The pain of it

PAIN IS the most common reason people seek healthcare. Acute or new pain arises from injury or disease and will usually resolve once the injury has healed or the disease is cured.

Occasionally, pain continues even after the injury has healed and this is known as chronic or persistent pain. It is a very disabling condition which is not well understood.

There are many types of persistent pain. However, the most common is low back pain, and this affects at least one tenth of the world’s population. The causes of chronic pain are not always clear and often involve a combination of physical, psychological, and social factors.

Physical causes of pain usually begin with acute or overuse injury. Common acute sporting injuries include hamstring strains, ankle sprains, anterior cruciate ligament tears and groin injuries. Different sports will have a higher occurrence of these injuries. Groin injuries are common in American football and hockey, while hamstring strains are common in sprinting. Overuse injuries include conditions like stress fractures, tennis elbow and carpal tunnel syndrome. These are caused by long-term repetitive movement of the body part, high training load, participating in endurance events, increased training volume in competition season, and higher number of years of participation.

In some instances, persistent pain may develop after corrective surgery, as in the case of nerve pain in the groin following hernia repair. Although the underlying mechanisms of injury are different, acute and overuse injuries may become chronic painful conditions that are difficult to treat and can interrupt or end an athlete’s career.

People who experience persistent pain are often frustrated because they may spend months or years trying treatments which do not remove the pain. Medical examinations and investigations may not show a clear cause for the pain.

For example, someone with chronic low back pain can have normal results on spinal X-rays, CT scans or even MRI. When physical causes of chronic pain are identified, they often include underlying factors such as osteoarthritis (joint degeneration), ligament instability (common in ankles and knees), kinetic chain abnormalities, muscle imbalance (groin pain and hamstring injuries), chronic inflammation (tendonitis), chronic nerve irritation (neuropathic or nerve pain common in wheelchair athletes and amputees), sleep disruption, inadequate nutrition, and calorie intake.

Other possible risk factors which may predispose an athlete to developing persistent pain include the specific team position in which they play (which may involve awkward postures and repetitive movements and high forces), high body mass index, family history, aging, competition and experience level, and muscle weakness.

Appropriate and early multidisciplinary treatment and rehabilitation are essential in reducing the risk of developing persistent pain. A comprehensive care plan might include analgesia, injections, exercise rehabilitation, electrical and thermal modalities, kinesio taping, orthotics, modification of training routine, and correction of faulty movements.

When pain does not respond to physical or pharmacological therapy, patients may worry that there is a sinister cause for their ongoing pain. In the absence of serious underlying causes such as cancer, and with certainty that tissue healing has occurred, psychosocial factors should not be overlooked.

Psychological factors in athletes include the experience of pain itself, distress, low and negative mood, and stress. Anxiety and fear are known to increase perception and intensity of pain, while positive mood and emotional states can reduce the experience of pain.

Other psychological and behavioural presentations which increase the risk of injury are aggressiveness, being too cautious during play, and hiding the presence or severity of an injury.

Social factors include pressure to return to play even while still injured, lifestyle, and sleep disruption. Returning to play too early could be because of social pressure to perform, financial incentives, or even a self-perception of invulnerability. The additional concern with returning to play too soon is that the athlete is now at higher risk of secondary injuries, thereby increasing the risk of developing persistent pain.

Athletes may also have protective psychosocial factors such as access to better healthcare, healthier lifestyles (no smoking, alcohol, or substance abuse), supportive team members, and better mental resilience to cope with pain. Adequate mental health support in the early stages of injury will help to prevent the progression of pain from acute to chronic.

Therapies such as cognitive behavioural therapy, mindfulness, stress management strategies and pain education are beneficial in the prevention and management of persistent pain.

Persistent pain is not always preventable, and, in many cases, is not curable. Patients and athletes may spend years seeking a cure to relieve their suffering, only to become frustrated and even angry.

In the acute and subacute stages of an injury, all causes of pain should be identified and treated to reduce the likelihood of chronic pain.

Delaying proper treatment of acute injuries increases the risk of chronic pain, so do not procrastinate in seeking medical advice when an injury occurs during sport.

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