If this is always true, why can we feel pain when we have not injured ourselves? 

For example, we feel neck or back pain after sitting for a prolonged periods or a trivial action like reaching for a towel causes severe back pain?
How is this possible if pain = damage? This is confusing.

What The Research Shows

The research tells a different story:

One study ( Brinjiki et al) showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.

In the shoulder, many studies have painted a very similar picture. One study (Grisih et al) found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. 

So you can see that tissue damage does not lead to pain in many cases, and pain can arise without  evidence of tissue damage. This is precisely why we constantly remind our patients that ultrasound scans don’t tell the full story.

The general understanding of pain and injury needs to be updated so that people can overcome pain more easily and get back to living their (best) lives.

A New Understanding of Pain

The new understanding of pain is that it is an output signal created by the brain, as a warning sign. It can be out of proportion to the injury. This serves to change behaviour to prevent further damage, which is often required to fix the problem.

The issue is that most people don’t understand this, and remain stuck with a painful condition because they are fearful to move in case it causes more tissue damage. The problem with this is that people are thinking about local structures, not the whole body. There are compensations and protective mechanisms that can develop in other areas of the body that can contribute to your pain…. Where your pain is located is not necessarily where it comes from.

For example, someone can get knee pain because they had a recent back pain episode that affected the way they walked. The back pain improved, but the knee persisted because of secondary protective mechanisms that have not resolved.

A Whole Body Approach

This is why we look at the whole body and how it works together. We want be as thorough as we can and find all the contributors, both local and remote for your pain. This will enable you to get back to the things you love doing without the pain you have been suffering.

We use a 7 step process (the ridgway method) that will find the main drivers of your pain and fix them quickly. It is scientific, objective and based on the latest neuroscience research. 

If you’re not open to a new understanding of pain, you will remain stuck and restricted by your pain and fear of movement. Are you really willing to let your pain dictate your quality of life? 

Or are you looking for a new approach to regain your lifestyle, independence and get on top of your pain long term?

If you’re ready to take control of your life, book an initial consultation with us. We’d love to help you!

References

Brinjikji W et al; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.

Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971

Nick and Andre are 2 AFL field umpires that were referred to our clinic by word of mouth last year (July 2022) due to recurrent calf injuries. They both had similar presentations, with multiple calf tears over several years, which would often occur more than once in the same season. Each time, they would have to miss 3-4 games while they were recovering and rehabbing their injuries. The cost to both of them was lost income, as well as loss of conditioning and opportunities to progress as umpires and secure finals positions. The emotional cost was also significant, with a loss of confidence in their bodies, and a sense of frustration and confusion…”why does this keep happening?”

The management of each injury was with standard sports medicine protocols, including MRI scan to confirm a tear and the grade, rest/deload, local Physiotherapy ( including massage, dry needling, ice, electrotherapy modalities) and a graduated strength and conditioning program and return to sport.

So why wasn’t this approach working for them and why were they having recurrent calf injuries?

Taking a Broader Whole Body Approach

To work out why Nick and Andre were having recurrent calf strains, we had to use a whole body problem solving approach known as the Ridgway Method. The team have all had extensive training in this method over the last 10 years.
This involved performing a whole body assessment looking for muscle knots, joints that don’t slide and nerves that don’t glide. It also involved assessing posture, strength, motor control and importantly a running video analysis.

The main principles of the Ridgway Method are:

1. Where you feel your pain may not be where the problem is located.
2. The structure that produces the biggest and most consistent gains in movement restrictions connected to your problem, is likely to be a primary contributor to the condition.
3. Behavioural change and motor control are important to reduce load on the primary contributor.

The main test movements we noted that were most guarded and restricted with both Nick and Andre were:

1. Lumbar flexion
2. Thoracic rotation
3. Hip flexion
4. Hamstring length

For both of them, there was one side of their body that was most restricted, and this did correspond to their symptomatic side.

After whole body assessment and treatment trials to find the best structures to continue to work on, their body charts looked like this below. These charts only show the unhappy structures that when trial treatment was performed, improvements in key tests were observed.

The Findings

We found the most dysfunctional structures that made the best gains in the movements signs for both Nick and Andre were actually remote from their calfs! In fact they both had segments in their lower back that were very stiff and painful, and working to release these made significant improvements in their movement signs and also released tension in their calf muscles. We labelled these segments, both from the front (anterior) aspect of their lumbar spines, the PCF or primary contributing factors to their calf conditions. For Nick their was also a secondary contributor in the thoracic spine, and for Andre the secondary contributor was the right sacro-iliac joint (SIJ).

The WHY?

So if working on these lumbar segments made the best improvements in key movement tests and also released calf muscle tension, why were these joints so stiff and problematic?

We performed a number of other tests, including strength tests and a video analysis of their running techniques.
Both Nick and Andre had some postural and control issues that we had to correct.
For Nick it is was about being too extended through his thoracic spine, with some rib flare. Nick also ran like this, with his chest up, which loaded his thoracic spine, and put him more in a lordotic posture which increased load on the lumbar spine. Nick also had some strength deficits in the left hip abductors and adductors, hip flexors and latisimus dorsi muscles, as well as poor gluteal activation.

For Andre, he stood in anterior pelvic tilt with knees locked back into extension. He ran with an anterior tilt also and an increased forward lean. This loaded up his lower back and SIJ. Andre also had a left limb apparent shortening, and we had to provide a heel lift for his left leg to regain symmetry through his hips. This was likely the reason his right SIJ was being loaded and had become stiff. Andre also had strength deficits in his right hip abductors and reduced gluteal activation also.

For both Nick and Andre, there were some mindset obstacles we had to address, which were mainly based around a loss of confidence in their bodies and a fear of re injury.

The calf injuries were then just a symptom of a more central problem, which when identified and treated with all contributing factors addressed also, resulted in no more calf strains and greater confidence in their bodies for both Nick and Andre.

The Results

After going through the Ridgway Method problem solving process late last year, implementing all the strategies we identified to be specific for both Nick and Andre, and adjusting their training, they have both made it through the 2023 season without missing any games. Yes, there were a couple of hiccups, but not with calf issues. Mid season, Nick got bowled over by a ruckman during a game, which jolted his body. Andre had an episode in his right lateral leg from a period of increased sitting. We were able to manage both of these incidents and keep Nick and Andre on track.

They both umpired in the finals and went as far as the preliminary final Carlton vs Brisbane at the GABBA (16th September, 2023), which is further than they have gone any any previous year… a real success story!

Other Factors That Contributed to Their Success

1. Both Nick and Andre were dedicated professionals, who attended all appointments including tune up sessions, followed through on all advice, and worked hard to keep their bodies in the best state.
2. They both had a team of support people around them, including AFL medical and physio staff, masseurs and pilates instructors, and their partners.
3. After meeting with their strength and conditioning coach in August 2022, their running training was modified to increase the amount of easy volume in their program. The research based 80/20 rule was adopted, where the percentage of high intensity training above 80% maximal heart rate represents a smaller fraction of their overall running. This is important for recovery from harder sessions/games and building resilience and conditioning in soft tissues. The amount of easy running (long slow running) was tracked and measured.
4. The AFL changed the amount of umpires per game from 3 to 4 during the 2023 season, which meant that each umpire had less ground to cover during a game.

In summary, this highlights the benefits of using a whole body problem solving approach for any injury, particularly persistent or recurrent conditions. The whole body is interconnected in ways that we are still coming to terms with, and local pain, eg in the calf in this case, can have a remote cause or primary driver, in this case, the lumbar spine.

So, what are you doing to recover?

In this article, we will go through the four fundamentals of recovery. Everybody is different, so an individualised approach is best. It can take a bit of trial and error to find out what works for you, but it’s well worth the effort to be competition ready when you need to be.

The Fundamentals of Recovery

There are four fundamentals when it comes to recovery:

1. Sleep
2. Nutrition
3. Hydration
4. Training Load Management

Sleep

Sleep is the ultimate recovery tool. When we sleep, our mental and physical reserves are restored so we can be in peak condition to deal with the stressors of life and training the next day.

For the average adult, at least 7-7.5 hours per night is recommended. Anything less than that builds up sleep debt. The more sleep debt you have, the more you suffer the detriments of sleep deprivation on your body and mind.

Recent studies also show that adolescent athletes who slept <8 hours on average were 1.7 times more likely to injury themselves than those who slept >8 hours. On the other end of the spectrum, elite athletes have been known to aim for up to 10 hours sleep to maximise their physical condition before competition!

If you want to learn more about Sleep Hygiene, read this article: How To Get A Better Night’s Sleep

Nutrition

Food is the fuel that restores what we use during our training. When your recovery nutrition isn’t right, you may feel more fatigued, have poorer performance, produce less gains in training, and feel sorer for longer.

Eating in the first 60-90 minutes after your session is the most effective time, especially if you have intense training sessions back to back. In terms of what to eat, a mix of carbohydrates to restore energy stores and protein for muscle repair is generally recommended. It’s always best to tailor to what suits your body and digestion.

If you want to learn more about Recovery Nutrition, Sports Dietitians Australia has great fact sheets you can read here.

Hydration

Proper hydration keeps your whole body system working well, from your heart to your metabolism to your brain. Many people don’t realise that if you have a dry mouth or feel thirsty, you are already dehydrated. When you are dehydrated, all of these systems operate less effectively: it can make a workout feel harder, make you feel hungry when you aren’t, and make it harder to concentrate.

So how much water should you drink? A good rule of thumb is 35ml per kg of bodyweight – for the average woman that’s 2.1L and for the average man it’s 2.6L. Bear in mind, if you are exercising or the temperature is high, you may need more than usual so keep that water bottle filled and close by!

Lastly, how can you tell you if are well-hydrated? Check your wee! A hydrated person will have light coloured, odourless urine – a key sign that you are hydrated and to keep drinking water at the same rate.

Training Load Management

Training for big competitions can often spans months, sometimes even years for some athletes. So how do you make sure you can keep this consistency going over an extended period of time without injury?

Managing training load is key. Sudden significant increases in load can lead to pain and injury if the body isn’t able to adapt quick enough. For example, a novice runner going from one 5km run a week to three may find they are stopped quickly by increased tension and pain. Gradual increases in intensity and duration are best – slow and steady wins the race!

The other important reason to manage your training load is to avoid overtraining, also know as ‘burn out’. Overtraining occurs when an athlete trains excessively without resting or recovering properly. After a while, the training begins to have a detrimental effect on the body. You may notice a decrease in your performance or gains despite hard training. You feel sorer, you get injured more often, and you feel unmotivated to exercise. While this may prompt you to train harder, it may actually make you feel worse in the long run.

Incorporating “deload weeks” into your training schedule can go a long way to preventing overtraining as well as improving your gains. Deloading is deliberately stopping or limiting your training for a short period before returning with renewed intensity.

Proactively planning lighter weeks into your schedule can ensure you’re injury-free and feeling at your best as you head towards competition. However, it is important to be reactive if you notice symptoms of overtraining. As always, listen to your body and make time to rest when it needs it.

To learn more about how to load your body safely, read Volume, Frequency And Intensity- The What And Why?

Other Recovery Methods: The icing on the cake

Once you have the fundamentals of recovery covered, then you may want to look into supplementary recovery modalities. Cryotherapy, massage, compression garments, and foam rolling are some of the most common methods athletes put in place. For the most part, the evidence for each is anecdotal – some people find these other methods helpful for recovery while other people do not. Everybody is different, so it’s important to trial these methods for yourself and assess how your body responds.

Don’t forget that there are other factors in our lives can also create “load” on the body. Longer hours at work, stress, moving house are just some of the common lifestyle factors to keep aware of if you are starting to feel the strain.

Plan Your Recovery

Just like with your training itself, being intentional about your recovery will make sure it’s effective!

A proactive approach will reduce the risk of injury taking you by surprise. Identifying what’s missing in your recovery and taking the steps to address it now means you won’t find yourself forced to rest due to injury later. However, be ready to flex if circumstances change! As your training intensity increases, so should your emphasis on recovery.

References

https://www.healthdirect.gov.au/dehydration

https://www.sportsdietitians.com.au/factsheets/fuelling-recovery/recovery-nutrition/

https://www.physio-pedia.com/Overtraining_Syndrome

https://www.webmd.com/fitness-exercise/what-to-know-about-overtraining

https://jamesclear.com/cumulative-stress

Sport and physical activity is a vital component of achieving good health.

Children and young people will not only reduce their risk of chronic illness, mental illness and obesity but also develop healthy lifestyles, friendships, life skills and a strong sense of belonging and community. 

Top ten most popular sports and activities (5-14 years)

Chronic vs acute

There are two kinds of sports injuries: acute and chronic. An injury that occurs suddenly, such as a sprained ankle caused by an awkward landing, or straining your shoulder in a tackle is acute.
Chronic injuries are caused by repeated overuse of muscle groups or joints. Poor technique and structural abnormalities can also contribute to the development of chronic injuries. This blog will discuss acute injuries       Emergency situations

Most competitive sports at junior and senior level have a designated trainer. As a physiotherapist attending my son’s soccer and later footy games that was usually me. They should have at least a Level 1 sports trainer certificate. Indoor facilities such as basketball or multisport venues should have a  trainer on site plus access to ice and bandages. Every team should be equipped with a basic first aid bag.
Injuries must be assessed and the severity will determine if the player can continue, needs first aid, or in the case of serious injury calling an ambulance.

Call an ambulance for:
-prolonged loss of consciousness
-neck or spine injuries
-broken bones
-injuries to the head or face
-eye injuries
-abdominal injuries.

We’ve all been there. Playing a sport and suffering an injury or watching our kids or friends play and seeing them injured. This can be a very concerning time.

The purpose of this blog is to clarify how to

1. Identity a ‘red flag’ injury and management
2. Discuss the important immediate and follow up steps that must be taken to ensure that an injury heals well. This means the player can back on the field participating again as soon as possible, reducing recovery time and minimising the risk of re-injury.

Top ten most commonly injured body parts during sport

Body region injured, Victorian emergency department presentations, 2004-2006.
Source: Victorian Injury Surveillance Unit, Monash University Accident Research Centre

P.R.I.C.E.R.

In the case of a less serious injury the PRICER and No HARM protocols should be used.
These simple acronyms are the keys to successful injury management.

Protection–The first principle is protection. The purpose of protection is to avoid further injury to the area by protecting the injured structures. The type of protection used varies depending on the injured area but may include supportive bandaging, the use of slings and supports and crutches for a lower limb injury.

Rest –. Keep the injured area supported. Avoid using the injured area for at least 48-72 hours as continued activity will increase bleeding and damage.

Ice – Apply ice to the injured area for 15-20 minutes, every 2-4 hours for the first 48-72 hours after injury. Ice reduces swelling, pain and bleeding. Ice can crushed or placed in a wet towel or plastic bag. Alternatively, a frozen pea packet or a cold pack wrapped in a wet towel can be used. Check the skin to ensure that there is no ice burn from prolonged application.

Caution: Do NOT apply ice directly to skin.

Compression – Apply a firm wide elastic bandage over the injured area, as well as above and below. Where possible hold ice in place with the bandage. Between ice treatments maintain bandage compression. Applying a bandage will reduce bleeding and swelling and also provides support for the injured area.
Caution: Ensure the bandage is not too tight. Some signs of the bandage being too tight may include numbness, tingling or skin becoming pale or blue. If these symptoms and/or signs develop remove the bandage and reapply again firmly but not as tightly.

Elevation – Raise the injured area above the level of the heart at all times. A pillow can be used to provide support and comfort. Elevating the injured area reduces bleeding, swelling and pain.

Referral – Arrange to see a qualified health professional (doctor or physiotherapist) as soon as possible. This will determine the extent of your injury and provide advice on the treatment and rehabilitation required.

No H.A.R.M.

No Heat – Applying heat to an injury increases bleeding. Avoid hot showers or baths, saunas, spas, hot water bottles, hot linament or heat packs. 

No Alcohol – Alcohol increases bleeding and swelling which delays healing. It can also mask pain and severity. 

No Running – Running or exercise increases blood flow to the injured site. This can make the injury worse and delay healing. 

No Massage – Massage or the use of heat rubs increases swelling and bleeding. 

By applying RICER and No HARM techniques you will be able to recover from your injury faster and get back to the sport or activity you love doing sooner. 

Early and correct use of RICER and NO HARM factors is essential for the initial management of a soft tissue injury.

RICER & NO HARM should be continued for 48-72 hours.

Prevention

In our experience there are many precautions necessary to reduce the risk of acute injury.

• Safe playing environment
• Appropriate equipment including protective aids such as mouthguards
• Conditioning and fitness preparation for the sport
• Medical or trainer coverage
• Specific supervised warm up routine
• Adequate hydration and prevention of heat stress
• Frequent player substitutions to avoid fatigue based injury

In clinic, the first priority of treatment for an acute injury is reducing strain or load on the injured part and surrounding tisues.
Healing time for injuries can vary, but a treatment plan based on objective measures of improvement is essential. This also applies to more serious injuries once a medical clearance is given to start rehabilitation.
When the acute phase has passed your physiotherapist will  use treatment and graduated exercise to improve the injured tissues capacity to take loading in preparation for a safe return to training and sports-specific drills.

A safe return to sport is based on objective improvement and a safe gradual increase in
training load. The decision should be made in conjunction with the treating therapist, player, parent and coach. A supervised treatment program is the best way to successfully return to sport and communication is all important.

Useful Links