www.irunfar.com/2017/08/six-signs-that-your-running-injury-is-nerve-pain.html and then follow the related links into his related blogs on treating nerve pain in runners.

I especially liked his guide to a neuropathic approach to healing www.irunfar.com/2018/05/six-principles-of-naturopathic-running-health.html

But if you are needing help with the healing process, cranial-osteopathy may be a technique that helps reduce your pain. And chiropractic interventions may help to find that ‘reset’ button to get everything working together again to move correctly without pain. Many athletes swear by the support chiropractors have given to get them back on-track.

Best of luck with finding something that helps!

Alex’s courage in talking about the loneliness of her head injury

If you have met Alex Danson MBE (gold medallist with the GB Hockey squad and since then the Captain of the England and GB Hockey teams), you will know her massive heart, her infectious smile and her complete passion for sport and team sport – and hockey especially.

It is so hard to see someone like Alex literally knocked out by the impact of concussion. But her courage in being searingly honest about how hard it is will be a lifeline to others who are injured. I also really hope that it will also be a lifeline to her with the massive outpouring of support for her on social media yesterday, and hopefully going forward in the coming weeks and months.

The most telling parts for me in her interview with The Times yesterday https://www.thetimes.co.uk/article/alex-danson-great-britain-hockey-captain-injury-post-0d09vm8bb were these lines:

“One of the hardest parts in all of this, aside from the physical trauma, has been losing my identity,” she wrote. “Going from leading my country, aspiring to qualify for the Tokyo Olympics to just trying to get through a day.

“Head injuries are serious, debilitating and lonely. When I have days when I feel well enough I will document some of my recovery. I’ve not been well enough to up to now and I’ve not been sure whether it’s something I wanted to do.”

They capture so brilliantly the complete stop that comes with an accident and injury, and the new mental framework that you have to build. And Alex’s commitment to make meaning out of this brutal, difficult and unfair injury by documenting her learnings and recovery to help others is totally inspirational.


Alex’s post on her Twitter feed @AlexDanson15 under the comment “It’s been a long 6 months….I’m thankful to say that I am on the road to recovery #mildtraumaticbraininjury”

Concussion is a very serious injury and many sports have now linked together to share the best knowledge. I am not an expert, but I would say that the Birmingham Sports Clinic is open to professional and amateur athletes over 16 years old, from all geographic areas. Instructions and how to get referred can be found here: https://www.uhb.nhs.uk/birmingham-sport-concussion-clinic.htm

Very best of luck for your recovery Alex. We are all rooting for you.

Imagining the Numskulls in the context of how bones heal

I don’t know whether you remember the Numskulls? This was a cartoon strip involving little people who lived inside the head of a person and did all of the hard work to make the person’s life function. 

I thought that they might be a helpful analogy for understanding why we really do need to give a broken bone the time to heal properly. So I created a couple of new characters:  

  • Mr(s) Preparation with a broom and all of the cleaning materials
  • Mr(s) Repair with a full tool-belt and DIY kit and team to help build the structure
  • Mr(s) Remodeller with the filler and sandpaper to make it fit in with the rest of the bone

Just like the healing of surgical cuts and tendons/ligaments/cartilage (covered in previous blogs) there are 3 phases, which I have added a little detail to below. Sadly all of this process goes a little slower when we are older (like most things!) – so worth adding a little extra time if you are older and ensuring that you pay even closer attention to the cues from your body.

  1. Reaction – with inflammation and initial tissue formation. The severed blood vessels in area of the break (or fracture – same thing) in the bone release blood into the area and this forms a clot very quickly (normally within a few hours). Then the first few days are characterised by a lot of inflammation as some of the body’s cells start to clear away the bone fragments and other damaged cells. In parallel, the new blood capillaries that have grown into the area bring the cells that start to build fibres to connect the bone and lay down the spongy bone structure.
  2. Repair – initially with a cartilage callus formation and then with bone: this stage starts after about 7-9 days and takes about 2 months to join the two ends together with a bony connection that has most of the bones original strength. During this time it hardens from being a fibrocartilaginous callus to a bony callus matrix, which evolves through two stages of bone hardening. This is often wider or thicker (so much so that you can feel this under the skin).
  3. Bone remodelling: The bony callus is remodelled over the next months (and often takes as long as 3-5 years) with the excess material on the outside and other locations being removed. There are also different layers of bone, so the remodelling gets back to the correct layering of these different types of bone – rather than the fast fix of the callus. Areas of well-healed breaks can remain uneven for years, but with 5-7% of bone mass being remodelled in the body each week, this will get fixed in time.

How is the fracture treated?

If you are lucky with your break, you have not got an infection in the fracture, and there is not the issue of the bone ends not coming together at all, or not coming together in the right way, or coming together too slowly.

These days it seems that many more people are having their fracture stabilised with surgical insertion of plates and screws (which generally stay in forever) and are being given a sling or protective boot, rather than the plaster-cast of old. The reasons for keeping away from the plaster-cast are often to maintain Range of Movement, but are not meant for you to keep doing your sport in the same way!

So what happens if you try to exercise with a broken bone?

Let’s go back to our friends the (new) Numskulls that I introduced at the start of this blog.

In those early days Mr(s) Preparation is out there working her socks off trying to clean everything up ready for Mr(s) Repair to get going. But if the area keeps getting moved, vibrated or jogged more bit of stuff keep falling off and Mr(s) Preparation keeps getting called back and getting in the way of Mr(s) Repair.

Likewise, Mr(s) Repair is trying to build out a new structure into the gap. This job takes weeks (like most building jobs!) and happens once the worst of the swelling and inflammation has passed. But if the area keeps getting moved, vibrated or jogged the bits fall off – meaning the work has to be done over and Mr(s) Preparation has to keep coming back and cleaning up again, rather than sitting down and having a cup of tea!

So activities like running and strong movement of the area lead to delay and having to repeat the healing

But there are a number of things that you can do to really help the healing:

  1. Good nutrition: the body needs a lot of nutrients to heal the bone, so ensuring that you have a good balanced diet with enough protein, and key vitamins (C and D) and minerals (Calcium, Iron, Magnesium and Phosphorus)
  2. Sleep well at night: a lot of healing happens in the deep sleep phases, so ensuring that you are getting your head down for a good uninterrupted 8 hours of sleep (or more if your body feels that it needs it) will be a big help.
  3. Avoid aspirin and ibuprofen, if you can: there can be a lot of pain, especially in the early inflammation stages, but the problem is that aspirin and ibuprofen delay the body’s natural healing process and therefore delay progress. So the sooner that you can stop taking them, the better. (There are some other medications that have impact – so worth checking with your Doctor, if you are taking any medication)
  4. Avoid smoking and limit alcohol intake
  5. Don’t feel tempted to test your broken bone whilst it is healing! Do keep it immobilised and work out how to take away risks in your day-to-day activities that could lead to a knock to the area. If you have been told that you must not be weight-bearing, then respect that and get shower chairs, scooting devices, crutches etc that enable you to do this all of the time (cycling gloves are brilliant for protecting your hands If you are on crutches).

So no sport at all?

You should review this with your medical team and coach. Depending on the fracture and the treatment, there may be some things that you can safely do that keep your strength and give you a cardiovascular workout whilst keeping the fracture immobilised. I have seen some really clever ideas that are safe and keep things going.

But if that is not possible? This is 6-8 weeks of your life. Add up how many weeks you have been alive (52 weeks per year!) – and this 6-8 weeks will be a very small percentage. Be kind to your body: let those Numskulls go their job without having to keep going back and repeating it, because you knocked down their hard work!

Good luck and keep smiling!

How do musculoskeletal injuries heal?

Following my blog on how the body heals from invasive surgery (http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/) , I thought that it would be useful to do the same for musculoskeletal issues, since these are common injuries for athletes. This is a really huge topic, and I have struggled to get down the most relevant parts into something that I think may be useful for injured athletes and coaches to understand what questions they will ask of the medical team treating them. I have not covered musculoskeletal diseases such as osteoarthritis, carpal tunnel syndrome, tendonitis etc (many of which qualify as a disability under Social Security, if the symptoms reach a certain level of severity), as these are much more complex and long-lasting.

The challenge of most of musculoskeletal injuries is that they generally involve tendons (which connect bones to muscles), ligaments (which connect bone to bone) and/or cartilage (the soft, gel-like tissue that provides cushioning and enables movement in joints). The white colour of these tissue types give a clue to the fact that they do not have their own blood supply. This means that they heal much more slowly than damaged skin or muscles (which have their own blood supply). The surgical view is that they do not regenerate and this is why often surgery is offered – mending torn tendons and ligaments and replacing ruptured ones.

You need to play an active role in healing musculoskeletal injuries

Whilst the fundamental phases of healing are the same as a cut or muscle tear, there are a couple of key differences that you need to act on:

  1. the pain signals through the healing phases are very different and you need to actively manage your way through this – at times managing the pain to protect the healing of the correct Range of Movement for your body. It seems counter-intuitive not to listen to the pain in your body, but this is the reason.
  2. you do need to actively rehabilitate the area through each of the 3 stages, as it is unlikely to heal correctly without your active focus and support: initially using the ‘POLICE’ protocol (see below) and then with range of movement for that joint and then specific strengthening of that area. When you are in a lot of pain, the constant health professional exhortations of ‘keep moving’ may not seem to be very helpful, but this is the reason why.
  3. this is a long-term game, and you can expect to need to focus on this for a period of 12 to 24 months. But for those who stay the course and do the right things, the results do come.

Stage 1 of musculoskeletal healing – Inflammation.

The swelling and redness may be hidden inside the joint, but the symptoms will be such that no time day or night is pain-free and you may be able to detect the heat coming from the joint, as well as the tenderness, pain and loss of range of movement. If rest or a change of position gives relief, then the healing has progressed to the repair stage. The inflammation stage generally lasts 3-5 days, but can last a lot longer and if you re-injure or re-inflame the same area, then you go back into this stage.

The point of this stage for the body is protecting the area with swelling whilst it lays the foundations for the healing – clearing out the damaged cells and starting to spin webs of protective tissue that bind the wound together and stop the flow of liquids through the area.

This is the stage that you really need to apply the ‘POLICE’ protocol. This has replaced the old ‘RICE’ protocol (see the table below). So that in the past, the recommendation was Rest, get an Ice pack on the area, use Compression and Elevate the limb. All of these are designed to reduce the inflammation and allow the body to get through this first stage. Interestingly, anti-inflammatory medications do reduce the inflammation, but interfere with the body’s natural management of inflammation – so as soon as you are out of the immediate pain it is best to stop taking these in order to encourage the cellular-level healing process to begin.

The new ‘POLICE’ protocol reflects the fact that the latest medical studies suggest that some movement is good, even at these early stages. So ‘Protect ‘the joint from the bad motion that has caused the injury (eg twisting), with support, splinting or bracing as needed. Then work to get ‘Optimum Loading’ – moving the joint through the range of movement in every-day activities, but not causing additional pain. This is why we see increasing numbers of people in protective boots and slings, instead of full plaster-casts. The view on ‘Icing’ has also developed – and the guidance is that you should not apply it for longer than 10 minutes and more than 3 times per day (as too much icing can also damage the tissues).

P = Protect
OL = Optimum Loading
R = Rest
I = Ice I = Ice
C = Compression C = Compression
E = Elevation E = Elevation

Stage 2 of musculoskeletal healing – Repair or Proliferation.

During this stage the body develops the new tissue, initially haphazardly and then starting to align these cells correctly. This stage usually starts from a week after the injury and lasts 6-12 weeks or longer. Pain usually comes and goes, according to the position or movement of the body. If pain or fear of pain inhibits movement in this stage, then the pattern with which the scar tissue is laid down can inhibit movement significantly and reduce your body’s ability to function. Failure to stretch and move at this time will lead to weak, but tight muscles that are intermittently painful and vulnerable to re-injury. Therefore you really need to consistently (and gently) put the body through a normal range of movement and the unhelpful cross-fibres will be broken and the useful fibres that support the usual range of movement will be strengthened.  If this repair stage does not lead to correct healing, the danger is that the body will start to develop workarounds and compensating movements, which can lead to aches and injuries elsewhere as the body moves into the third stage of healing with the wrong fundamental structure in the injury area.

Stage 3 of musculoskeletal healing – Remodelling or Maturation.

In this stage the tissues build their flexibility and strength, and this lasts at least 6 months and can be two years or more. Even now, you may get some pain with certain movements (especially when you take the movement to the end-zones of the Range of Movement – which you do need to do), or you may be pain-free. This is why usually from around 4-12 weeks after injury (depending on the injury: follow your surgeon’s or physio’s advice), you should be adding in some strength-based training – starting very gently and slowly building up to 3 sets of 10 repetitions (working to failure), with a day or two of rest between sessions for the body to recover and rebuild (in line with the progressive overload model of development) and obviously backing off if the level of pain increases.

If you do not keep rehabbing the area, there is a very strong probability of significantly reinjuring it because it is so far below strength. This is very challenging, as it is usually just one or two exercises that you need to do over and over again, gently progressing them. And before you have done this, it may well be too premature to go back to a repetitive loading activity like running, or even cycling. Many people do not have the patience to do this progressive strengthening over the period of 12-24 months that it takes, and this is one of the reasons why re-injury is common. Even with the correct rehab, the area often stays 20% weaker than before the injury.  Hence you will need to keep looking at your form to check that there are not compensation behaviours that will cause other injuries, and look at your activities to check that you are giving it the protection that it needs.

Why pain makes this all so much harder

The challenge for many people in chronic pain* is that the correct level of managing the inflammation, mobilising the joint to get the range of movement and strength building across the 3 phases is hard to do. The pain makes them avoid exercise and stretching required for correct healing. At times the level of incorrect healing in stage 2 can need significant manipulation (even under general anaesthetic) to break up the adhesion and re-stimulate inflammation. You then effectively start back at phase 1 of healing, and need to ensure that stretching (for Range of Movement) and exercise (to stimulate the limited blood supply to the area) then begin the process of rehabilitation.

As well as medications, guided corticosteroid injections into the area are common and can bring very significant short-term relief. You need to make the decision on these with your Orthopaedic Consultant. The only anecdote that I would pass on is one where an athlete had a number of injections into the tendon over a 2-year period, and the tendon did rupture. One of the questions was whether the perforations from the multiple injections had played a role.

* The definition of chronic pain varies, but it is long-term pain and most seem to define it as having lasted for over 3 months or over 6 months. I think that the key definition is having been in pain for that length of time, you get to the stage where you adapt your physical, mental and emotional approaches to life (whether consciously or unconsciously) as a consequence of the pain. As well as these external impacts on your life, the internal impacts of your body swimming in the chemicals associated with inflammation and the nerve pain patterns can also have significant impacts on your healing.

How do you heal after invasive surgery?

Just recently I had two athletes each bemoaning the fact that they were not successful in returning to training within 2 weeks of surgery. They had both had abdominal incisions and were having issues with the wound not sealing and a lot of pain in the surgical area.

So how soon can you start back to training?

I thought that it would be useful to understand the hard work that our bodies are doing in this time. The hard part of today’s ‘instant-everything’ world is that we are not giving ourselves a chance! But we can help ourselves by looking after the wound and the healing process.

The healing process is 4 stages – and last in total over a year and possibly two years!

The four stages of healing happen in an organised and sequential way – but they can progress better or worse, depending on factors associated with you (both as a patient and how you treat the wound). The second part of this blog will look at the factors for you to promote better healing.

Stage 1 seals the wound and is really quick!

The hemostasis phase closes the wound with a clot (usually in a matter of minutes/hours). Various components of the blood combine to create a mesh that forms a clot that adheres to the wound and closes it off. You need to protect that. There used to be a school of thought that you had to let the wound be open to air for the scab to harden properly, but the new hospital dressings allow it to do this without removing the dressing – so you will probably be advised by the hospital to keep the same dressing on for some time, in order to stop infection entering the area.

Stage 2 prepares the wound area for the growth of new tissue

The defensive/inflammatory phase focuses on destroying bacteria in the area and removing any debris, such that the wound area is all set for the growth of the new skin and tissue. White blood cells and microphages in the blood do this. It normally takes around 6 days and you can often see and/or feel swelling, redness of the skin, heat and pain. Obviously if the area keeps getting new infections into the area, then this period is extended. During this time it is absolutely critical to keep the scab dry – so you will need to find some good waterproof dressings or a different way of staying clean (wrapping cling-film over the area does not work!)

Stage 3 is the progressive filling and covering the wound, starting from the outside edges

The proliferative phase follows three distinct stages: 1) filling the wound, 2) contraction of the wound margins, and 3) covering the wound with new skin. You probably remember watching this as a child, as the new, pink skin forms from the shallowest and outside parts of the wound and eventually closes it up. It is a very clever process that remakes the blood vessels, tighten the open wound (often giving an uncomfortable feeling of tightness for a time) and then the skins cells work their way up from inside the body to form the boundary layer. This can all last anywhere from 4 to 24 days, and during this time dissolvable stitches on the surface should drop out. In order to protect the wound, it is still really important to keep the scan dry in order to protect it from damage, although to the latter end of the timeframe many nurses say that you can have a quick shower, but must keep away from baths and any kind of swimming pool/hot tubs etc until it is all completely sealed. Also across this time, a lot of nurses suggest gently putting Vaseline or moisturiser on the scab, in order to keep it flexible and stop it cracking and getting damaged.

Stage 4 is where the scar gains strength and flexibility

The maturation phase is where the tissues reorganise and remodel as they mature. During the proliferative phase the tissue gets laid down haphazardly, whereas the uninjured tissue is all lined up in a standard structure. Over the usual replacement of the layers of skin, this slowly gets addressed and as it does the way that the scar tissue moves stops being a big block and starts to move with the body and has strength. This phase can vary from 21 days to 2 years, and you can help it by gently massaging the wound and encouraging the tissue to realign. Also many nurses recommend rubbing in Bio Oil or a Vitamin E cream, which seems to visibly help the scar to fade in colour and settle back to flat with the skin.

So it all takes time

Back to our athletes – getting the wound to seal and be ready for the forces of movement in the area of the surgery is probably around 6 weeks, and within this time nurturing the area to maximise the healing will really help.

Things that you can do to encourage faster healing

There are many factors that mean that people heal differently. Some of these are inherent to you as the patient. Age has a direct effect on how fast we heal – as we get older, the skin is thinner and less elastic so we need to allow it more time. There are also factors associated with your body make-up in terms of how your body lays down the scar tissue, which you cannot change.

However, there are a number of things that you can look after.

  • What you eat is really important – You need to ensure that you are getting some good protein at each meal, and foods that are high in zinc, copper, vitamins A, B and C can also help the healing,
  • Good hydration really helps too, as this has a direct effect on the blood stream.
  • A good overnight sleep is key. The body’s repair mechanisms work hardest during the deep sleep cycle – so do make sure that you are getting your head down and getting a good quality 8 hour overnight sleep (or more if your body needs it)
  • Reducing inflammation – many people swear by arnica. Obviously the cream cannot be applied to open wounds, but I found major reduction in the bruising around where the cannula was inserted by using the cream on the adjacent skin areas. And you can buy oral arnica from homeopathic providers such as https://www.helios.co.uk/ and it generally does not have any interactions with other medication that you may be taking (although check with your own Doctor and/or surgeon)
  • Managing your weight – skin heals better when it has the blood supply into the tissue, which muscles give but fat does not. This helps the supply of all of the agents for the different phases of healing, as well as oxygenating the wound area.
  • Keeping the wound area dry and clean – this is so important for the right conditions for wound healing. This can be hard to do, but is a really significant factor. Try to get the right balance between waterproof dressings to stop external moisture and getting it open to the air if it is in an area of your body that stays damp and then covering it again.
  • Medication can slow healing down – some medications slow healing by impairing the inflammatory response, leading to a reduction in the collagen production which is key, especially in the 3rd and 4th stages. Treatments such as chemotherapy affect the new cells, so have a strong impact on healing, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that you may commonly take as over-the counter drugs can also slow down the process. Obviously you are likely to need medication after major surgery, but it will help if you can keep it to the minimum that you need and bear in mind that you may need to allow longer for your body to heal. 

So best of luck with your healing – do nurture your amazing body to do its thing! And after a major surgery taking a good month or 6 weeks off training that involves the juddering of impact, or the strain of strength training could be well worth it. It is also worth saying that there are other factors from surgery – for instance, anecdotally many Doctors say that it takes around 6 months for the body to completely recover from a general anaesthetic.