Why going to a Pain Clinic can be a really good step to recovery

When the physiotherapist mentioned going to a Pain Clinic, everything about it that I could find suggested to me that this was a last resort – a place that you go once you have lost every last vestige of hope that you can get better and just want to manage the pain to try to find a way to get through the minutes and hours of an agonized existence. And talking with a number of other people in pain, this perception is very common, and none of the things that I could find online change that view.

However, the reality was so very different, and this is why I wanted to write this to help others to get the help that they need faster.

They never dismiss your pain

I can imagine that one of the challenges for Health Care Professionals is when they have to admit that something is complex and they don’t really know the answer. The downside of this is that thousands of people every year are dismissed by comments and inferences that imply that the pain is ‘all in their head’. You only need to take to Twitter or patient forums to hear the things that people have been told (or at least how they have interpreted comments from Doctors and Physiotherapists).

At the pain clinic, dealing with serious pain is their ‘thing’ and they are overflowing with compassion, knowledge, support and genuine interest in your pain. This alone is a huge relief, when you have been spending months battling to get people to listen the symptoms and take them seriously. It feels like getting into a comforting, warm bath! Plus they have models and simple explanations that help you to make sense of how your life is unravelling and what you can do about it.

One model that was enlightening for me was the ‘pain triangle’ that they said was universal in serious pain – where the relentlessness and intensity of it makes you feel helpless and hopeless, and your incapacity and reliance on others then drives feeling worthless. Then each point of this ‘helpless, hopeless, worthless’ triangle reinforces the other points, dragging you lower and lower until you can find something to break out of the vicious cycle.

They really want to get to the root cause

The next bit of brilliant news at the pain clinic is that they profoundly believe that your pain has a cause and that with work, they can find it. I felt that there was almost a detective vibe – where they are searching for the cause with different clues, hypotheses and points of evidence. They listen intently to every clue that you can give them, weighing it and thinking about what it could mean in a medical sense.

The pain clinic felt different. How? Well, I sometimes joke that when you see a consultant, they only have the 3 N’s (kNife, Needle or Nothing) and physiotherapists only have the 3 P’s (Poke, Push or Pray). This is of course brutally unfair and negates all of the knowledge and complexity of what they do, but as a patient it can reflect the outcomes and the lack of transparency in the process where they have the knowledge and you are just left with the problems. But, in the pain clinic, it felt like there was a logic in the way that they assessed the total body and looked at the interactions of different body parts. This is especially important when there are different body parts involved or overlapping conditions that come under two different surgical specialties because it leads to a lack of clarity about where the leadership and ownership sits between the different specialties once you are an out-patient. Whereas in the pain clinic it is all assessed together and at the same time (almost like you are one person with all of the parts of your body connected!)  

They take a multifunctional approach

The other brilliant bit is that all of the different disciplines work together and talk to each other in the pain clinic. This is so different from life as an out-patient and even as an in-patient, when even when you try to get the physiotherapy and surgical side to align behind one treatment plan and talk with each other, one party always resists it (even if you promise to sign GDPR releases, volunteer to manage the phone call within your appointment and volunteer to step outside if there is something that they want to discuss without you present).

At the pain clinic they have a common goal to reduce and eliminate your pain, and they each bring their own specialist skills to this team goal. It feels like a sports team, with everyone rooting for each other and working hard to get a result. As a patient, you feel in good hands.

This team support is important. If there was one tip that I would give to Physiotherapists in the out-patient context it would be ‘don’t comment at all on any previous physio that the patient has had’. I have seen nine different physio’s through the path of my pain and universally in the first stage (when they ask you lots of questions about what has happened and what you have done before), every single physio has critiqued what the previous physio has done with very negative tones and criticism. This really does not help! We cannot turn time back and I have already decided to change physio to see you, so there is no need to justify why you will be better. It makes me (as the patient) feel vulnerable and scared, because it makes me wonder if I allowed the ‘wrong’ treatment to be given to me (even though there was no way that I could have had the knowledge to make this judgement). And when you have seen as many as me, you start to build a picture that there is no common view of best practice and that there may be a lot of snake-oil sales people in the physiotherapy profession who maybe have not kept up-to-date with best practice. I hope that this is not true, but is a clear impression that the criticism of others can generate.

So my advice for patients is to seek out a group who work together across functional boundaries with your wellbeing as a patient as their over-arching goal.

When should you go to a Pain Clinic?

There is not really a clear view on when to go to a pain clinic, and again you can get a lot of contradictory advice. The textbooks says that pain is considered to no longer be ‘acute’ and to have become ‘chronic’ after 3 months, although many GPs seem to operate on 6 months.

I also think that there is a lot of pressure on the resources of the pain clinic (and there is a really long waiting list for it – over 9 months in our area). My hunch is that this leads to a tendency to hold off from a referral to the pain clinic until it has been a very long and serious issue. If you have health insurance, there are also private pain clinics, although you will need to have a look at the terms of your policy to see whether this is covered and what the referral process is.

I would suggest that for the reasons above a pain clinic may be especially helpful if:

  • You have overlapping conditions that make you feel that you are falling through the gaps
  • You are not making any progress and need a different approach
  • You are reaching a point of despair

I wish you the very best of luck – you are not alone, and there is a brilliant team somewhere who can help you! Stay strong in order to find them and start to move forward.

Recognising other bloggers who have cast helpful light and perspective on my own challenges

It has been quite some months since I last wrote a blog. The back end of last year was a hard road of trying to get the pain medications to the balance that made the basics of getting through the day possible, and working out how to shrink life to the things that I could get through. Then facing up to the surgeon’s persuasion that a tenth surgical procedure was the best way forward.

Through this time I struggled to find a way to share my experience in a way that I felt could help others.

Plus, I have to say that I found various bloggers and communities who are sharing their experiences and I felt were sharing a lot of the things that I had been searching for over the last two years.

So I wanted to blog to share links to some of them – in the hope that this is helpful for people reading it.

Joletta Belton – My Cuppa Jo (www.mycuppajo.com)

Jo shares her experience of over a decade of pain stopping her ability to work as a firefighter and to run and pursue the sport and life that she loved. She has gone on to do a huge amount of study about posture, musculoskeletal issues and pain, now sharing this with others in her beautiful and inspiring blog posts and also as a patient advocate at international conferences.

Tina – Living Well Pain (www.livingwellpain.net)

Just as Jo has pioneered the path in Canada, Tina has done the same in the UK. Tina’s accident was over two decades ago and she shares her experience of how to live well with persistent neuropathic and musculoskeletal pain with lots of practical tools and advice from her own experience. These come in the form of blog posts on specific topics and most recently as a patient advocate, she has written a guide for patients called ‘Making the most of Physiotherapy’.

Pete Moore – the Pain Toolkit (www.paintoolkit.org)

Pete attended a pain management programme in 1996 and since then has dedicated himself to sharing the best information and knowledge with both patients and clinicians across the globe dealing with persistent pain, especially back pain. He has a great website and has written a number of excellent guides on pain. Most recently he has set up a monthly Pain Toolkit Online Café on Zoom, where anyone is welcome to digitally ‘pop-in’ and chat or listen to others working with similar issues to their own.

Barbara Babcock – Return to Wellness (www.returntowellness.co.uk)

Barbara’s experience of her own neurological illness and also caring for her husband meant that she saw up-close-and-personally the life-changing impact that a serious health issue can have. This led her to use her coaching experience to restore emotional wellbeing and look positively towards the future. Her blogs and self-help tools help across: managing the health issue, reclaiming emotional health, reclaiming relationships, returning to work, reclaiming meaning & purpose in life, reclaiming hobbies & interests and support for carers and supporters.

Jo Moss – A Journey through the Fog (www.ajourneythroughthefog.co.uk)

Jo is bed-bound as a consequence of the health issues that she suffers from. She writes her blog to give other people in the same position a bit of hope. She says “My life isn’t easy, but it is worth living. I may cry a lot, but I also laugh a lot. I may get depressed, but I’m also optimistic. No matter how bad things seem right now, they will get better. You can take back control and give yourself hope for your future”. Her blog is frequent, searingly honest and brutally insightful on topics that others may shy away from.

Sheryl Chan – A Chronic Voice (www.achronicvoice.com)

Sheryl lives and blogs from Singapore, living with multiple lifelong illnesses. Her blog sets out to help other sufferers with a toolbox, but more widely to raise awareness of long-term illnesses from a number of perspectives and encourage empathy amongst all facets of society, and not just healthcare. Her blogs are frequently very practical, covering both the physical and the emotional challenges with equal frequency.

The Princess in the Tower (www.princessinthetower.org)

This site has a number of useful resources for learning about chronic pain and how to manage it and reduce it. The blogs focus a lot on the emotional impact, and ways to manage this.

Then, I also discovered some really useful communities:

HealthUnlocked (www.healthunlocked.com)

This is like a medical version of Facebook and there are different groups that you can sign up to. One of the groups is Pain Concern (a charity that also have a helpline that you can call and lots of other support tools that you can access at www.painconcern.org.uk)

Anyone can post a thread and expect to get genuine responses from others. The tone is universally helpful (in my experience) and can get some good insights. Obviously, this is not professional healthcare advice, so it needs to be seen in that context.

The Injured Athletes Club on Facebook

This community was set up by Carrie Jackson Cheadle and Cindy Kuzma to go with their book ‘Rebound: Train your mind to come back stronger from sports injuries’. They moderate and facilitate the group to get to a mix of being able to vent about challenging times, ask for advice/perspective and celebrate progress, with ‘Winning Wednesdays’, Monday Motivation and Friday Feeling themes running most weeks.

I hope that you find some of these inspiring and helpful, just as I did. If you have others that you think are excellent, then do share!

Why I asked for my money back on the FAI Fix

The FAI Fix was recommended to me by a friend of a friend. It was developed by two Personal Trainers (PTs) in the USA – Shane and Matt – who both had significant hip issues and manage to overcome pain, impingement and poor Range of Movement (RoM) without surgery – although they do admit that this has taken up to a decade of daily work! It comes with a number of success stories on the website: https://www.thefaifix.com/ and is supported by some really excellent YouTube videos and emails that made me really feel that Shane and Matt understood the issues and challenges of hip pain, and also explained the anatomy aspects of it really clearly.

However, when I was thinking about signing up for the programme I could not find any impartial reviews of how people had got on with the programme. And I saw tweets and messages of others looking for the same. So I thought that I would write about my experiences in order to support others.

The programme

There are 2 levels of the programme. The basic one is the FAI Fix Basic for $129.95 USD – a one-off payment that then gives ongoing access to the exercise library. There is then a further payment to do the more advanced programme for athletes who want more hip movement (eg powerlifters). But they are clear that this is a much smaller group, and is a progression from the first programme once you have resolved the pain in your hips in usual daily activities.

On the homepage, they explain their TSR system – Tissue Work, Stretching and Reactivation. This is a common (and well-proven) structure for many rehab programmes:

  1. releases with the foam roller, ball, knobbler etc to release the overactive muscles
  2. stretching to lengthen the tight muscles
  3. reactivation to activate and strengthen the underactive muscles

It is impressive how much more RoM you can get by doing targeted muscle releases before stretching that area.

There are a minimum number of tools that you need in order to be able to follow the programme – a foam roller, a strap (which could be a belt from a dressing gown), a lacrosse ball (or small, hard ball – there are different levels of hardness in therapy balls and the idea is that you progress) and possibly a ‘knobbler’:

The tools! The ‘stick’ was an optional extra, and the blue one is the ‘knobbler’ – but most of the programme could be done on the floor in front of a mirror with the foam roller.

When the programme link arrives there are 13 tests which are meant to narrow down which of the 5 key muscle groups is the issue. Then there is a TSR exercise set for each muscle group and a 6th workout that is a combination across muscle groups.

My experience with the programme

In advance of signing up for the programme, I was uncertain whether it was suitable for me given that I was 6 months on from hip arthroscopy surgery. However, I got a response that looked like it was a response from one of the 2 PTs reassuring me that it would be suitable – although looking back, I now think that it was probably compiled from a series of standard paragraphs.

Working through the programme is quite intense – the diagnostic exercises take quite a lot of set up and checking the form and RoM in front of the mirror. If you or someone in your family are not quite experienced in Personal Training and muscle groups it would be quite difficult to work through. And the challenge for me was that the tests were not discerning for me – all of them were painful and all of them had less-than-ideal RoM, so it was hard to diagnose where to focus.

I diligently followed the programme daily for 4 weeks. The good news is that I did see an increase in my RoM, but no reduction in the pain before, during or after the exercises. Therefore, I followed the process to get advice from Shane and Matt. I wrote a summary of how I had interpreted the 13 tests and what I had been doing, but got only a 2-line response from someone other than them telling me that I needed to choose just one muscle group and focus on that, but no further details on how to make that choice or how to better understand the diagnostic tests (given that all were painful and low RoM).

I followed the advice for another 4 weeks and then got in touch again, but did not get any response this time. In the meantime, the general emails from them changed. In the first couple of weeks, they had been bits of advice and case studies which were definitely motivational – especially on fixing the body through movement rather than surgery. But after that, the emails continued to come 3-4 times per week, but were now trying to sell more stuff (tools, personal coaching, other programmes etc). 

So, I decided to ask for my money back (which in-line with their no-quibble money-back guarantee they refunded immediately – although interestingly they did not ask for any feedback on what had worked and not worked, or why I was asking for my money back).

My summary

The exercise video library is good (there are probably 50 exercise variants covering the 5 muscle groups), but I would suggest that the money is much better spent with a Movement Trainer who specializes in Corrective Exercise and can really help you to diagnose which are the problem movements and then focus a personalised programme on just what you need. This should actually start to address where you have the pain and monitor development and progress you see with the exercises, in order to then make choices on how to progress.

That said, the overall message that you can make progress on your hip pain without surgery is profoundly supportive. Plus there is a strong sense of realism in the sense that they are clear that it will take work and time.

Good luck with getting to the bottom of your hip pain and finding the key to unlocking the pain.

My experience with hydrotherapy

I have not blogged for a while whilst I have been trying new things, doing lots of research and trying to make progress on reducing my pain and increasing my ability to cope with day-to-day tasks and activities. It has been an interesting voyage where I have become clearer that there are many paths to recovery – and no-one has the universal answer, so you have to try lots of things! With this in mind, I thought that I would share in a few blogs over the coming weeks some of my recent experiences.

Hydrotherapy was one of the things that was suggested after each of my surgeries. It is 45 mins drive to the nearest hydrotherapy pools and there are none in my local authority area. Plus you have to have a medical referral form and go through some extra checks to get access, so it all took a bit of organising. But I think that is was well worth it, as I think that it reduced pain in the short-term and had an incremental improvement in the Range of Movement (RoM) in the scar tissue and the affected muscles.

What is hydrotherapy?

The hydrotherapy pool is kept at 37 degrees Celsius, which consistently feels very pleasant and after 30 mins of doing structured exercises feels positively hot!

It is about shoulder depth and about 10m across, so it is easy to get the benefit of the water resistance as well as the immersion.  There is also easy access, including a hoist so that you can get in and out even when your body is not working well. Given that there is only space for a small number of people, it is key to reserve the slot and be there changed and ready in time.

You can work with a physio in the session, but once you have a routine it is relatively easy to work through the exercises on your own. There are ‘weights’ made from floats to create additional resistance by pushing them down in the water and inflatable ‘noodles’ for support.

How is it better than a normal pool or hot tub?

I had tried both the normal pool and hot-tub, and would say that the hydrotherapy pool is much better.

Doing my exercises in the pool was hard work (remember that 1 litre of water is 1kg – so there is lots of weight in the water resistance), and the cooler water temperature that makes it suitable for swimming means that there is not the therapeutic benefit of the muscle release that helps with RoM and probably with the pain reduction too.

I had also used the pool to try a little aqua-jogging with the float-belt (as shown in the photo). This is used a lot by elite athletes when they have injuries and it is claimed that you can keep 80% of your running fitness if you put the same hours in at the pool. This should work really well for lower limb injuries where you need to keep the muscle memory, but avoid the impact (especially in stress fractures and some soft-tissue overuse injuries). But given that for me the inflammation affects the movement pattern, I found that it was too tough at this stage.  

The aquajogging float belt clips around you to keep you upright without your feet touching the bottom of the pool (you need a pool deep enough for this!) and you can add difficulty by holding a waterbottle in each hand and changing the amount of liquid in it for more difficulty.

The hot tub is useful for me for the muscle release and for managing some of the pain. But it is not deep enough or large enough to do all of the exercises, so it is not as good as the hydrotherapy pool. I think also that the 30 mins slot, where everyone else is also working on their exercises, brings a level of focus that really helps.

Did it make any difference?

My own experience was that it was a very supportive environment – everyone there is working on getting better and is very willing to share what they have had success with.

In terms of the physical impact, the warmth definitely had a positive impact in terms of reducing pain for a few hours (just like hot water bottles etc when at home). My understanding is that this is not universal – some people find that the pain is reduced with cold, others with warmth.

Plus, I found that 30 mins of hydrotherapy definitely improved RoM for a period of 24-48 hours and if I did it 3 times per week, I saw real progress on my land-based exercises. That said, it was positively hard work – after 30 mins the combination of the temperature and the hard work was very tiring and I was keen to get out and have a nice drink of water! And the travel on top made it quite a bit harder. So, I would say that if you have a hydrotherapy pool nearby, do make use of it in your recovery and rehabilitation.

Is it time to learn from a flea?

Fleas are amazing athletes – with the ability to jump 50 times their body length!

But the inspiration for injured athletes comes from the oft-quoted experiment with fleas in a jar. It is said that if you put fleas in a jar, then they jump out. But if you put a lid on the top to stop them jumping out, you can remove it a short period later and for all that they could jump out they do not. And this lasts for the life of those fleas – they have learned their new limits and do not exceed them.

The path to rehabilitation involves false starts

The really hard part of rehabilitation is that we need to keep trying things and pushing the body to learn and adapt. Sometimes this can hurt a lot, and rekindle the kind of pain that has been so hard to cope with before.

But somehow we have got to find the discipline and strength of mind to keep doing the activities recommended by the Doctors or Physios. Even if previously this led to pain or set-backs. Because this time ‘the lid to the jar’ may have been removed. And we can only find it out by trying.

This is especially hard for athletes

Every single injured athlete that I have met has pushed themselves too hard in the early stages of recovery. We love to believe that we can always be in the top 5 or 10% of people, and always beat the timings and goals through sheer willpower and determination. Sadly that cannot always be true for our bodies.

So as time goes on, the people around us get used to warning us and holding us back. And we too often start to look on the more pessimistic side, in order to avoid slipping backwards and to protect ourselves. But when is the time to move on from this important protection and guarding behaviour? How can we know?

Keeping a diary of activity and pain is very useful

Just like a good training log, a diary of activity and pain levels really helps to show the trends and ensure a gentle progression, together with the right nutrition, hydration, sleep and rest. It can also help to look at the potential reasons for times when the pain is bad, or you slip backward.

So we need to learn from the fleas as we progress down the rehabilitation path and need to spot the moments where we are being too conservative and could be holding ourselves back. Our loved ones and closest friends can also be really useful advisers, and we should ask them to look out for signs of when we need to step up and leave our injured past behind in order to get to the recovering future that we want so much.

Gaining the lift to recover after a difficult injury can be very hard, and takes work both mentally as well as physically.

Why you need to get out of pain, right now!

It sounds obvious doesn’t it? Getting out of pain has to be one of the key goals, if not the over-arching goal! But if you are badly injured, pain can become your constant companion – whether you are lying inactive, or trying to move around.  And when this situation lasts months or even starts to be measured in the years, getting out of pain seems to be impossibility. You get so used to the fact that even breathing hurts and you can start to lose sight of the goal of getting out of pain. But it is really important, and needs to remain front and centre.

You may have thought that pain is just an electrical signal

Back in biology class at school, you may have been taught that pain passes as an electrical signal up through the nervous system, in order to get the body to move away from the source of pain. More recent work has proved that even the electrical components of this are more complex (Pain Gate theory), as well as the fact that there is a chemical cascade that is set into motion by the nociceptors (the scientific word for the sensory receptors for painful stimuli in the nervous system). The nociceptors release Substance P and this triggers a release of histamine. Both of these chemicals are neurotransmitters, and the histamines are also involved in the inflammatory response.

The bad news is that these two chemicals have additional impacts – they increase the sensitivity of the nociceptors to pain, and the excess histamine has been linked to increased anxiety in the brain and inhibiting the release of serotonin and dopamine (classic feel-good chemicals in your system).

So if you get into long-term pain, the chemical soup is working against you  

Once you are into the chronic pain (pain that has lasted more than 3 months), you are likely to become more sensitive to pain for these chemical reasons. You can start to hurt in new places. And of course the impact on your mental coping strategies for the pain, and the loss of sleep can lead to irritability and depression.

This is why sometimes the medical team talk about taking blood tests to understand the levels of your inflammatory markers, in order to understand your situation better. On the basis of the imbalances (deficiencies or excesses) of neurotransmitters such as serotonin, GABA, dopamine and norepinephrine, the clinician can develop the right treatment plan for you.

How chronic pain can link to depression

Depression and chronic pain share some of the same pathways in the central nervous system of the brain and spinal cord, and the same chemical transmitters are involved.

In addition to some of the chemical reasons why chronic pain can make you feel very low, there is another negative cycle – pain creates anxiety, irritation and agitation in everyone. This tension and stress on your system , which can cause sleeping issues, physical incapability, loss of appetite and a sense of not being able to cope with all of the other issues.

Articles suggest that perhaps half of people who complain of pain to their Doctors are depressed. And depression makes pain feel worse. This in turn is even more depressing.

If you are worried that you have a lot of the symptoms of depression, do talk to your GP about it. Hopefully this blog has set up that a combination of the chemical and physical realities are the reason that people end up in this place. And hence a combination of medication and Cognitive Behavioural Therapy (also known as Talk Therapy) can help .

This is why you need to break the cycle

I found this excellent Pain Management guide from NHS Ayrshire and Arran – with full recognition of the excellent work from the NHS team there. I think that you may find working through it is a breakthrough for you.

https://www.nhsaaa.net/media/5071/pain-management-workbook.pdf

Within it, I would strongly recommend that as an injured athlete you turn to the section on ‘Managing Activity’, which starts on page 22. Mapping your activity and pain cycles may seem a little difficult, but if you keep some notes over a few days and then draw them out as a graph over time the patterns become very clear. Are you yo-yo-ing through an Over-Under cycle? Or pushing too hard with an Over cycle? (You can read more about these on pages 22 and 23).

You have got to get your activity down to a sustainable level

Whilst you may find these low levels utterly ludicrous and frustrating, you must give your body the chance by getting your activity down.

This means looking at your day and:

  • Planning – not going on feel and overdoing or underdoing it
  • Prioritising – you will not be able to do all of the things that you want or need to do, so prioritising will help you choose
  • Pacing – breaking things into more manageable chunks with more rest

This should help to avoid flare-ups, but they can still happen. So you also need to have in mind your plan of how to avoid them, and then how to minimise the impact and calm the system down again. For instance, if you go out – can you take a car or have the numbers of friends who might be able to pick you up if you need to get home quickly to manage a flare-up in pain levels.

You will have your own pattern of what causes flare-ups and how you can manage them. But having a plan can reduce the number and impact of flare-ups. (There are also some good worksheets in the booklet on pages 29 and 30 for this).

In summary

So in summary, don’t keep pushing through as the challenge of getting out of pain will only increase. There are things that you can do and it is both the right goal, and an achievable goal to get out of pain – even if you have to involve your GP and other clinical support.

Best of luck in your journey to pain-free!

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!

When should pain stop my running?

Most of us have seen track athletes lying writhing in agony with the lactate in their legs, or even track cyclists suddenly vomiting from the amount of lactate that they have built up. And endurance runners always talk about it being painful and ‘pushing through the pain barrier’, so how does anyone know when they should actually stop, recover and rehabilitate? The goal of this is to help to create good training habits in terms of injury management and resilience for runners, triathletes and those who do a lot of running mileage as a part of their training (but it does not cover the impact of high lactate levels from very high intensity work using the anaerobic system).

The key is learning to understand the signals from your body

Development in training is built on the principle of progressive overload of the muscles, and so there is likely to be a level of soreness when you are training hard. This can be during and immediately after the run, or 12-72 hours later in the form of Delayed Onset Muscle Soreness (DOMS).

The reason that you get this muscle soreness is that exercise creates micro-tears in the muscle and with rest these recover and grow back even stronger, ready to do the challenge again. This cycle is called adaptation. You can help this process by doing a few good things:

  1. Getting some nutrition into the muscles within 30 minutes of finishing your workout. The muscles need protein to build the muscle and carbohydrates to replace the glycogen stores that you have used up. Testing of 4:1 ratio of carbohydates to protein have found these to be good at building lean muscle mass and restocking the glycogen – so things like chocolate milk can be very good (especially as liquids get into your system a little faster than solids)
  2. Giving your body enough time to recover with quality sleep and rest.
  3. Compression clothing on the legs has also been shown to have benefits immediately after exercise (as long as the foot is also covered), which is thought to be from reducing blood pooling in the leg muscles, and pushing all of the waste products out of the muscles and into the bloodstream.

DOMS is an additional level of soreness and lasts much longer. It is often characterised by agony going down stairs – check out the DOMS Stair Test within the Fellrnr wiki: https://fellrnr.com/wiki/Delayed_Onset_Muscle_Soreness.  Many people find that gentle movement is best – walking or very slow recovery runs on smooth, flat surfaces will help to flush out the toxins and let you recover. If you are routinely experiencing DOMS, then you are probably progressing the length and intensity of your runs too quickly, so scale back and replan your training.

But what about those pains that are not just soreness?

There is a different territory of pain: sharp, spikey pains with clear pain centres, or any pains that you would describe as burning, prickling, cramping or spasms. These words tend to match pains that go beyond the muscles, into the harder-to-repair areas of tendons, ligaments, joints and nerves.

I am in the process of writing other blogs on nerve pain, and reviewing some of the excellent material on the impact and treatment of nerve pain for runners and other athletes. But in the meantime the headline is that there are dimensions of pain that if you find yourself describing them with these words, the indications are that it is a lot more than muscle soreness.

This is where a good training logbook is worth its weight in gold

Hence these are all pains to take very seriously and get straight onto monitoring. If you keep a training logbook or diary, you should note down any level of aches and pains, so that you can look back and see when did you first have even a minor twinge in this area, how fast has it progressed, and is there is a pattern of low-level pains. For instance, is there a pain that you get only when running on certain surfaces? Or at certain intensities? Or distances?

In turns out that there is no measurable unit of pain

Whilst most things in life have a measurable scale, pain is sufficiently complex and individual that it has to be scored individually and subjectively. There are lots of different scales https://paindoctor.com/pain-scales/ but the most common one (and used by most UK healthcare professionals) is scored by the individual on a 0 to 10 scale, where zero is no pain and 10 is the worst pain that they have ever experienced.

It is really hard to think about this when you are in pain, so here are some words that might help:

Pain Level Description
0 No pain
2 Pain, but it can be ignored
4 Pain interferes with tasks
6 Pain interferes with concentration
8 Pain interferes with basic needs
10 Pain requires bed rest

But what does this mean for running?

I know how hard people find it to decide when to stop running, so here is my personal suggested scoring for pain:


My table of pain scale and what it means in running, with a suggested recovery action for you to take

I would suggest that whilst racing may take you to all of the way up to a level 5 (where in training you should stop immediately), you need to listen to your body and know whether this is a race that you should choose to DNF or ease back to simply make the line, vs hanging in there at all costs.

And I really hope that in training, at a 3 you would be walking and deciding whether to get your phone out and get a lift home to let your body recover for another day.

I always believe that the mark of a great training plan is the consistent build-up of sessions that progress you, but leave you ready to do the next session with quality, to get yet another progression.

Best of luck out there on the roads and trails! Make good decisions and look after your body!

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 I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

Your basic bodycare toolkit