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.”

The ‘First Law of NeuroKinetics’

Have you ever had the experience of releasing tight muscles one day, only to be right back there within a day or two with the same level of tightness in the same place? I certainly have, and have now learned the ‘First Law of NeuroKinetics’! (This is my labelling, rather than a formal academic name!) But it is very useful indeed as a framework for daily bodycare!

What’s the solution?

The challenge of releases – whether a sports massage, stretching or releases is that usually the results are transient. The muscle patterns are leading to overload on that muscle group are not changed by releasing the muscle. So for all that it feels good, it does not change the cause of the tightness and hence it comes back very quickly. So rather than recovering, it can feel like painting the Forth bridge – constantly going back over the same areas.

So I have learned ‘the first law of NeuroKinetics’, ie that releases must always be accompanied with focused activation and strengthening of the opposing muscle in the pair. And then into additional activation that recruits the synergists correctly – probably involving bigger movement patterns than the more focused agonist/antagonist activation exercises. [I have to admit that there are some parts of the body where the interactions are more complex and one muscle may be inhibiting two, three or four others! Still the same principle, but a much more complex unit.]

Looking back I can see that this was in some of the programmes that I have been given. But having it front and centre of my mind is very useful indeed.

Working through a case study

As a ‘for instance’ – if the adductors are tight it suggests that they are doing a lot more stabilising of the hip region than they should be. The simplest opposing movement is abduction, which involves the gluteus medius, gluteus minimus and tensor faciae latae (TFL). And the synergist to adduction is the inside edge of the quads, whilst the synergists to abduction are more spread across the lumbopelvic area – involving the psoas, piriformis, quadratus lumborum and rectus femoris.

Releasing

The first job is to release the adductors – and there are a lot of them. Some people talk of the ‘long’ adductors (which give you the feeling down the inside of the leg between the groin and the inside knee) and the ‘short’ adductors (which you can feel in vertical lines as you move out from the groin across more towards the hip and before you reach the rectus femoris).

There are five adductors and one of the mnemonics to remember them starting from nearest the hip and moving through the groin and into the inside leg is ‘Please Baby, Love My Groin!’ – ie Pectineus and Brevis (the ‘short’ adductors), Longus, Magnus, Gracilis (the ‘long’ adductors).

The reason that it is useful to understand this is in the stretching and releases. The long adductors are normally stretched with the legs more than shoulder width and dropping the weight vertically over a bent knee on one side. However, there are three different foot positions for the straight leg and these stretch the three different adductors. The short adductors are usually stretched with the ‘frog’ stretch, but it will take some hip movements side-to-side and the weight forward and back to stretch both of the adductors involved.

Likewise, using the edge of a foam roller or a ball to get into the areas for release will require different locations to find which ones need the most release and then getting into them to release them.

For completeness, I need to mention that good breathing methods and Proprioceptive Neuromuscular Facilitation (PNF) can really make a difference to the quality of the releases and stretches.

Activating

Then we need in the exact same session to get into the activation exercises. There is no need to fear that they will tighten up the area that you have just released. In fact, it is the exact opposite! The more the agonist contracts successfully, the better the antagonist switches off and relaxes. 

The reason that you do the exercises is two-fold:

  1. Neuromuscular repatterning. You are programming the nervous system to send the right messages and the muscles to respond to them. It is likely that the body has got out of the habit – and this is why perfect form is so important (you need to teach the body correctly) and why usually it is sets of 15, 3 times with a recovery interval of around 1 minute between the sets (to ensure that the body ‘hears’ the message).
  2. Muscular strengthening. You will also be putting the demand on a muscle that may not have been working for a little while. So the load over a period of a couple of weeks will ensure that new fibres are made and the muscle strengthens.

So back to the example, side-leg raises are a great starting point and then we can include some abduction movements (opening the hip) either on machines or via the ‘opening the gate movement’. More complex movements can include side plank (or side half-plank if it needs regressing) with moving the top leg up and down, forward and back and then in half-moon movements starting from close to the floor in front of the lower leg and finishing close to the floor behind the lower leg.

Then we can move into some more overall movements to get the synergists moving – for instance a front or back lunge, probably breaking it into stages of movement to make sure that each part of the movement is balanced and strong, whilst moving smoothly between the positions.

If it still remains tight

If after two weeks of a daily programme on both the releasing and the activating is not making any difference to the tightness, then it does not mean that the law is wrong! It just means that with the complexity of the body’s movements and interactions we did not choose the correct opposing movement and therefore probably have the wrong muscle pairing. So we need to go back to the analysis stage and look at what other interactions are going on and simply go again with another pairing. Patience and focus does pay dividends.

Best of luck!

PS – for any Urban Dictionary readers, this is all IRL!

This is THE book!

This is the book and the community that I had been looking for. And I would recommend that if you know an injured athlete, then this book is probably the best gift that you could give them.

I came across it when I was listening to one of the podcast series that I often listen to and heard it mentioned: ‘Rebound: Train your Mind to Bounce Back Stronger from Sports Injuries’ by Carrie Jackson Cheadle and Cindy Kuzma.  As well as reading it cover to cover, and going back through it over and over, I also discovered the Podcast series and the Facebook page under the title of ‘The Injured Athletes Club’.

Practical support

The book has forty-nine mental drills that map against fifteen key mental skills that you can build to aid recovery from injury. It is built from real experience helping athletes through successful rehabilitation from injury – and the core belief that one can rebound from injury.

The book includes

  • narratives describing athletes’ journeys through injury, including the key inflection points
  • Scientific explanations of the underlying psychology
  • Key points to take away and work on
  • Specific mental drills that you can incorporate into your recovery

But perhaps the community is the most important part

The book opens with talking about the fact that you are not alone, and that with that pillar in place – there is a path forward.

The community allows for the stages of grieving – accepting and defusing the negative emotions, finding the clarity and support for the steps needed for your progress and then having a genuine cheerleading group to celebrate the simple, baby-steps steps of progress towards your bigger goals.

What I really like about the book

What I really like about the book is the fact that it is flexible and multi-faceted, so you can keep coming at things from different angles and building up even as your situation evolves and changes – whether that is progress or a slip backwards.

I hope that it brings you or your friends support and strength when this is most needed.

Round and round in circles

My experience of rehab is lots of circles!

Whilst finally being able to move a little can feel like a release from incarceration and make you want to re-explore the world that you once knew, the reality is that it probably needs to be much closer to home!

You need to be ready to stop and rest, or stop and return home at any stage – as pushing through pain can lead to a major set-back. So, I have built loops with benches, coffee stops and quick routes back to the car (in order to return home).

I think that I now know the distance to all of the benches within a half-mile radius of home! And even bought one of those walking sticks with a pop-up seat. It was surprisingly inexpensive, and actually comfortable enough for a little rest and recovery – although you would not want to sit on it for a long period!

Having a goal, but being flexible on the way of achieving it

Initially, I struggled because the goals seemed ridiculous – for instance 4 laps of 200m in a day and then a rest day seems petty when you have run marathons and ultra-marathons.

And then I struggled even more because I could not complete them without being doubled-over with the strobing pain – the other part of the goal was without any increase in pain level.

The goals are really important – as they help you to make and monitor progress over time, without over-extending yourself. And I learned to stop deriding how petty they were and to start to think of little rewards if I managed them, like a square of dark chocolate or a cup of coffee.

I also learned how to regress it when I could not achieve it – either by reducing the distance, or by increasing the rest interval. So I would walk to the bench with my book and if my body was not ready to walk back, I would either sit for a while or read for a while and then head back. And then do the same later in the day.

The psychological benefit of a change of scenery

I would also drive to wooded areas so that even very short loops looked and felt different as I walked them. And the opportunity for a nice cup of coffee as a reward sitting at a different café and taking in a different view!

Rule number 1 – leave the watch at home!

I have to admit that the only time I would do laps was as a part of training – whether a track, road or off-road loop – the goal would always be to look at the splits of each lap! This mentality of constantly pushing yourself is not at all the mode of gently listening to your body for the early cues of progress or issues – so it is important to leave the watch at home, and avoid cheeky glances at the lap times!

The hardest parts & my coping mechanisms

The parts that I struggled with were:

  • Stopping in time – since often the worst pain would be later in the day, I struggled to find the cues of when to stop if the session needed to be curtailed. The two insights that helped a little were: (i) spotting the very early signs of fatigue and stopping whilst there was at least one more lap in me and (ii) leaving enough time for my body to settle in between each one – so I would plan to sit for at least 10 minutes and at times 30-40 mins and even an hour to let the body settle and see how it felt.
  • Keeping the discipline and only doing the plan, even on days when I felt I could do more – because I couldn’t wait to be better and make faster progress, it was hard not to over-extend by adding an extra little walk to see something when I was feeling great. Especially when I was with friends, for whom so little activity was quite boring and their natural temptation was to tacitly or explicitly encourage you to go faster or do more. My two coping mechanisms were (i) for all that it was lovely to see people, doing these was better done alone and meeting them for a coffee later (ii) keeping a log of all of the exercises and what level and type of pain I had was a useful tracker for the programme and to talk with the medical experts.
  • Sometimes these leave me very inflamed and I then struggle to sleep – so I always do the sessions in the earlier part of the day in order to give the body more time to recover.

In summary – celebrating the circles!

As you probably gather, I found the process of going round and round in small circles rather hard to get my head around. So planning for it and finding ways to celebrate is key – every single one marks progress and is an opportunity for some fresh air and seeing different things. So well worth celebrating!

Finding Goldilocks!

Looking back at the time since my injury, I feel like this has been one of the areas that I have learned the most about – and so I wanted to share it with you.

In training, I think that you are always looking for that ‘Goldilocks zone’ – where you are stretched and make progress, but not to the level that it breaks you and forces you back. So that across your week’s training it is not too easy, and not too hard, but just right to get the adaptation that you are looking for.

When injured, this zone is even harder to find because there are no benchmarks. Indeed all of the normal benchmarks that you have are based on your previous, un-injured self and lead you seriously astray! It can be so hard to leave your ego behind in terms of what level is worthy of effort and exhaustion. An additional difficulty is that my sense is that the gap between stretch and stress is much narrower when you are injured, so you need to be more precise and wary of the smallest signs of over-reach, before the body stops you in your tracks. And these ‘tells’ may be completely different from those that you got when you were in full-on training and the onset may even come hours later (especially in the case of nerve-pain).

My own search for Goldilocks was a long one! In spite of constant commitment and tracking, I had a very long period where week after week I failed to get through the ‘simple’ exercises that were set – sometimes collapsing or passing out with the pain, sometimes just completely seizing up and suffering for the rest of the day and night before my next attempt. So managing to do the prescribed exercises consistently for the whole week between appointments really was a big deal.

I had no idea how much it had been torturing me. Realising this issue and actually managing to do seven days in a row of completing the prescribed exercise and actually managing to progress the reps, I now feel so much lighter in mood and belief. I start to believe that I am starting to recover and starting on my way back to life. Even though I know that these exercises are easier than a good proportion of my previous exercise sets, completing them means so much.

Why the breakthrough?

I still have a file of all of the exercise sheets that I have failed to make over the last 18 months (a few of them across 2-3 months of appointments with constantly trying and failing, and almost all of them still beyond me today). I should probably have put them in the bin, but have been keeping them for the day when I improve enough to get through and make the progress to be able to underpin the basics that could mean a return to life and sport. Looking back over them compared with what has worked for me over this last week, these are the things that stand out as differences:

  1. This exercise routine is broken down into a daily gentle mobilisation routine and the progressive part of the set is only every other day to allow for a recovery day. Many of my other programmes were up to 3-5 times per day, and always daily, which seems to have been an intensity that my body could not cope with.
  2. The first few months of the programme are all bodyweight movement exercises and only progress to include weights once I have built up to that.
  3. There is a ramp into the reps and sets, as the body adapts – with the first set very easily within my current capability.
  4. A golden rule is to always stop with at least 2 reps still in the tank. And never, ever going to the point of failure – as that can put the body into a state of alert and lead to more ‘guarding’ behaviour from the muscles (which can take weeks and months to then unlock).
  5. Every single exercise has one or more regressions to make it easier, in case the pain gets worse and I start to struggle – so I can do drop-sets, or easier sets. I have learned that every exercise has regressions, and what a difference that makes! Previously the exercises had been much more binary – it was do the exercises and if you fail early, then stop.
  6. We have gone through all of the key form points and gone to the point at which compensation sets in. For the compensations that we went through, I have a physical cue to keep the body on form (such as a roller balanced in the small of the back, a strap to keep under tension at all times, or the knees in contact at all points of the move etc)
  7. There is a clear goal to be able to breathe deeply and calmly throughout, not straining or bracing, or pushing through pain (but it is OK for the muscles to get tired or ache, as they used to when training). This is really useful, as there have been so many different views on whether you ‘push through the pain, as it is just guarding behaviour’ or ‘stop and respect the pain, as it is there for a reason’.
  8. We’ve got a clear commitment between us to keep to the recovery interval, reps and form precisely, even if that means a ‘fail’ – as this helps us to get to the root of the issues quicker and more accurately. This makes it feel like a partnership where we are both working on the problem together, rather than me feeling that as the patient I am the problem.
  9. The programme follows a clear and specific order of releasing overactive muscles and gently activating the specific muscle and then integrating it into the wider movement. This does make it a longer programme and means that there are no short-cuts, but really makes a difference. It also only works at the end-range for a short time, as this is very demanding indeed.
  10. There is a path forward with really small increments for the progression, such that there is a clear glidepath for progress, with check-steps and alternatives to take a different approach to address lack of progress. This fits into an overall ‘treatment’ plan that looks like a training plan, complete with blocks each with their own objective, quantitative progress testing every 2 weeks and a clear functional progression thread underlying all of it.  Naturally every athlete wants to know ‘how long until…’ but I have really learned now to trust the process and just to focus on the progress in each of the 2 week testing blocks and making fast interventions when something happens that is not what we expected.

Why did not managing to complete the exercises come to have such a big meaning for me?

I have to admit that I am only just starting to pick away at and release the layers of blaming myself that I feel for letting everyone down, not managing with the basics of life, and for not recovering as expected. This is all psychologically very difficult.

As an athlete I had always believed that consistent and hard work would be rewarded. And that in a recovery context this meant doing always the exercises from the physio – no ifs and no buts. Early in my recovery a friend who is a physio told me that the level of adherence to exercises from the physio is only thought to be about 20% (and actually admitted that even when she goes to see a physio herself, she rarely does the exercises!) I vowed never to be one of those 80% not doing their exercises.

So when pain overtook me over and over again such that I would collapse weeping with the pain and retire to bed or lying on the floor to recover, I felt that I was letting myself and everyone else down. That I did not deserve to recover.

But that is all in the past now! And I think that if I had known the questions to ask (based on the 10 bullet-points above), I could have got there more quickly.

So what should you do if you are currently struggling?

Even if not injured, I think that we are all in search of the Goldilocks zone and can apply these principles in our training to get to the stretch zone, but not the stress zone! In rehab we probably need to dial it even further back – to ensure that we are progressing, but not getting into the overload zone.

Having now spent a lot of time studying corrective exercise and reading a lot of books, and doing online study, I have learned that there is literally no exercise that cannot be made more basic – moving it right back into exercises lying on the floor and building from key underpinning exercises of the correct muscle recruitment in breathing. So always ask how to regress (and progress) an exercise; you also learn a lot in the process too! I realised that I did not ask this enough – I would tell the physio how I had got on and we would either just try again the next week without changing anything, or they would tell me to stop doing anything for a week.

And when doing the exercises, always focus on form and the correct rest interval – stopping as soon as the form slips. This ensures that you get the real benefit. Plus see the sense of achievement with the progression. This does mean becoming more of a Strength & Conditioning (S&C) student than ever before! Watching athletes do S&C I’ve seen that strong athletes’ bodies often (effortlessly) find another way around by using the synergist muscles rather than activating the main muscle – so knowing the cues and checks is important. Things that your body could get away with before injury can put you deep into pain post-injury and relying on dominant muscles misses a lot of the benefit of the exercises!

Finally, I would say that often the focus is on strength (which is about the muscles) but can be about the recruitment (which is the messages from the nervous system). So it is worth understanding which of these it is, as that should change the pace and type of movements in the exercise programme.

Good luck in your search for Goldilocks!

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.