Last week I attended the Faculty of Sports & Exercise Medicine (FSEM) conference at the Royal College of Surgeons Ireland. This year the Conference had a focus point in the return to play post shoulder injury. For those of you that don’t know what FSEM is – it’s an annual gathering of doctors, surgeons, researchers, physiotherapists, and of course athletic therapists, presenting findings from studies as well as new methods of rehabilitation and surgical interventions to conditions and injuries. We basically come together to discuss the latest developments in the field of physical health. This allows for a body of knowledge, that would normally never be dispersed to be tangible for all.
There was some savage speakers this year. With the likes of Eanna Falvy, the Irish rugby team doctor who spoke about on field management and the occurrence of shoulder injuries in rugby. He interestingly spoke about how rugby has evolved from its beginnings to something barely comparable to what it once was pre professional era. Body size, strength, play style and aggression have all lead to an increase in injuries especially those in the shoulder where the ideal of aggressive rugby in the breakdown via the poaching of a ball and active clear out has lead to an increase in shoulder injuries. He also spoke of the need to prepare athletes for the season ahead of them as you cannot prepare the athlete mid season, when training load and type are dictated by schedules and physical conditions there and then.
Edel Fanning described the return to play for contact athletes after shoulder stabilisation surgery. She described how the loading of the uninjured side and reductions in strength from one side to another or from internal to external rotators can make it difficult for athletes to return to a position where equilibrium is achieved once more. She also showed how rather than basing rehab plans off pre described time frames and rather base it off objective and measurable improvements from the athlete.
Nick Grantham described a very different int of view coming from a strength and conditioning background but showing how no one field within health and fitness is isolated. He described the strength, power and honestly versatility of an athletes shoulder using downhill biking as an example and showing how specialised a certain activity can make an athlete. He described rehab in a far less rose tinted light than it is often portrayed with the focus being placed on the avilable resoucrces and pjysical attributes being available to each and every specific athlete. We often to much on the on the structures that have become injured rather than the reason why they have become injured sometimes trapping ourselves in a loop of repeated returns and failures of tissues.
Probably my favorite piece of information from the entire conference which states that essentially just following information previously recorded and not catering rehab as an individual experience will not produce outcomes where rehabilitation’s effectiveness is maximised. Essentially, everything is situational and so you cannot paint every injury or condition with the same paint brush. Sean O’ Brien also spoke on his professional career and often as therapists we can forget but the athlete or patients point of view regarding their injury and rehab.
In all i really thought the conference was great and a huge amount of knowledge and opinions were expressed. Not all pieces were directly relatable to every field of expertise but something to better your skills as a practitioner was present in nearly every talk, workshop or conversation on the day.
Should you always be able to practice what you preach? Being in a profession within the healthcare system many people have asked me am I capable of doing everything that I normally ask of my clients, be in strength, mobility or balance related. The simple answer is no, I cannot do everything that I often expect and seek from others. This can present some what like an irony that I would not consider myself to me injured or currently harboring a condition but I cannot do some of the things I ask from those that do. The honest answer is that regardless of what you may try and teach someone and expect them to be able to replicate each person has different body structures and capabilities. Each person has also developed differently including their health history regarding the injuries they have sustained and they way in which thy have recovered from these injuries. So very rarely do you find someone who is perfectly functional by the standards we test people. To the extent that when I access someone who is perfectly functional I’m almost shocked.
I have gone through my fair share of injuries so If I was to be tested for things such as ankle or shoulder stability someone may think that I may currently be carrying an injury but as of right this second I’m good. We are not always capable of doing the tests and assessments that we use to grade individuals musculoskeletal health. At times we can hold the testing methods we use a little to strongly. As those who are testing these people and trying to push them forward it can at times create goals that can be excessively difficult for people to cross. People are sometimes not capable of reaching what is perceived to be perfect functionality but most are still capable of doing the sports or events that they wish to undertake. There are always ways around certain functional shortcomings. This may mean doing things in an unconventional manner or simply by breaking activities down to their base elements.
At the same time most people involved in health and sports related activities need to be able to do the basic requirements of that activity. Be it simple skills or some of the functional movements that are heavily demanded in the sport, it is essential purely because to understand the sport and what is demanded of those involved, the best way to help them and make their plan applicable to them and their sports is to be able to understand the sport at a basic level and recreate it. Not to be able to understand every fine nuance of a game but to see the way an individual moves and the way this interacts with surrounding players or athletes can at times be one of the most valuable assets you can have. To understand how an athlete should move in their position and how they normally move themselves can lead you down a path where you realise that they may be carrying an injury or weakness. Seeing a player act differently or out of character can lead you to help them to overcome what may be effecting their game. Behind games, and this is especially true for athletes, lies the core of an individual. So if you cant put yourself in their shoes you may miss the signs behind certain problems. You are not a mind reader although many expect us to be. But at the same time make sure you can practice what you preach, to a certain degree, even to understand where your clients and athletes are coming from to better help them and to allow yourself to keep up with the hectic demands of a physical and demanding job.
In my profession I help a lot of people to return from injury, be it chronic or acute, it is my job and my drive to get people back to a position where they can return to a healthy and functional condition, if not get them to a position where they can become even better than they were before injury. I have done this and regularly guide, and at times convince people, to give their best efforts towards this end goal. Although I get great satisfaction from helping people to return from injury I have always found it difficult to produce the same level of intensity in my own rehab and return from injury. I myself have until recently been injured or returning from injury for a little over 5 years. My life definitely dramatically changed after injury and lead to a domino effect of injury, rehab followed by complications, rehab and what seemed like an up hill struggle to return to a point where I could confidently under take the activities I wanted to without having to worry about what may happen.
My uphill struggle began in my first few weeks of college when I ended up getting a Talor dome fracture to my ankle damaging all of my lateral ligaments in the process. It occurred in the final three minutes of a rugby game in which a fluke fall and tackle interacted to cause the injury. I had began my Athletic Rehabilitation course and so I had my ankle accessed and was quickly sent to a clinic to get the ankle scanned. Before I made my way to the hospital I went to where I was staying and ended up hitting my ankle off the steps of the stairs attempting to climb them and due to the shock and pain I ended up fainting and collapsing at the top of the stairs. I went to the hospital the following morning but was told there was no fracture, merely ligament damage so I was to just rest it and it would be fine. I proceeded to attend 3 days of college before one of my lecturers told me I was being foolish and was to go home and rest as I was so tired walking around with crutches from one lecture to another that I kept falling asleep in classes.
I attended the hospital several times over the following 2 months where the assessment of my injury changed per visit. This aggravated me and I couldn’t understand where I stood with it all so I decided I would rest it and do my bit of rehab I had gotten and make a return to rugby and normal life. I spent a year getting back to walking normally but something wasn’t right. My entire leg appeared to have rotated inwards and I was unable to walk more than 5 minutes before pain would make me stop and take a break before I could walk again. In this time I had thrown my efforts into gym work and it was a saving grace but there was a very large gap left by rugby and not because I was a skilled athlete but merely because I had played rugby every year up to this point since I was 6 years old. It was a constant in my life at that point and it was where I had made most of my friends through out as well.
I had decided after a year of this that I had finally had enough and went about getting an appointment with a consultant as rehab, no matter how much effort or dedication I applied to it, was no longer helping and I had changed a number of aspects in my life that I would never have even had to give a second thought about previously. Upon meeting the specialist and getting an MRI I had found out that i had a piece of cartilage that had calcified in the center of the joint as well as a piece of cartilage on the medial edge of the joint that had torn away from the joint line. This was not the worst case scenario and key hole surgery was possible so I agreed to a date there and then. I decided to get it done the summer before third year as that was when my placement began and I needed to be able to walk and stand and just move to do it. So i gave up Summer to be alright for the coming college year. I entered the day of surgery and wasn’t nervous. I had learned a lot already and knew what they were going to do to my ankle. I was more impatient if anything. They rolled me in to the anesthetists and nearly as soon as I remember being wheeled in I was awake back in my corner of the ward post surgery. I began to come to and the pain hit me like a truck at first. Each pulse seemed like agony and it felt like someone raised the temperature in that one ward by about 20 degrees.
My doctor soon came over to me and told me the physiotherapist would be with me soon to talk everything out. I honestly only picked up every second word because I had finally noticed the massive full length leg boot I had on. He only stayed a short time but he told me it was a success and that he would see me in a week. I waited around for my dad to show up and take me away so I fiddled around on my phone and let everyone I knew know that that I was out and in a lot of pain. The physiotherapist came to show me how to use my crutches, little did she know I was a seasoned expert at them by now. I feel bad for her now looking back as I was standing and straight over to the bathroom before she even got a chance to fully explain it all. I got my tea and toast and eventually my dad arrived. I was still feeling the effects of the pain and drugs so I didn’t even realise how long I had been under for. I arrived home and went to sleep or at least what sleep was with a massive boot on your leg. My first real day began with me slipping down the stairs as I fell trying to get myself to the bathroom and me having to go to Shannon Doc to get stronger pain medication. Three days later my letter describing the surgery arrived and I read exactly what had occurred. My key hole surgery of one hour had turned into a four and a half hour surgery involving the removal of cartilage, removal of a bone growth, reconstruction of my Deltoid ligament complex and removal of excess tissue from around my Achilles. I had yet to open my boot so after reading my letter I did to notice I had more than just two dots as scars of my surgery.
My plan slightly backfired so I did rehab and work throughout the Summer but it took 6 months before I was back walking again. Thankfully at this point I was deep into the rehab phase and almost back to normal. Normal sadly did not mean I was able to return to the gym or rugby yet with another 6 months of mobility, balance and strength work needed before I was at the point where I could comfortably enjoy a gym session or a long walk again. I finished out my last year of college and just recently started to play rugby again. My body still remembers what to do but its a few steps behind what my brain demands from it. I still have difficulty and am sore to some degree but in comparison to where I was, where walking was near impossible for long periods, its like a whole different world. Looking back as a qualified health practitioner now I can barely believe the way I went about things. I refused to take proper care of myself and even held onto the belief that because of what my course was, that I knew how to sort my problems. Present me can scarcely believe my naivety but it also gave me a perspective on what pain and injury was and how people view their injuries and themselves while injured. Sort of like a person who has never been to a certain location can never truely describe it, long term and chronic injury is very much a unique journey for everyone. Im glad that my road to recovery has come to its end but now the road to performance has only started.
A topic that often doesn’t get discussed very often is the psychological aspects of returning from and injury. Whether it be returning to sport or just everyday activities and work depending on the level, type or location of injury many people will struggle to return to normality issue free. I don’t just mean people struggling with debilitating issues mentally regarding their return to health but many people will have times where the struggle mentally in recovery.
Injuries are something that can suddenly shake our attitudes and confidence which in itself is an unsettling feeling for most. We all very much feel that we can just bounce back and if you can all the better. Sadly at times the road to recovery is slow and an uphill struggle. The grind to return is at times monotonous and frustrating especially severely acute or long term chronic issues. I think many people do not give themselves enough credit for the efforts they put in their attempts to recover. We often see athletes and the injuries they go through and we belittle the issues we have ourselves. Its true athletes normally receive far worse types and degrees of injuries but many athletes will have several major injuries and returns to play in their career while having a well developed support system that to them, unless very serious, its just another speed bump in their business.
Yet the fear and difficulty of injury can be intense for even those in the general public. Injuries makes us feel fragile physically and mentally where we fear hurting ourselves or re-injuring the affected area again which makes us overly cautious and, in a vicious cycle, makes us more likely to hurt ourselves. We become nervous of the movements or actions we do that caused the injury so we limit the movement or stop that activity all together. This means our tissues become accustomed to this reduced level of activity meaning in return it takes far less force to injure ourselves. This dents our mental fortitude further and is the cause for many to give up on many new sports or activities. This fear is not something only attributed to the general public, various studies have shown that athletes at a high level express greater levels of fear even after one injury when returning to sport , with certain studies even showing that fear, due to the possibility of injury, can cause stress hormones to be released, reducing the quality of tissue; e.g. https://journals.humankinetics.com/doi/pdf/10.1123/jsr.2017-0075
Speaking from experience of returning from injury to sport, the fear of pain can be worse than experiencing the pain itself. Pain does not always means we are at risk of injury. It is the ability to educate ourselves and overcome this fear logically to allow us to return to ourselves that we all need to become far more accustomed to. Fear is natural, but overcoming that fear and not letting it control the way in which our very bodies act is one of the most important things after an injury.
This is just a very simple video showing that injuries happen and the mental aspect of returning from injury is far more important than we all think.