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Ice or Heat?

Pain and gain – how athletes can manage and overcome pain?

Pain is inevitable, but suffering is optional.’ So goes a well-known but anonymous quote. For many athletes, pain is a normal everyday experience and success is often achieved in spite of pain. But what’s the best strategy for coping with and overcoming pain and how can athletes distinguish between benign and potentially damaging pain? Matt Lancaster looks at the latest evidence
Pain is synonymous with sport. Endurance athletes relish the challenge of ‘pushing through pain’ while boxers expect to fight on regardless of a jarring blow to the chin. Adulation is reserved not just for the star rugby player, but anyone who can play through pain and contribute to the team. Winners and heroes overcome pain. Losers don’t.

But the price of pain can be high. Pain both demands attention and creates fear(1). It can restrict the ability to concentrate on performance and take away the opportunity to compete. Pain can even end sporting careers. The relationship between pain and sport is filled with challenges for sportsmen and women as well as those who support them. However, although pain of some description is no stranger to most athletes, it’s still a curious phenomenon in many ways. For example, consider the following questions:

How are some people able to shrug off a painful injury?
How can two athletes with the same injury experience different pain?
Why do some pains seem to last ‘forever’?
Why can some people compete, seemingly regardless of pain, while others struggle to overcome even a minor niggle?
This article will explore these questions, offering practical advice about when it is appropriate to perform in the presence of pain, when you should consult a professional, and how to best approach pain in a sporting environment.

The diagnostic dilemma

If you tear your hamstring muscle or sprain an ankle it hurts – obviously. Since the 17th century, the medical and scientific world has sought to diagnose pain by identifying the particular tissue that has been injured. For example, the philosopher René Descartes proposed that a pure pain sensation is transmitted from the damaged body to an entirely separate organ, the mind, just as… pulling on one end of a rope…makes to strike at the same instant a bell which hangs at the end(2,3). Descartes separated the body from the brain, and even today it is usual for people to make a distinction between physical pain and mental pain(3,4).This is especially the case in sport.

However, there are some problems with this classical view of diagnosis. For instance, an extensive network of nerves supplies the various tissues in your back, making them potential sources of pain when injured(5). It follows that if you can identify the damaged spinal tissue, for instance using magnetic resonance imaging (MRI), it should be possible to explain the pain.

The problem is that while MRI findings of severe damage to the discs or nerves is associated with the experience of pain, studies have failed to demonstrate a clear relationship between the majority of tissue damage observed on MRI and the patient’s pain(6). What’s more, almost 40% of people who have no history of back pain have abnormal, damaged spines at more than one spinal level when scanned using MRI(7)! Likewise, the damage shown by ultrasound investigations of athletes with painful patella tendons (jumper’s knee) does not necessarily correspond directly to the degree of pain experienced by the athlete(8).

This doesn’t mean that identifying the injured structure is not important or that it isn’t crucially involved in your pain. But looking to tissue damage alone (which is both frequent and often quite subtle in sporting injuries) to explain the relationship between pain and sporting performance is probably not sufficient.

A painful process

Another theory, first proposed in 1965, suggested that far from acting like an old-fashioned telephone exchange, your brain and spinal cord can actually increase or inhibit the transmission of pain signals(9). Gate control theory was revolutionary because it proposed a mechanism for the brain to have a modulating influence on the generation of all pains, and not just mental pain(10). While the original theory has been modified and expanded, it has essentially stood the test of time and been supported by 40 years of scientific research(11).

If you listen to the language people use to describe their pain, it soon becomes apparent that pain is quite simply pain, and is not separated into physical or mental compartments. All pain invokes not just a pure sensory response, but a range of thoughts and emotions also(3,12) and pain emerges from the integrated, combined action of the pain system(2,3). Simplistically, this system can be viewed as three separate parts of the nervous system, all of which modulate pain.

How do some people shrug off a painful injury?

Remember that following an acute injury, such as an ankle sprain, pain receptors are first stimulated by the mechanical stress and strain placed upon the tissue. ‘Inflammatory soup’ soon floods the tissue leading to peripheral sensitisation. Several hours later, similar chemicals will also lead to spinal modulation(19). Pain and sensitivity to movement and pressure increase over a period of a few hours; the time between the transition from the original mechanical pain (which may pass) to the maximum sensitised state may provide athletes with a ‘window of opportunity’ to shrug off their pain and continue competing.

However, this mechanism is probably only the tip of the iceberg. When you are totally focused on your opponent, or consumed by the contest, supraspinal and spinal modulation may act to inhibit the transmission or limit the awareness of the pain signal(18). We’ve all heard stories of sportsmen and women who have continued despite an injury which (theoretically) should have caused them to stop: a boxer with a broken hand, rugby players with torn ligaments, a long jumper with a strained hamstring etc. In the cut and thrust of competition, the pain system can ‘shut the gate’, and athletes are able to continue in spite of injured tissue(18). However, once your attention is drawn back to the acute pain (particularly following competition), awareness of the pain becomes strong again, especially if this also coincides with an increase in peripheral and spinal modulation.

So, should you ignore pain and try to shrug off an injury? Acute sensitisation is a normal, helpful process to encourage you to stop using the injured tissue and avoid further damage(20). It might be helpful to ask yourself the three questions in the box below.

There are a few other questions, which are perhaps even more important. We’ll get to these later. But remember, acute pain usually occurs for a good reason. It makes sense to seek professional advice as soon as you can. Sometimes people can overcome acute pain and continue to compete, but that doesn’t necessarily make it a wise decision!

How can two athletes with the same injury experience different pain?

Studies have confirmed that people respond differently to similar levels of painful stimulation(19). Differences exist not just in our individual sensitivity to a painful stimulus, but also in our perception of pain and how we display it. Pain is individual, even when the stimulus is not, but while we cannot know exactly what someone else is experiencing, our brains undergo quite similar activity when confronted with someone else’s pain(21). This is the basis for empathy and acknowledging someone’s pain is normal and important.

Our individual sensitivity to pain is in part explained by our genetic makeup (22-24), while studies involving twins have shown that learned behaviours are also important (25). Again, the division of pain into real and mental is unhelpful and the variation in pain between two athletes with the same injury lies at all levels of the pain system. Even for the same athlete, pain sensitivity varies under different circumstances, and perhaps not surprisingly, can become significantly less during competition(26).

It’s also worth noting that different groups in society may have significantly different pain responses, and this applies within sport. A study performed 40 years ago demonstrated that contact sport athletes could tolerate experimental acute pain for longer than non-contact athletes, while both groups could tolerate more acute pain than non-athletes(26).

Pain sensitivity may also be different in different people at different times; the way athletes display that they are in pain can vary, both between individuals and also between groups of athletes from different sports. It might be an extreme example, but imagine a footballer who could potentially be rewarded with a penalty responding to the pain from a kick in the shin. Now, assuming the tissue damage is equivalent, think about the same incident involving a Thai kick boxer who is in the middle of a title fight. Get the idea?!

Why do some pains seem to last forever?

During ongoing or chronic pain, adaptive changes at all levels of the pain system often outlast their usefulness in helping us protect injured tissues. Movements and pressures that would otherwise be normal continue to cause pain long after the risk of further injury has passed and often even once the tissue has essentially healed.

Examining possible tissue damage remains important when considering ongoing or recurrent pains, but a broader approach is required to address an athlete’s fear and anxiety about their ongoing pain and help them return to their sport. Focusing too much attention on pain can actually increase pain(18). It is probably more helpful to concentrate on working hard to strengthen the tissues at a sensible rate, regain normal fitness and aim to return to training.

Providing an appropriate environment for people to overcome ongoing pain is important and not always easy in sport. Coaches or team-mates who are angry at or ignore athletes with ongoing pain may contribute further to those athletes avoiding the very things that will help them return to full activity (such as a rehabilitation programme), and generate further anxiety that doesn’t help either(27). Getting this balance right and remaining positive is therefore important. People who develop an exaggerated, negative mindset towards their ongoing pain have been shown to experience both increased pain and emotional distress(28). Pain is a normal part of sport but the right mental approach can prevent it from becoming a catastrophe.

Does this mean it is okay to ignore ongoing pain? Well, it’s not quite that simple. Once again consider the three Cs. Any pain that has been present for more than a week or so, or keeps returning periodically is worth getting checked out by a professional who can not only assess for tissue damage but can also understand your pain and hopefully point you in the right direction before the maladaptive changes to your nervous system become entrenched.

Why are some people able to compete, seemingly regardless of pain, while others struggle to overcome even a minor niggle?

Although pain (especially acute pain) is related to tissue damage, this damage alone is not sufficient to explain pain fully. Pain is not just a sensation but results from the interaction between sensory inputs and brain processes, such as emotion and conscious thought. And pain is individual, not just to you as an athlete, but also to the time, circumstance and environment you find yourself in. Within the mechanics of the pain system, individual variation and modulation occur subconsciously, which helps to answer this question.

To ultimately address the relationship between pain and sport however, it is necessary to consider one further aspect of pain: your own ‘personal values’. We’ve already considered the three Cs as a guide to considering how to act in the presence of pain; however, as anyone involved with sport knows, making decisions about athletes in pain is often a judgement call. The three C questions only have meaning if we add a further, more personal line of questioning:

  • Am I prepared to cope?
  • How important is contributing a worthwhile performance to me?
  • Am I prepared to suffer the consequences?

Having a pain killing injection two days before an Olympic final, regardless of the risks, would seem quite a reasonable thing to do for most elite athletes if it was the only way they were able to compete. Under similar circumstances, few casual joggers would agree to the same injection just days before a fun run. Entering a boxing ring, running 100 miles a week or crashing into a rugby scrum is not for everyone. Some people can continually and repeatedly overcome pain for the sake of their sport because they are prepared to. Sometimes they are rewarded with success, and sometimes, despite their desire to cope and contribute, their body succumbs to the consequences. Winners and heroes overcome pain sometimes. Losers often try and fail. Perhaps the most successful sports people are those who best understand the relationship between pain and performance: they are prepared to overcome pain, but make wise, informed decisions about when it is worthwhile trying to do so.

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Runner Injuries

Are you amongst the running wounded? You’re likely suffering from one of these annoying injuries.

As mindful runners, we can take all the proper precautions to make sure that we’ll never have to worry about hurting ourselves, but the reality is that no one is immune to injury.

Here we will take a look at the common types of running injuries, how they manifest themselves and will discover the best treatment methods available for them.

Plantar Fasciitis

Sharp pain at the base of the heel is a common characteristic of plantar fasciitis.

In my experience, plantar fasciitis is the peskiest problem that plagues the running wounded. During my almost four-year stint working as the manager of a specialty running store, complaints of persistent heel pain were heard more often than any other injury or ailment. Most times, the culprit could be pegged as plantar fasciitis – a sharp, tight and painful sensation at the base of the heel that was annoying to some and excruciating for others.

Many a customer would describe the first steps out of bed in the morning, or first few strides of a run, as comparable to stepping heel first onto a nail. Eventually, the pain might go away as the day or run carried out, only to return afterward or again the next day. It’s a vicious cycle for sure.

What causes plantar fasciitis? Overtraining, overuse and improper or worn-out footwear, yes, but the real root of the problem lies in tight and weakened muscles that aren’t able to handle the training you are trying to do.

The fix: Orthotics and high stability shoes oftentimes serve as effective bandaids and can help eliminate a lot of people’s symptoms in a short period of time. And while I’m not absolutely against these quick fixes, by no means are they the only – or the best – way to make the pain in your heel go away. In the short term, avoiding bare feet, stretching the calves, rolling your feet around on a golf ball and icing the affected area will provide some much-need relief relatively quickly. Long term, however, diligent stretching, combined with strengthening the muscles in and around the feet will address the root of the problem and help offset a reoccurrence of this awful injury.

Achilles Tendinitis

With so little blood flow to the achilles tendon, the healing process is often slow.

A closely related cousin to plantar fasciitis, pain that manifests itself at the back of lower leg just the above the heel is often an issue with the Achilles tendon – the thick band of tissue that attaches the calf muscles to the heel bone. Runners who suffer from Achilles tendinitis will often complain of pain and swelling close to the heel, which is oftentimes sharp and can be incapacitating. In my own experience suffering from this injury, I could pinpoint the pain, had significant swelling and recall hearing a “crunchy” sound when I would move my ankle.

What causes Achilles tendinitis? In my case, the injury could be traced to tight calves. Because my lower legs were so tight, a lot of strain was put on my Achilles tendon, and over the course of many months of hard training, this awful overuse injury developed. How awful? It took me nearly nine months to fully recover! With so little blood flow to this area of the body, the healing process is often slow. Aside from tight calves, unsupportive footwear (Note: the definition of “supportive” depends on the individual) can overburden the Achilles tendon over time, or a quick increase in volume and/or intensity can have the same effect much more quickly, so it’s important to pay attention to both your feet and your training – especially when you’re training hard!

The fix: Resting, icing and stretching will all help to relieve symptoms, and things such as orthotics, heel lifts and highly structured shoes are short-term solutions. Long term, however, it’s worth your while to pay close attention to stretching and strengthening the lower legs, as well as what’s on your feet. And of course, keep an eye on your training. Don’t do too much, or go too hard, too quickly.

IT Band Syndrome

Ever feel like somebody is stabbing you in the side of the knee when you run, especially when going downhill? This is one of the classic symptoms of IT Band Syndrome, an annoying injury that can often become crippling if not addressed and corrected.

What causes IT Band Syndrome? The short answer is: lots of things. In talking to other runners about their experiences with this injury, the most common correlations I’ve noticed involve downhill running or always running on the same side of the road. Both put a lot of stress on the side of the knee and cause friction between the IT band and the femur. Over time, the IT band tightens and may swell, pain emerges and eventually intensifies to the point where it keeps runners from running.

The fix: Stretching the IT Band, massaging the muscles around the area and foam rolling will help loosen things up, while a regimen of icing and taking ibuprofen will assist in reducing inflammation. Avoid downhill running, and if you always run on the same side of the road, switch directions evry so often. According to Ross Tucker and Jonathan Dugas’ book, The Runner’s Body, “overcoming this issue is simply a matter of providing variety, which balances out the impact stresses and minimizes injury risk.”

Runner’s Knee

Feel a constant ache underneath your kneecap when you run? You likely are experiencing runner’s knee, or patellofemoral knee syndrome. The main symptom is pain just below the kneecap that usually gets worse as the intensity of exercise increases, says Tucker and Dugas.

What causes runner’s knee? As with the other common running injuries listed here, the answer varies depending on the runner. Everything from uneven running surfaces and poor shoe selection to weak quads and hips, as well as unaddressed biomechanical flaws can contribute to this common injury. In most cases, runner’s knee can be traced to the inability of the tissues surrounding the knee to recover in between runs.

The fix: If your knee continues to hurt, don’t run. If there’s inflammation, work on reducing it with the aforementioned ibuprofen/icing regimen. Long term, switching up the surfaces you run on, making sure you’re running in the proper footwear along with employing some simple form fixes will help keep your cranky knee from getting angry with you.

Shin Splints

Shin pain can often be traced back to the sudden spike in training volume and intensity.

Perhaps the most misunderstood of all the running injuries, the term “shin splints” can refer to any number of ailments that involves pain in the shin area. At their worst, shin splints can turn into a stress fracture along the tibia, and pain will be felt with every stride; in less severe cases, the shin area may be tender and inflamed, and pain lessens a few miles into the run. Either way, shin pain is a surefire way to make your running experience rather unenjoyable.

When I was working at the running store, the most common complaints of shin splints came at me from two different directions: during the first few weeks of a beginning runner’s training program, or at the start of high school track season. Why? In both cases, the shin pain could almost be certainly traced back to the sudden spike in volume and intensity during the first week or two of running workouts.

What causes shin splints? As mentioned in the preceding paragraph, quick increases in volume and intensity can usually receive the biggest blame. Think about it. When you start running, especially if you haven’t been doing much of – or any – of it, what takes almost all of the initial impact forces that run through your body? The lower legs. Combine that with regular running on hard surfaces and worn out or improper footwear and you have a recipe for imminent disaster. And as with many of the aforementioned injuries, tight muscles don’t help matters much, either. The less mobile the muscles surrounding your shin are, the more stress there is on the entire area.

The fix: Rest, ice and ibuprofen will do wonders right off the bat and will help reduce the tenderness and inflammation. As you ease back into running, pay attention to your training, as well as your equipment and environment. Increasing volume and intensity too quickly will almost always lead to trouble. Running on soft surfaces such as trails or grass will help reduce the impact on your lower legs, and paying close attention to the mileage on your running shoes will ensure that you’re not trotting on tired treads.

Tennis Elbow

General Overview

Tennis elbow, or lateral epicondylitis, is the most common injury in patients seeking medical attention for elbow pain. Exactly what causes tennis elbow is unknown, but it is thought to be due to small tears of the tendons that attach forearm muscles to the arm bone at the elbow joint.
Tennis elbow occurs when there is a problem with the tendons that attach to the outside of the elbow. These tendons are the attachment of the muscles that function to cock the wrist back. Specifically, the extensor carpi radialis brevis has been implicated in causing the symptoms of tennis elbow. This muscle attaches to a part of the elbow bone called the lateral epicondyle, thus giving tennis elbow the medical name ‘lateral epicondylitis.’
It is is commonly misconstrued to be as simple as just the “inflammation” of these tendons. In all actuality, it is the degenerative process as a result of repetitive use. This process occurs when microscopic tears are incompletely healed within the tendon.

Pain over the outside of the elbow
Pain when lifting objects
Pain radiating down the forearm

Suggested Therapy & Treament

Implement immediate first aid to prevent any further injury and manage the initial pain
Seek thorough medical diagnosis and follow all medical advice throughout the recovery period
Attend a clinical practice for appropriate electrotherapy treatment, to aid recovery, re-establish function and rebuild strength
Between visits to the clinic, supplement your treatment with personal electrotherapy and manual exercise; this may reduce the recovery period
Manage on-going pain with pain relief on-demand
Help to prevent a recurrence of injury by strengthening surrounding muscle or groups of muscle.

Like all other methods of pain relief, including pharmaceuticals, TENS may not be effective for everyone.
Like all other methods of physical therapy, including manual exercise, NMS may not be suitable in all cases of muscle weakness.
Use of analgesic TENS is intended to relieve the symptoms and associated pain – never the cause.

In conjunction with any massage and exercise program devised for you, you might also follow this program at home. It may help with pain management and to hasten recovery.
Apply mild analgesic TENS therapy to assist with:
Fast and long lasting pain relief
Increased cellular activity – which starts the healing process as early as possible

Continue TENS applications of at least 60 minute duration whenever you choose, throughout the entire recovery period.
When the pain is under control, commence mild NMS physical therapy of the common extensor tendon. At this stage NMS may assist to:
Increase circulation
Continue to enhance cellular activity
Remove waste product
Deliver protein and nutrients

Follow the treatment program instructions below. Remember that, in most cases, the speed of recovery is directly related to the frequency and length of treatments.
To help with the Rehabilitation stage we recommend you use a comfortable NMS Exercise frequency and follow the instructions below.
Once the elbow has returned to normal functioning you can start exercising the common extensor insertion and the muscle junction. See below for guidance.

Tendinitis

Overview

Tendons are cords of tough, fibrous connective tissue that attach muscles to bones. Tendinitis is an inflammation of the tendon. The condition may also involve the tendon sheath, usually close to where the tendon joins the muscle. Tendinitis is also informally spelled tendonitis.

Tendons are generally healthy structures that appear glistening white to the naked eye. If you’ve ever carved a turkey, the tendons are the tough bands you cut through to get the drumsticks apart.

Causes

The most common cause of tendinitis is overuse and repetitive motion from recreational, athletic, or occupational activities. Risk factors for tendonitis include repetitive movement, trauma, thermal injury to the tendon, use of certain antibiotics (such as levofloxacin andciprofloxacin), and smoking. Tendinitis can also occur in people with diseases such asrheumatoid arthritis, obesity, and diabetes.

Most common types of tendonitis

Medial epicondylitis (golfer’s elbow, baseball elbow, suitcase elbow) is caused by inflammation of the tendons that attach to the medial epicondyle of the elbow. If you put your arms to your side with the palms facing forward, the medial epicondyle is the bony part of the elbow nearest to your body. Repetitive movements involving forceful wrist flexion and rotation can cause this elbow tendinitis.
Lateral epicondylitis (tennis elbow) is caused by inflammation of the tendons that attach to the lateral epicondyle of the elbow. If you put your arms to your side with the palms facing forward, the lateral epicondyle is the bony part of the elbow farthest away from your body. Repetitive movements involving extension and rotation of the wrist can cause this elbow tendinitis.
Rotator cuff tendinitis (swimmer’s shoulder, tennis shoulder, pitcher’s shoulder) is caused by sports that require movement of the arm over the head repeatedly. This repetitive motion causes inflammation on the rotator cuff, a group of muscles that control shoulder rotation. The supraspinatus, infraspinatus, teres minor, and subscapularis tendons form the rotator cuff tendons.
Calcific tendinitis is caused by calcium deposits in the rotator cuff tendons.
Bicipital tendinitis is inflammation of the tendon that attaches the biceps muscle (located in the front of the arm) to the shoulder. Wear and tear over time or overuse are common causes of bicipital tendinitis.
Patellar tendinitis (jumper’s knee) is inflammation of the patellar tendon that attaches the kneecap to the tibia. Patellar tendinitis is caused by repetitive jumping, running, or cutting movements.
Popliteus tendinitis is a form of tendinitis behind the knee caused by downhill running or walking.
Achilles tendinitis is caused by downhill running, jumping, or other activities that can strain the calf muscles.
Peroneal tendinitis is inflammation of the tendon that is located in the side of the ankle and foot. Excessive hiking, tennis, or many other activities may cause peroneal tendinitis.
De Quervain’s tenosynovitis is a painful inflammation of the tendons on the thumb side of the wrist. De Quervain’s tenosynovitis is caused by repetitive movements of the wrist and hand, such as lifting up young children from under their armpits.

Sciatica

Overview

Pain that radiates from your lower (lumbar) spine to your buttock and down the back of your leg is the hallmark of sciatica. You may feel the discomfort almost anywhere along the nerve pathway, but it’s especially likely to follow a path from your low back to your buttock and the back of your thigh and calf.

The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating discomfort. Sometimes it may feel like a jolt or electric shock. It may be worse when you cough or sneeze, and prolonged sitting can aggravate symptoms. Usually only one side of your body is affected.

Some people also experience numbness, tingling or muscle weakness in the affected leg or foot. You may have pain in one part of your leg and numbness in another.

When to see a doctor
Mild sciatica usually goes away given time and patience. Call your doctor if self-care measures fail to ease your symptoms or if your pain lasts longer than a week, is severe or becomes progressively worse. Get immediate medical care if:

You experience sudden, severe pain in your low back or leg and numbness or muscle weakness in your leg
The pain follows a violent injury, such as a traffic accident
You have trouble controlling your bowels or bladder

Causes

Sciatica occurs when the sciatic nerve becomes pinched, usually by a herniated disk in your spine or by an overgrowth of bone (bone spur) on your vertebrae. More rarely, the nerve can be compressed by a tumor or damaged by a disease such as diabetes.

Peripheral Nerve Injury

General Information

Cuts and tearing on an arm or leg caused by knives, glass and bullets are a frequent cause of nerve injury.

Many involve complete or partial division of the nerve.

Treatment

When sharply cut, the nerve may be repaired by stitching the ends together.

In injuries associated with extensive crushing and tearing of nerve fibers, repair must be delayed three to four weeks to let the damage take its course before repairing nerve fibers that will survive the injury.

Stretch and Traction

General Information Nerves can stretch to a certain degree. However, when their limit is exceeded the nerve can be torn apart, resulting in a nerve injury ranging from mild to severe.

Often associated with bone fractures, stretch or traction is a common cause of brachial plexus, radial and peroneal nerve injuries.

Treatment These injuries should be treated conservatively at first. The spontaneous recovery rate is 65 percent to 85 percent. Of those nerves that recover, 90 percent do so within four months of injury.

Surgical exploration is performed on patients who do not recover spontaneously in four to six months.

Thermal Injury

General Information While not a common cause of peripheral nerve injury, injury by flame, fluid, steam or hot elements can result in neural damage ranging from temporary loss of nerve function to full loss of motor and sensory nerve function when tissue is destroyed by fire.

Treatment Long lengths of the nerve are often involved, requiring nerve grafts. Prognosis for recovery is poor in these cases.

Herniated Disc

The most important thing to remember is that back pain is usually the result of a structural problem, and until the structure of your spine is addressed the pain will persist.
Your spine is composed of several bones called vertebrae, and between each vertebrae is a fibrous structure with a soft inner core called the disc. The outer portion of the disc is called the annulus fibrosis and the soft inner structure is called the nucleus pulposus. This structure provides flexibility and cushioning to the spine. It also creates space between thevertebrae so that the delicate spinal nerves can pass through the openings called foramen to reach their target destination. If the discs become damaged in any way, a cycle of pain begins with the start of progressive problems which can culminate in a Herniated disc or ruptured disc.

How are discs damaged?

Overall, discs are very tough and resilient; however they are very susceptible to injury with repetitive activity and loading.
For example when you lift incorrectly or sit in one position for long periods of time the fibers in the disc begin to weaken. An example of this is a common paper clip. If you bend the paper clip one time it doesn’t break, but do it over and over again it just snaps in half.
The fibers of the outer portion of a disc, the annulus fibrosis behave in much the same way. As the stresses on the disc are repeated (such as repetitive lifting or even sitting in one position for long periods of time) the fibers break down. This creates small cracks and fissures in the discs creating a pathway for the softer inner nucleus to slowly leak out. This is the beginning of a disc bulge or herniation.

What is a Herniated disc?

When your disc is injured or torn, the nucleus — the soft jelly like substance inside the disc, can leak out. If it leaks out completely, it’s called a herniated disc. If the outer material is not torn, discs can bulge without herniating. It’s like if you step on a balloon and it doesn’t pop. The balloon bulges out to one side or the other without the rubber breaking.
When a disc bulges or herniates it is a major cause of back pain. It can also pinch the delicate nerves that pass by as they come out of the spine. That’s what can cause radiating pain. In other words, pain, tingling and numbness going down your leg or arm and possibly into your toes or fingers!
This radiating pain is often referred to as sciatica in the leg, or cervical radiculopathy in the arm.
As the outer portion of the disc weakens, the pressure on the discs causes the inner nucleus to migrate through the small cracks and fissures that have been created. This pressure changes with various activities and an activity such as lifting incorrectly can dramatically increase the pressure inside the disc.
When the pressure in the disc increases, the forces push the inner material outward. And if there are small cracks or tears in the outer fibers of the disc this material can literally “squeeze out.”

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Depression

We used to believe that brain tissue couldn’t regenerate, couldn’t grow only prenatal and during early postnatal development. Since than neurogenesis or the process creation of new neurons (nerve cells) has been demonstrated in vitro and vivo experiments and animal research.
It has also been shown that this neurogenesis has an age-related decline from preadolescence (8–10 years old) to adulthood (30–35 years old) in humans.
A brain region that supports neurogenesis is classified as neurogenic. Neurogenic implies the presence of immature precursor cells and a microenvironment that is permissive for the production of new neurons. In the adult mammalian brain, there are two neurogenic regions that are generally accepted, the olfactory system and the hippocampus
What relates adult neurogenesis in the hippocampus to depression?
•The neurogenic hypothesis postulates that a reduced production of new neurons in the hippocampus relates to the pathogenesis of depression and that successful antidepressant treatment requires an enhancement in hippocampal neurogenesis
•Preclinical evidence has shown that stress suppresses hippocampal neurogenesis
•Clinically, stressful life events are known to precipitate depression in vulnerable individuals
•About half of the patients suffering from depression have dysregulation of the HPA system of which the hippocampus is an important part
•Most antidepressant treatments elevate hippocampal neurogenesis only following chronic administration, which parallels the time-course of the emergence of clinical therapeutic effects
•Impaired declarative learning and memory and diminished cognitive flexibility is apparent in patients suffering from depression
•Magnetic resonance imaging showed that depressed individuals have reduced hippocampal volume with the magnitude of the atrophy related to the frequency of the depressive episodes and the duration for which the depression went untreated
•Although hippocampal neurogenesis might not be involved in the pathogenesis of depression, it might be important for some of the therapeutic effects of antidepressant treatments
•The several week delay in the therapeutic onset of antidepressant treatment coincides with the maturation time of newly born hippocampal neurons and that is one reason for believing that adult hippocampal neurogenesis is a possible substrate for the actions of antidepressants
•Other treatments that have antidepressant effect, such as exercise and environmental enrichment, also increase hippocampal neurogenesis
•Antidepressant treatments blocked the reductions in hippocampal neurogenesis caused by stress

The authors of this extensive review summarize the neurogenesis of hippocampus on a cell level as:
Neurogenesis could serve to increase the number of dentate granule cells, provide a reservoir of highly plastic immature neurons, generate multiple cell types, and/or drive the turnover and replacement of mature granule cells The role adult neurogenesis plays in hippocampal function and disease etiology will begin to be more understood as more selective, inducible, and reversible manipulations of in vivo neurogenesis are developed. The discovery of novel therapeutic compounds for various diseases may involve mechanisms that induce a superior regulation of adult hippocampal neurogenesis

The key question is how changes in neurogenesis may be translated into changes in affective behavior that could be beneficial in treating depression.

Bursitis

Causes, incidence, and risk factors

Bursitis is the swelling and irritation of a bursa. A bursa is a fluid-filled sac that acts as a cushion between a muscles, tendons, and joints.
Bursitis is often a result of overuse. It can be caused by a change in activity level, such as training for a marathon or by being overweight.
Bursitis can also be caused by trauma, rheumatoid arthritis, gout, or infection. Sometimes the cause cannot be found.
Bursitis commonly occurs in the shoulder, knee, elbow, and hip. Other areas that may be affected include the Achilles tendon and the foot.

Symptoms:

Joint pain and tenderness when you press around the joint
Stiffness and aching when you move the affected joint
Swelling, warmth or redness over the joint

Treatment:

Your doctor will talk to you about strategies to help you resume your normal activity.
Tips to relieve bursitis pain:
Use ice 3 – 4 times a day for the first 2 or 3 days.
Cover the painful area with a towel, and place the ice on it for 15 minutes. Do not fall asleep while applying the ice. with the ice on. You can get frostbite if you leave it on too long.
When sleeping, do not lie on the side that has bursitis.

For bursitis around the hips, knees, or ankle:

While experiencing bursitis. try not to stand for long periods of time.
When you are standing, stand on a soft, cushioned surface. Stand with an equal amount of weight on each leg.
Placing a pillow between your knees when lying on your side can help decrease your pain.
Flat shoes that are cushioned and comfortable often help.
If you are overweight, losing weight may also be helpful.

You should avoid activities that involve repetitive movements of any body part whenever possible.
You can couple device therapy with additional treatments, including:
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen

Physical therapy:

You can do exercises in the convenience of your own home to strengthen and maintian joint mobility as the pain relieves over the use of your Magic Massage Pro.
This also helps to remove fluid from the bursa and getting a shot of corticosteroids”

Treatment of knee area:

Choose mode 1 to massage for 40 minutes and choose mode 3 to knock for 40 minutes; twice to three times daily.
Patients who have joint conglomeration should consider strength therapy.
Please restrain from hyperactivity or hyper-extending the knee to avoid further injury while recovering.

Calf Strain

A calf strain – muscle tear or bruise – is a very common injury in contact sports. Impact to the calf muscles can cause more damage than might be expected and should be treated with respect. The muscle can be crushed against the bone and if not treated correctly or if treated too aggressively further complications may result.

The injury can present in two ways:

Intramuscular contusion is a tearing of the muscle within the sheath that surrounds the muscle. Initial bleeding may stop early (within hours) however the fluid is unable to escape as the muscle sheath prevents it. The result is considerable loss of function and significant pain that can take days or weeks to recover. You are not likely to see any bruising come out with this type of injury – especially in the early stages.

Inter-muscular contusion is a tearing of the muscle and part of the sheath surrounding it. This means the initial bleeding will take longer to stop – particularly if you do not ice it. However, recovery is often faster than intramuscular injury as the blood and fluids can flow away.

Pain – following a blow to the leg
Swelling – in the calf region
Bruising – can be extensive discoloration to the foot and lower leg but not in all cases
Restricted movement
Magic Massage Pro recommends the following best practice injury management:
Implement immediate first aid to prevent any further injury and manage the initial pain
Seek thorough medical diagnosis and follow all medical advice throughout the recovery period
Attend a clinical practice for appropriate electrotherapy treatment, to aid recovery, re-establish function and rebuild strength
Between visits to the clinic, supplement your treatment with personal electrotherapy and manual exercise; this may reduce the recovery period
Manage on-going pain with pain relief on-demand
Help to prevent a recurrence of injury by strengthening surrounding muscle or groups of muscle.
Like all other methods of pain relief, including pharmaceuticals, TENS may not be effective for everyone.
Like all other methods of physical therapy, including manual exercise, NMS may not be suitable in all cases of muscle weakness.
Use of analgesic TENS is intended to relieve the symptoms and associated pain – never the cause.
In conjunction with any massage and exercise program devised for you, you might also follow this program at home. It may help with pain managment and to hasten recovery.
The acute stage of the injury may last for up to three days. Rest, apply ice and a compression bandage and keep the leg elevated.
During this time, also apply mild analgesic TENS therapy to assist with:
Fast and long lasting pain relief
Increased cellular activity – which starts the healing process as early as possible
Continue TENS applications of at least a 60 minute duration, whenever you choose, throughout the entire recovery period.
When the swelling has reduced and pain is under control, commence mild NMS physical therapy of the calf muscle. At this stage NMS may assist to:
Increase circulation
Continue to enhance cellular activity
Remove waste product
Deliver protein and nutrients

Follow the treatment program instructions below. Remember that, in most cases, the speed of recovery is directly related to the frequency and length of treatments.

Muscles waste and become weak when they are unused due to immobilization.

To help with the Rehabilitation stage we recommend you use a comfortable NMS Exercise frequency and follow the instructions below.

Once the calf muscle has returned to normal functioning:
bruising reduced
swelling has gone down
no further pain

- you can start exercising the calf and help prevent against a recurrence of the injury. See below for guidance.

Place electrodes on either side of the calf muscle.

Anxiety

The study of anxiety is fast merging with the science of memory. No longer focused just on symptoms like social isolation and depressed mood, scientists are turning to the disorder’s neural roots, to how the brain records and consolidates in memory the frightening events that set off long-term anxiety. And they are finding that it may be possible to blunt the emotional impact of even the worst memories and fears.
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The war in Iraq has lent a new cultural urgency to this research. About one in eight of the troops returning from combat show signs of post-traumatic stress disorder, or P.T.S.D., which is characterized by intrusive thoughts, sleep loss and hyper-alertness following a horrifying experience. Many are so traumatized that they fail utterly to respond to antianxiety medications, talk therapy and other conventional treatments.

P.T.S.D. is one of the most worrisome of the generally recognized anxiety disorders. There are four others: generalized anxiety disorder (G.A.D.), obsessive-compulsive disorder, phobias and panic disorder. G.A.D. is the most common, but all are familiar complaints in doctors’ offices: more than 20 million Americans will suffer one of these during his or her lifetime.

Genetics and the environment play roles in the development of anxiety disorders, but the point where these influences intersect is clearly the brain. The biology of anxiety has been very difficult to untangle in part because it is so familiar, so integral to our survival.

Most people can and do cope with many causes of anxiety, including demanding jobs, rocky relationships, second mortgages and even combat. Every day uncounted millions are beset by the sudden, heart-pounding dizziness of panic. It is normal, even necessary, to feel fear and stress. The brain’s anticipation of threats is an invaluable survival tool. The question for scientists is: Why can’t some people turn down the voltage?

When mammals sense threat, at least two important brain circuits swing into action. One pathway runs through the frontal lobe of the cerebral cortex, the layer of the brain that regulates consciousness, thinking and decision-making functions.

The other circuit is more primal, running deep into the unconscious brain and through the amygdala, a pair of lozenge-sized nubs of neural tissue (one on each side of the brain) specialized to register threats. This unconscious circuit is “quick and dirty,” a primal survival instinct that increases blood pressure, heart rate and alertness well before the thinking cortex is fully aware of what is happening.

The difference between the two may be crucial to understanding how an irrational fear forms. The amygdala records sights and sounds associated with a harrowing memory, and it is capable of sending the body into high alert before a person consciously processes the stimuli.

Most drugs currently prescribed for anxiety, like benzodiazepines and antidepressants, work to ease the symptoms of anxiety and have little effect on the underlying trigger. But scientists are now taking tentative first steps toward altering the brain’s age-old dynamic.

Researchers have been experimenting with a heart disease drug called propranolol, for instance, which interferes with the action of stress hormones like epinephrine. Stress hormones are central to the human response to threat; they prime the body to fight or run, and appear to deepen the neural roots of a terrifying memory in the brain. When the memory returns, these hormones flood again into the bloodstream.

But in one series of studies, people with P.T.S.D. who took propranolol reacted more calmly — on measures of heart rate and sweat gland activity — upon revisiting a painful memory than did similar subjects who took a dummy pill. By blocking receptors on brain cells that are sensitive to stress hormones, experts theorize, the drug may have taken the sting out of the frightening recollections.

Propranolol has not been proved to reliably ease the effects of trauma, but the investigation of such drugs is only beginning. Another candidate, an antibiotic called D-cycloserine, may help severely anxious patients alter the way they think about and react to current everyday concerns.

In one experiment, 28 people who were terrified of heights received so-called exposure therapy, including computer simulated rides in a glass elevator. The therapy helped all the subjects cope with their anxieties. But the participants who also took D-cycloserine learned to override their fears far more quickly than those who did not.

The drug may speed up a process that researchers call fear extinction, the unlearning of frightening associations. In theory, a successful fear-extinguisher might even complement analytic talk therapy in which patient and therapist work to understand how symptoms might be linked to loss, poisoned relationships or childhood traumas. The anxieties that flow from these events flourish deep in the brain, but now there is evidence that they can be rooted out.

Arthritis

What is arthritis?

The word “arthritis” means “joint inflammation.” Inflammation is one of the body’s natural reactions to disease or injury, and includes swelling, pain, and stiffness. Inflammation that lasts for a very long time or recurs, as in arthritis, can lead to tissue damage.

A joint is where two or more bones come together, such as the hip or knee. The bones of a joint are covered with a smooth, spongy material called cartilage, which cushions the bones and allows the joint to move without pain. The joint is lined by a thin film of tissue called the synovium. The synovium’s lining produces a slippery fluid called synovial fluid that nourishes the joint and helps reduce friction. Strong bands of tissue, called ligaments, connect the bones and help keep the joint stable. Muscles and tendons also support the joints and enable you to move.

With arthritis, an area in or around a joint becomes inflamed, causing pain, stiffness and, sometimes, difficulty moving. Some types of arthritis also affect other parts of the body, such as the skin and internal organs.

Understanding Rheumatoid Arthritis (RA)

What are the many types of arthritis?

There are more than 100 different types of arthritis. Some of the more common types include:

Osteoarthritis. This is the most common type of arthritis. It occurs when the cartilage covering the end of the bones gradually wears away. Without the protection of the cartilage, the bones begin to rub against each other and the resulting friction leads to pain and swelling. Osteoarthritis can occur in any joint, but most often affects the hands and weight-bearing joints such as the knee, hip and facet joints (in the spine). Osteoarthritis often occurs as the cartilage breaks down, or degenerates, with age or overuse. For this reason, osteoarthritis is sometimes called degenerative joint disease.

Rheumatoid arthritis. Rheumatoid arthritis is a long-lasting disease that can affect joints in any part of the body except the lower back and most commonly involves the hands, wrists, and knees. With rheumatoid arthritis, the immune system — the body’s defense system against disease — mistakenly attacks itself and causes the joint lining to swell. The inflammation then spreads to the surrounding tissues, and can eventually damage cartilage and bone. In more severe cases, rheumatoid arthritis can affect other areas of the body, such as the skin, eyes, lungs, and nerves.

Gout. Gout is a painful condition that occurs when the body cannot eliminate a natural substance called uric acid. The excess uric acid forms needle-like crystals in the joints that cause swelling and severe pain. Gout most often affects the big toe, knee, and wrist joints.

Different types of arthritis have different symptoms and the symptoms vary in severity from person to person. Osteoarthritis does not generally cause any symptoms outside the joint. Symptoms of other types of arthritis may include fatigue, fever, a rash, and the signs of joint inflammation, including:
Pain
Swelling
Stiffness
Tenderness
Redness
Warmth

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Athlete Pain

Pain and gain – how athletes can manage and overcome pain?

Pain is inevitable, but suffering is optional.’ So goes a well-known but anonymous quote. For many athletes, pain is a normal everyday experience and success is often achieved in spite of pain. But what’s the best strategy for coping with and overcoming pain and how can athletes distinguish between benign and potentially damaging pain? Matt Lancaster looks at the latest evidence
Pain is synonymous with sport. Endurance athletes relish the challenge of ‘pushing through pain’ while boxers expect to fight on regardless of a jarring blow to the chin. Adulation is reserved not just for the star rugby player, but anyone who can play through pain and contribute to the team. Winners and heroes overcome pain. Losers don’t.

But the price of pain can be high. Pain both demands attention and creates fear(1). It can restrict the ability to concentrate on performance and take away the opportunity to compete. Pain can even end sporting careers. The relationship between pain and sport is filled with challenges for sportsmen and women as well as those who support them. However, although pain of some description is no stranger to most athletes, it’s still a curious phenomenon in many ways. For example, consider the following questions:

How are some people able to shrug off a painful injury?
How can two athletes with the same injury experience different pain?
Why do some pains seem to last ‘forever’?
Why can some people compete, seemingly regardless of pain, while others struggle to overcome even a minor niggle?
This article will explore these questions, offering practical advice about when it is appropriate to perform in the presence of pain, when you should consult a professional, and how to best approach pain in a sporting environment.

The diagnostic dilemma

If you tear your hamstring muscle or sprain an ankle it hurts – obviously. Since the 17th century, the medical and scientific world has sought to diagnose pain by identifying the particular tissue that has been injured. For example, the philosopher René Descartes proposed that a pure pain sensation is transmitted from the damaged body to an entirely separate organ, the mind, just as… pulling on one end of a rope…makes to strike at the same instant a bell which hangs at the end(2,3). Descartes separated the body from the brain, and even today it is usual for people to make a distinction between physical pain and mental pain(3,4).This is especially the case in sport.

However, there are some problems with this classical view of diagnosis. For instance, an extensive network of nerves supplies the various tissues in your back, making them potential sources of pain when injured(5). It follows that if you can identify the damaged spinal tissue, for instance using magnetic resonance imaging (MRI), it should be possible to explain the pain.

The problem is that while MRI findings of severe damage to the discs or nerves is associated with the experience of pain, studies have failed to demonstrate a clear relationship between the majority of tissue damage observed on MRI and the patient’s pain(6). What’s more, almost 40% of people who have no history of back pain have abnormal, damaged spines at more than one spinal level when scanned using MRI(7)! Likewise, the damage shown by ultrasound investigations of athletes with painful patella tendons (jumper’s knee) does not necessarily correspond directly to the degree of pain experienced by the athlete(8).

This doesn’t mean that identifying the injured structure is not important or that it isn’t crucially involved in your pain. But looking to tissue damage alone (which is both frequent and often quite subtle in sporting injuries) to explain the relationship between pain and sporting performance is probably not sufficient.

A painful process

Another theory, first proposed in 1965, suggested that far from acting like an old-fashioned telephone exchange, your brain and spinal cord can actually increase or inhibit the transmission of pain signals(9). Gate control theory was revolutionary because it proposed a mechanism for the brain to have a modulating influence on the generation of all pains, and not just mental pain(10). While the original theory has been modified and expanded, it has essentially stood the test of time and been supported by 40 years of scientific research(11).

If you listen to the language people use to describe their pain, it soon becomes apparent that pain is quite simply pain, and is not separated into physical or mental compartments. All pain invokes not just a pure sensory response, but a range of thoughts and emotions also(3,12) and pain emerges from the integrated, combined action of the pain system(2,3). Simplistically, this system can be viewed as three separate parts of the nervous system, all of which modulate pain.

How do some people shrug off a painful injury?

Remember that following an acute injury, such as an ankle sprain, pain receptors are first stimulated by the mechanical stress and strain placed upon the tissue. ‘Inflammatory soup’ soon floods the tissue leading to peripheral sensitisation. Several hours later, similar chemicals will also lead to spinal modulation(19). Pain and sensitivity to movement and pressure increase over a period of a few hours; the time between the transition from the original mechanical pain (which may pass) to the maximum sensitised state may provide athletes with a ‘window of opportunity’ to shrug off their pain and continue competing.

However, this mechanism is probably only the tip of the iceberg. When you are totally focused on your opponent, or consumed by the contest, supraspinal and spinal modulation may act to inhibit the transmission or limit the awareness of the pain signal(18). We’ve all heard stories of sportsmen and women who have continued despite an injury which (theoretically) should have caused them to stop: a boxer with a broken hand, rugby players with torn ligaments, a long jumper with a strained hamstring etc. In the cut and thrust of competition, the pain system can ‘shut the gate’, and athletes are able to continue in spite of injured tissue(18). However, once your attention is drawn back to the acute pain (particularly following competition), awareness of the pain becomes strong again, especially if this also coincides with an increase in peripheral and spinal modulation.

So, should you ignore pain and try to shrug off an injury? Acute sensitisation is a normal, helpful process to encourage you to stop using the injured tissue and avoid further damage(20). It might be helpful to ask yourself the three questions in the box below.

There are a few other questions, which are perhaps even more important. We’ll get to these later. But remember, acute pain usually occurs for a good reason. It makes sense to seek professional advice as soon as you can. Sometimes people can overcome acute pain and continue to compete, but that doesn’t necessarily make it a wise decision!

How can two athletes with the same injury experience different pain?

Studies have confirmed that people respond differently to similar levels of painful stimulation(19). Differences exist not just in our individual sensitivity to a painful stimulus, but also in our perception of pain and how we display it. Pain is individual, even when the stimulus is not, but while we cannot know exactly what someone else is experiencing, our brains undergo quite similar activity when confronted with someone else’s pain(21). This is the basis for empathy and acknowledging someone’s pain is normal and important.

Our individual sensitivity to pain is in part explained by our genetic makeup (22-24), while studies involving twins have shown that learned behaviours are also important (25). Again, the division of pain into real and mental is unhelpful and the variation in pain between two athletes with the same injury lies at all levels of the pain system. Even for the same athlete, pain sensitivity varies under different circumstances, and perhaps not surprisingly, can become significantly less during competition(26).

It’s also worth noting that different groups in society may have significantly different pain responses, and this applies within sport. A study performed 40 years ago demonstrated that contact sport athletes could tolerate experimental acute pain for longer than non-contact athletes, while both groups could tolerate more acute pain than non-athletes(26).

Pain sensitivity may also be different in different people at different times; the way athletes display that they are in pain can vary, both between individuals and also between groups of athletes from different sports. It might be an extreme example, but imagine a footballer who could potentially be rewarded with a penalty responding to the pain from a kick in the shin. Now, assuming the tissue damage is equivalent, think about the same incident involving a Thai kick boxer who is in the middle of a title fight. Get the idea?!

Why do some pains seem to last forever?

During ongoing or chronic pain, adaptive changes at all levels of the pain system often outlast their usefulness in helping us protect injured tissues. Movements and pressures that would otherwise be normal continue to cause pain long after the risk of further injury has passed and often even once the tissue has essentially healed.

Examining possible tissue damage remains important when considering ongoing or recurrent pains, but a broader approach is required to address an athlete’s fear and anxiety about their ongoing pain and help them return to their sport. Focusing too much attention on pain can actually increase pain(18). It is probably more helpful to concentrate on working hard to strengthen the tissues at a sensible rate, regain normal fitness and aim to return to training.

Providing an appropriate environment for people to overcome ongoing pain is important and not always easy in sport. Coaches or team-mates who are angry at or ignore athletes with ongoing pain may contribute further to those athletes avoiding the very things that will help them return to full activity (such as a rehabilitation programme), and generate further anxiety that doesn’t help either(27). Getting this balance right and remaining positive is therefore important. People who develop an exaggerated, negative mindset towards their ongoing pain have been shown to experience both increased pain and emotional distress(28). Pain is a normal part of sport but the right mental approach can prevent it from becoming a catastrophe.

Does this mean it is okay to ignore ongoing pain? Well, it’s not quite that simple. Once again consider the three Cs. Any pain that has been present for more than a week or so, or keeps returning periodically is worth getting checked out by a professional who can not only assess for tissue damage but can also understand your pain and hopefully point you in the right direction before the maladaptive changes to your nervous system become entrenched.

Why are some people able to compete, seemingly regardless of pain, while others struggle to overcome even a minor niggle?

Although pain (especially acute pain) is related to tissue damage, this damage alone is not sufficient to explain pain fully. Pain is not just a sensation but results from the interaction between sensory inputs and brain processes, such as emotion and conscious thought. And pain is individual, not just to you as an athlete, but also to the time, circumstance and environment you find yourself in. Within the mechanics of the pain system, individual variation and modulation occur subconsciously, which helps to answer this question.

To ultimately address the relationship between pain and sport however, it is necessary to consider one further aspect of pain: your own ‘personal values’. We’ve already considered the three Cs as a guide to considering how to act in the presence of pain; however, as anyone involved with sport knows, making decisions about athletes in pain is often a judgement call. The three C questions only have meaning if we add a further, more personal line of questioning:

Am I prepared to cope?
How important is contributing a worthwhile performance to me?
Am I prepared to suffer the consequences?
Having a pain killing injection two days before an Olympic final, regardless of the risks, would seem quite a reasonable thing to do for most elite athletes if it was the only way they were able to compete. Under similar circumstances, few casual joggers would agree to the same injection just days before a fun run. Entering a boxing ring, running 100 miles a week or crashing into a rugby scrum is not for everyone. Some people can continually and repeatedly overcome pain for the sake of their sport because they are prepared to. Sometimes they are rewarded with success, and sometimes, despite their desire to cope and contribute, their body succumbs to the consequences. Winners and heroes overcome pain sometimes. Losers often try and fail. Perhaps the most successful sports people are those who best understand the relationship between pain and performance: they are prepared to overcome pain, but make wise, informed decisions about when it is worthwhile trying to do so.