Pain and Injury - The Problem With Finding ‘The Problem’

It's a common experience for anyone who has worked through any injury that has ranged from 'nagging' to 'life-altering' - seek out a specific provider or treatment in hopes that they will have answers as to why you are hurting and, in turn, help you fix the issue. This isn't unique to athletes, either. Billions of dollars are spent each year by people searching for answers via physical therapy, chiropractic, surgery, and so on in hopes of getting themselves out of pain. However, what is unique to athletes is the level of complexity that comes with the amount of stress and strain they subject their bodies to during competition and their training. This opens the door for various interpretations by different providers as to why they may have an injury in the event one arises. In my experience, however, seeking out a single answer - whether it be a strength deficit, mobility issue, or something more complex often leads to further complications for that athlete down the road, regardless of whether the methodology was helpful or not in the short term.

When having a discussion on pain and injuries in general, we need to have at least a mild understanding of the biopsychosocial model of pain. If you're reading this article, there's a likelihood you have seen at some point this illustration:

This is one of the most comprehensive illustrations of the complexity of pain you will find. And while we don't need to get into the weeds of it, the main gist should resonate that there are A TON of contributing factors as to why someone may be experiencing pain. And if you look closely, you'll notice that some aspects are more significant contributors than others. If we take this concept a step further, we should understand that this chart will vary significantly from person to person and from injury to injury. Based on that, two people experiencing very similar injuries can have very different contributions to that injury. Additionally, the same person can have different injuries at varying times of the year, and the contributing factors will also vary depending on what that person has going on in their life. This isn't me saying all injuries are just a manifestation of what is going on in an athlete's life, and we need to ignore tissue contributions completely. However, certain variables at play can increase or decrease an athlete's likelihood of experiencing pain or injury, and we need to be aware of that.

So, if we agree that there often is a musculoskeletal or tissue component, what is the issue with seeking treatments that are trying to figure out what that component is? Well, if there are multiple variables at play when it comes to pain and injury, there are also numerous variables at play regarding recovery from an injury. If you pay any attention to current rehab literature, you know that the crux of it all is "everything can work, just not for everyone" and "no one treatment is the best." The main takeaway is that there's a good chance that any treatment you seek will be successful, especially if you create the right environment for it to do so.

Walter recapping current rehab literature

Then what constitutes "the right environment"? This is where we can tap into those other factors in the illustration above. Again, there can be a lot, but the main ones I would argue contribute the most to recovery from injury are going to be:

• Removal or reduction of the injurious activity (not as apparent as you would think)

• Improving general recovery - eating good quality foods and adequate calories, sleeping an appropriate amount, hydrating, managing stress well

• Contextual factors

Contextual factors are the ones that get overlooked the most in the equation of what helps someone's pain reduce. Typically, this comes down to the question, "Does the patient believe what they are doing will help?" Something as simple as thinking your provider cares about you is a contextual factor that will likely positively influence the outcome of your treatment. Additionally, things such as the perceived knowledge of the provider (their reputation) and the rationale they give for an injury or subsequent treatment matters. Those things create buy-in, which is a massive driver of someone recovering from an injury. Couple those with improved lifestyle habits and the athlete reducing the painful activity so now the body can heal any damaged tissue that may be at play, and all of a sudden, that person has just had an amazing rehab experience.

The problem, though, is that we don't give credit to what actually happened. The athlete thinks they saw an expert who provided them with a magic treatment that fixed their tissue problem, so the tissue had to be the main issue the entire time. They neglect, however, that they just had strong beliefs about the treatment they were receiving being effective, they improved their lifestyle, and time has allowed the body to heal itself - all these things that address those other factors. Often, the provider will feed into that belief as well (an entire blog post in itself) - and will continue to push the narrative that their treatment provided the relief. This is how the flywheel of patients continuing to see a provider for months and/or years gets created. They are bought in, and anything that the provider says from now on is gospel, and the patient will behave as such.

'But if someone is back to playing their sport and doesn't mind seeing their provider regularly, does it matter what they believe got them better?'

This is certainly a valid point one could make. The athlete feels good and is back on their field; who cares about the narrative used to get them there? Well, financial and time implications aside from seeing a rehab provider regularly, I would argue that the beliefs that are being made about one's own body during this journey are setting them up to be a detriment in the long term. 

The central common belief you see get played out in these scenarios is the athlete thinking, 'My body isn't resilient.' Through their experiences, they've been led to believe that they are broken or injured to the point where the standard laws of rehab and healing no longer apply to them, that they need something more that only another person can do to keep them on the field and stay healthy. In my experience, this mindset becomes an issue for athletes because it leads them to avoid beneficial activities, both from a health and performance perspective. This is often driven by the athletes themselves or the provider's advice. So now they may have eliminated a valuable exercise from their training, or maybe they are doing something like thinking they need to walk in a specific manner to avoid further injury. All things that are constantly reinforcing to themselves, 'My body isn't resilient.'

Taking this a step further, what happens in the unfortunate event that an athlete sustains another injury? As I stated earlier, the same athlete can have different injuries and contributing factors at any given time. Well, perhaps, in this instance, the contributing factors are different, and this injury doesn't respond to the same treatments as their previous injury. The provider they were seeing doesn't have a good reason why their treatment isn't working, so they blame other things the athlete is doing 'wrong' in their training, day-to-day, etc. We've now just further reduced the scope of activities the athlete is 'allowed' to do while at the same time continuing to destroy that person's beliefs about their body and increasing the stress that is going to be associated with injuries in the first place. Does this sound like the athlete is set up for ongoing success on the field? Or even, later in life, once they are done playing? Absolutely not.

So, if the treatments we typically seek aren't necessarily working for the reasons we think they are, does that mean we abandon it all? Of course not; we just need, as both clinicians and athletes, to be aware of the narratives we are using and leverage those other factors that come into play regarding recovery. Some good points to keep in mind when working through a new injury:

• Stop trying to push through high levels of pain: I am not advocating complete rest from every injury. But we do need to remove or reduce the irritating stimulus to allow the body to start healing.

• Make sure you are hammering the basics: Sleep at least 7 hours a night, eat good, healthy foods and plenty of them, drink lots of water/decrease alcohol consumption, and manage your stress well. 

• Find a provider you trust: You don't need to be locked in with someone after one visit if what they tell you doesn't sit right. Find someone who will listen to you and isn't going to sell fancy gimmick treatments.

Returning from any injury is challenging enough, both physically and emotionally. Don't make things more difficult for yourself by buying into the idea that you aren't a strong, robust person. It may take time, but given the appropriate environment, you will return to being your dominant self.