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.”

Surgical skill or bedside manner?

We had a great debate over breakfast the other day. The question was –  if you had to choose, would you prefer a surgeon with great surgical skills and average bedside manner, or average surgical skills and great bedside manner? Of course, one hopes that you never have to make this choice, but it was a good debate!

My argument was that I wanted great surgical skills, given that I am unconscious at that point and once you are opened up they need to deal with whatever the situation actually turns out to be (which may be rather different from the best guesses on the scans). Having seen how incredibly thin and fine things like nerves are in many places, the fine-motor skills of dealing with this feel very important (and obviously in things like arthroscopy are one-step removed like a computer game!) I have to admit that I was only conscious once as I got wheeled into theatre (the other 6 times I was in a small ante-room with just the two anaesthetists) – but I was completely stunned to see 10 people and realised what a team leadership role the surgeon has!

But the counter-argument for the importance of bedside manner was a great one. The sad statistic is that many people continue to have pain after surgery (for instance, failed back surgery is said to run at about 40%, according to Penn Medical in the USA). So what you most need is to find a person who has the depth of skills to really understand what is going on in your body, and what interventions are most likely to help the situation. Therefore, someone who has a good ‘bedside manner’ to truly understand what is going on and whether surgery is a good option is what you most need. It can save you a lot of trauma and uncover a much better path.

The argument goes further. If you do have the surgery, the recovery phase is critical. Being able to explain what recovery and rehabilitation approach works best, and adaptations to make really increase the chance of recovery. Not to mention the softer factors, such as the level of trust and belief, which many would argue also play a key role in the mentality of the patient and therefore their biochemical make-up during the recovery phase.  

Supporting evidence that bedside manner may be much more important…

Having had four male surgeons, I was somewhat stunned that there was a statistically significant difference in the outcomes by the gender of the surgeon in this British Medical Journal comparison of postoperative outcomes amongst patients treated by male and female surgeons via a population-matched cohort study. It showed that fewer patients treated by female surgeons died, although there was no statistical difference in the proportion that were re-admitted to hospital or had complications within 30 days, compared to the matched group treated by male surgeons. If everything in your mind is screaming out that this cannot be true, then I will leave you to read all of the statistical analysis in the paper (including the interesting finding that the same pattern was true in emergency surgery, where the patient did not choose their surgeon):

https://www.bmj.com/content/359/bmj.j4366

But perhaps more interesting is the why’s, which the paper says need more study. But they already suggest that there is a gender difference in how male and female physicians practice medicine, such that it can affect patient outcomes.

They say that there are 4 core components of surgical practice:

  • Knowledge
  • Communication skills
  • Judgement and
  • Technical proficiency.

Obviously, post-surgery there are more people involved in the care so there are more factors too – and a previous study of beneficiaries of US Medicare that were treated by female general internists in hospital had lower rates of 30-day mortality and readmission than those treated by male internists (Tsugawa et al), which they attributed to female doctors being more likely to:

  • use a patient-centred approach and
  • to follow evidence-based guidelines

So what could this mean for your surgery?

Having never been in this surgical world before it was thrust upon me, I had no idea how to move forward. So here are a few tips that I would say now:

  • If you have Medical Insurance, ensure that it allows you access to the maximum pool of consultants (they generally operate in a number of different hospitals and each of them is self-employed, so worry about the surgeon access, not the hospitals)
  • Always try to find a surgeon who has worked with sports people.
  • Get recommendations from people in the know. There is no meaningful data that you can access on the outcomes by different surgeons, but nurses and people in the hospitals know it. Call on your network shamelessly to try to understand the real story. Take time over this – for all that you probably feel that you do not have time on your side in your situation, it is really worth doing lots and lots of investigation.
  • If you have to wait, it is a good sign. Whilst none of us want to wait when we are in pain, it is much better to be seen by a surgeon with a full plate and lots of patients, rather than the one with lots of gaps. Firstly, it is an indication of their reputation. And secondly, if they are busy, human nature suggests that they may be more balanced in whether surgery is the best option for you.
  • Don’t be afraid to ask for a second opinion. Many people say always go for a second opinion before surgery, and that surgeons should not be offended as they should also recognise that it is a big decision. I would say that if what they say doesn’t seem to fit, or you want to have more comfort before making a big decision like a second or third surgery, then a second opinion really helps. They say that the key is not to tell the second person what the previous diagnosis is so that you get a genuine fresh pair of eyes on the issue.
  • Go into the appointment with a list of questions and a second person in support. My experience is that almost all of the surgeons that I have met are extremely introverted and tend to say very little. Therefore it is down to you as the patient to elicit responses, and to keep asking the questions until you feel that you have understood the answer adequately. This is why I always take someone else to the appointments who also has the list of questions and understands what we are trying to understand from the appointment, as I have felt quite intimidated and not managed to get all of the responses that I was looking for when I was alone.
  • Always go to another medical specialist too. The old saying is that when you have a hammer in your hand, everything looks like a nail. So the surgeon is always likely to come back with the choice of wait and hope it gets better, or do surgery. Hence getting an alternate view of how another specialism would approach your issue is very useful – go to:
    • a good clinical physiotherapist (one who has done cadaver work, reviews scans, and works across a range of techniques that are not just manual therapy and strengthening exercises),
    • a chiropractor with a good track record (who again reviews scans and uses more approaches beyond the classic ‘twist and crunch’)
    • a sports rehabilitation specialist (who again reviews scans and does screening to present a treatment plan that shows clear milestones with review points for reassessment and case studies of where this has worked before with/without surgical intervention)

So I changed sides on the debate

Through the debate (and long after I had finished breakfast), I realised that the core of the issue for me is that I was falling into the trap that I think many of us fall into – the idea that surgery is a quick intervention that creates an instant fix.

Once I articulated that I believe that surgery is sometimes one step in the rehabilitation path, it becomes clear that the communication skills to make the right decisions with the patient are much more likely to get to a better outcome. And since communication is a two-way street, we as patients also need to do lots of work to make sure that we communicate and understand well through the process.

The skinny on scar tissue

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

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

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

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

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

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

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

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

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

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

What can you do about this before surgery?

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

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

Straight after the surgery

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

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

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

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

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

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

How do you heal after invasive surgery?

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

So how soon can you start back to training?

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

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

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

Stage 1 seals the wound and is really quick!

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

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

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

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

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

Stage 4 is where the scar gains strength and flexibility

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

So it all takes time

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

Things that you can do to encourage faster healing

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

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

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

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