3 top tips for coping with the sense of loss that goes with injury

This week we have a guest blog from a 15-year old hockey player who has spent almost three years with serious knee injuries, culminating in surgery in 2020. She shares her experience here, finishing with 3 top tips that you will definitely want to read!

Over to her:

“My injury came very out of the blue (like I’m sure most injuries do). One minute I’m saving a goal then, the next thing I know there’s this horrible clicking sound and I have collapsed to the floor my right knee in agony. After many X-rays, MRI’s and countless appointments they discovered that I had fractured my kneecap, ruptured the patella tendon, torn my Medial Patello-Femoral Ligament (MPFL) and to top it all off, my kneecap never went back into the right place.

“The first thing that I can remember thinking after hearing all of this is: How? How did I do so much damage to my knee whilst performing what I would call a reasonably easy save? Then the next thing I thought was: ‘I have county try-outs in two weeks I can’t miss them that’s what I have been working towards for the last year’. Well, I did miss those county try-outs. In fact, I missed the rest of the hockey season – only getting back on the field for a few weeks of the next season before dislocating my left knee and then tearing the MPFL in that knee!

“In total, I have been completely knocked out of any sport for almost two years.

“Since dislocating my right knee the first time in March 2018, I have dislocated my knees a total of 4 times and I have now had an operation on my right knee to hopefully prevent me from dislocating it again. But I think that it was the time that I dislocated my left knee that I found hardest to deal with. I had done all of the physio exercises, worked to gradually get back to the sport and I had finally got the all-clear from both my consultant and my physio to get back to goalkeeper training. Then, on my first goalkeeper training session back since I had dislocated my right knee almost exactly a year earlier, I saved a goal and felt my left knee go in almost the exact same way (I was even on the same pitch!) What made this time worse was the fact that my left knee was supposed to be my ‘good’ knee- it wasn’t meant to be the knee that I was worried about! Also, this time I knew how long the process of recovery would be and I knew that I would miss the rest of the hockey season and county try-outs for the second year in a row. This time the overriding feeling was annoyance: I was annoyed at myself for getting injured again, I was annoyed that no one knew why my knees kept on dislocating and, as selfish as it seems, I was annoyed that I was the one to get injured again- wasn’t it someone else’s turn?

“Every time I got injured, I really struggled with the feeling of loss. By hockey being torn away from me, it felt like I had not only lost connection with my teammates, but I had also lost my identity. Before all of this started, I was playing hockey competitively 5 times a week for 3 different teams (in 2 of which I was the captain) and so it did take up a huge part of my life and it always has. Ever since I was 3 and got my first hockey stick, I have been totally obsessed with hockey. I used to beg my Mum to let me go to her games to watch and as soon as I was old enough, I joined a team. So, by not being able to play hockey I felt like I didn’t know who I was anymore. Not to mention that some of my teammates are more like family to me, and so the fact that I wouldn’t be seeing them every week also had a major impact on me.

“Although I have spent a large amount of the last two years on crutches, I have tried my hardest to not let it hold me back. For example, the first time I was on crutches I went on a French Homestay with my school and I even got to go up the Eiffel Tower! And, only two weeks after I dislocated my right knee for the second time I climbed the stairs into the Batu Caves in Malaysia (granted very slowly) but I took it very literally one step at a time. I will never forget the feeling of dread that I had standing at the bottom of those stairs looking up, but I will also never forget the feeling of achievement I had standing at the top looking down!

“When I look back there are three things that I wish someone had told me at the beginning of this experience:

  1. Even if you can’t participate in the way you normally would you will not lose the sporting community. Over the last two years, I have really discovered how important the people in the sporting community are to me and, through injury, I have made new connections with some amazing people who have helped me through this process.
  2. There will be setbacks and it’s OK to be annoyed about them. Sometimes by trying so hard to stay positive about the situation, it made me feel worse and I wish that I had reminded myself that it is ok to not be ok because being injured and facing setbacks sucks and it is ok to be annoyed about it (as long as you don’t wallow in that annoyance for too long)
  3. It is OK to aim high but remember to celebrate the small achievements too. My long-term goal will always be to get back to hockey but along the way, I will make small achievements (such as being able to get upstairs to my bedroom for the first time in 8 weeks) in order to get there and by celebrating those it makes the journey to recovery feel just that little bit shorter.

“I am still on the long road to recovery and working on my goal of getting back to hockey but, at least now that I have had my operation, I know that I am on the right track and I can put even more effort into physio and trying to make small achievements every day.

I wish everyone luck for whatever stage of recovery you are in and I’m sending healing vibes your way.”

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.