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​In 2019 Dubois & Esculier (2020) came up with the acronym of ‘Peace & Love’ for managing new injuries.
​
Its sounds a bit twee doesn’t it. A proposed scientific model for managing something that just happens to spell a catchy acronym. Looking selectively at only certain pieces of research has meant the catchy acronym can be delivered possibly at the cost of a balanced viewpoint and failing to acknowledging where there is conflicting evidence. Unfortunately the authors were selective in the use of research, narrow in the range of studies used, and biased in the sporting populations that the research evidence came from.….not all sports injuries and pain are running injuries. More on this later.

Here’s what the wider scientific evidence suggests you should consider with a new injury.

Was it an sudden onset actual injury? Did something traumatic happen that you recall or did you just the develop the pain over a more prolonged period of time and sports training?

Caneiro et al. (2021) have highlighted that sudden onset non-traumatic pain in athletes is often NOT a structural injury (trauma) but related to tissue tolerance (chemical pain). Pain can also be due to mechanical dysfunction which is often associated with tissue tolerance pain. This should be remembered. Repetitive micro-trauma can lead to tissue-based pain so pain emerges gradually – this has often been termed overuse injury although we tend to drop the ‘injury’ part of this as it implies tissue damage. The high adrenaline levels during training and sport can also mean that it doesn’t feel like much at the time, but if pain and swelling develop over a few days then get it checked out. Lots can be done to help rehabilitate tissue tolerance-based and mechanical (nociceptive) pains also. Additional symptoms, such as feelings of weakness or instability, pins and needles, tingling or numbness should also be checked out if you want to know whether it’s a good idea to keep exercising or not.
 
The injury was sudden onset. Should I protect it?
The evidence from all soft tissue injury guidelines over the past 30 years agree that protection is important to create stress shielding of fibres in the case of new injuries. Reducing training load, wearing an appropriate brace, support or sports taping for a few days can all assist. Do we always need to ease back every time we experience pain. No not necessarily but only a professional medical or advanced physiotherapy opinion will really answer this for you – there are many different factors and many different reasons and contributors to pain. Certainly if there is a pattern that the problem is not resolving you would benefit from a professional opinion.
 
Should I elevate a newly injured limb?
There is only weak scientific evidence that this may be helpful in the first 1 to 3 days. You should certainly only consider it if there is significant swelling present and not if there isn’t.

Should I apply compression?
A systematic review by Hansroni et al. (2015) reported no positive effect on functional recovery in ankle sprains and even reported that compressive bandages may be linked to increased analgesia use.
 
Should I take anti-inflammatories for it or use heat or ice?
Heat for a new injury hasn’t been included in the physiotherapy or medical guidance for a new injury in any of the guidelines produced in the last 30 years. In tissue tolerance scenarios heat can sometimes be indicated due to the benefits of increased blood flow and changes in the chemical environment it can bring. Heat can also help ease off very guarded muscles and help ease nerve pain. There is an underlying question: if there is significant muscle guarding of a body part, why is this? Assessment of significant ongoing or recurrent pain, stiffness or guarding is helpful.
Dubois & Esculier (2020) have advised that anti-inflammatories and ice packs should now be avoided with new injuries. - not everyone agrees. The idea here is that we should allow swelling to happen rather than ‘treat the swelling’. They reference  Singh et al’s  2017 study on icing of contusion (direct impact) injuries in rats. This study has several problems: it’s done in rats; only for impact injuries; there were problems with the staining techniques used on their physiological markers; and the study authors state that the changes are not sufficient to affect the muscle regeneration seen at one week post-injury! Other studies using more dynamic physiological markers (this is probably better!) do show benefits of icing. Reducing secondary cell death is not mentioned in Dubois & Esculier’s model but previous studies and guidelines have supported the position that icing reduced secondary cell death.
The scientific jury has been unable to reach a clear verdict on this one yet.

My Clinical Advice:
Protect the body part, perhaps reduce loading to a degree. Try and see if you can make good progress over a few days without any anti-inflammatories or ice packs. If you are not making good progress and it’s interfering with your life or sport, or the problem keeps recurring, then it’s time to get your injury assessed and get some specific professional advice. Symptoms, such as feelings of weakness or instability, pins and needles, tingling or numbness should be checked out by a suitably qualified professional.
 
A Critical Summary of the P-E-A-C-E regime for what to do in the first few days post-injury:
It’s ‘YES’ to the P (protect) and the E (educate); it’s inconclusive for the E (elevate), A (avoid), and C (compression).
A biased case of trying to create a snappy, headline hitting soundbite perhaps over a rounded evaluation of the research.
 
Now to the Sub-Acute Phase: What to do from day 3 post-injury onwards?
 
Should I still be resting the injury?
For soft tissue injuries we should gradually try to increase the load we put through an injury. Exceptions to this include where a joint feels unstable or unsupported, or you are experiencing weakness – my best advice is to get it assessed by a specialist in musculoskeletal injury. If it’s a one-off overtraining or overloading issue pain should naturally ease off quickly over a few days (unless you are in a bad pattern). If it’s a tear it’s likely to become more painful if too much load is put through it and may worsen the injury if done too soon.
 
Should I just push on through?
There is plenty of research to support us encouraging positivity. Developing fears, worries, and anxiety tend to make the body more sensitive and over-reactive and the person unhelpfully over-protective.  However, if a joint ‘doesn’t feel right’ it can also be due to an instability which does place the tissues at risk of more significant injury. Most injuries will improve well so do expect this but if something is not feeling right having a physical examination done will tell you with greater certainty whether there may be anything else going on, putting your mind at ease, and helping you retain a healthy and balanced optimism, not blind faith. Joint stability tests are very useful in well trained hands, and neurological examination can screen for and detect more serious problems that should be considered. A risk with the YouTube world of quick fixes and self-appointed gurus is that problems are not professionally assessed – good luck with that! Also be careful to see the right professional for the right problem. Look for a professional trained in high level assessment and diagnosis. Diagnosis and professional opinion precedes treatment and management planning. If you’re going to fix your own car you will need some training in how to fix it and you’ll need to know what the problem is you are trying to fix.
False optimism is not helpful. Be confident and smart but don’t be a confident fool. Many an injury has been exacerbated, either short or long term by the over-zealous over-loader. Great results come with dedication to progression in training over time. Hard work pays off doesn’t mean its quick or easy.
Rehabilitation needs to be paced and structured just like training does.
 
It hurts to lift weights, can I do some cardio at the meantime?
After a few days, encouraging blood flow to injured or sensitive tissue if a good idea. Doing some light and pain-free cardio, such as on a bike, rower or other ergometer of some sort is helpful in so much as blood flow helps deliver oxygen and nutrients to tissue. So as long as the load isn’t too high, yes it’s good to move, as long as your body is liking it and no symptoms are getting worse as a result. A light easy run may even be helpful when heavy lifts or high intensity are not feeling happy but pace work and hills are a different issue again. Taking a graded, active approach to recovery is supported by multiple research studies across a range of musculoskeletal conditions and can help physically and psychologically – it’s a general guidance though and doesn’t tell you exactly what you should do for any one specific problem. Movement generally helps healing rather than hinders it but there are 10,001 different injuries and issues that mean one size fits all is not possible and knowing how much of what is most helpful depends on the individual circumstance and the specific presenting problem, so often we come back to the questions ‘what is the actual problem?’ and ‘what’s the best management or treatment for my problem?’. Being specific and accurate about this matters.
 
A Critical Summary of the L-O-V-E regime for what to do in the sub-acute phase of injury:
It’s ‘YES’ to L (load, graded) – O (optimism, but not false optimism), V (vascularisation, think blood flow without tissue overload), and E (exercise, active rehab is central to your sustained progress). It’s the 'how' that a professional can help you with.  It's the specific steps taken within these variables that is the key to excellence in sports medicine.

So, it’s YES to L-O-V-E.

I’m going to close with a summary statement by Bleakey, Glasgow & MacAuley (2011):

“A loading strategy for injured tissue should reflect the unique mechanical stresses placed on the tissue during functional activities, which varies across tissue type and anatomical region. Optimal loading is sport specific. The challenge is in determining the optimal dosage, nature and timing of loading."
 
Get a specific assessment of your pain problem and then you can have a specific action plan.

I recently posted on my facebook page a blog from strongerbyscience.com on the why & how of tapering & peaking for athletes. It’s a good summary article, and here I have added some key additional research detail on tapering which was not included in the summary or post..

At the end of the day training can be a numbers game (how often to run, how far, how fast) and tapering decision-making should be too. So to help inform your decisions regarding taper variables here’s some of the known outcomes of tapering according to the research studies. Remember, the aim of tapering is to achieve a ‘supercompensation’ to the pre-taper training stimulus and the best race day performance you can achieve in the circumstance. And when training has been disrupted due to pain, illness or injury you may need to adapt your decision making to be ready on race day.

How much does tapering improve race performance?

• Elite track athletes can experience  0.3-0.5% improvement in performance through tapering (Hopkins 2005).
• This gain can potentially be from 0.5% to 11% in non-elite athletes (Mujika & Padilla 2003).

How much can a moderately trained athlete decrease training frequency in a taper and not adversely affect race day performance?

• Moderately trained athletes maintain physiological adaptations even when there is a  decrease in training frequency of up to 50% during a taper (Bosquet et al. 2002, Mujika & Padilla 2003).

How much can an athlete reduce training intensity during a taper and not adversely affect race day performance?

• During a taper, a training intensity of less than 70% VO2 max has been shown to maintain or reduce performance (no supercompensation occurs) (West et al.2013, Kiecolt-Glaser et al. 1998).
• During a taper, maintaining a training intensity of more than 90% VO2 max is associated with improved performance (supercompensation occurs) (Cook et al. 2011).

Tapering protocols assume an athlete has reached a satisfactory training distance in the month preceding taper start date, and an undefined but decent number of miles in the legs over the preceding weeks & months. This is individual but typically considered to be a minimum longest distance run of 18-19 miles, and possibly up to 22 miles dependent on experience and the level of athlete (e.g. novice, intermediate, advanced, elite). If your longest distance is below 19 miles you should seriously consider withdrawing from the marathon – there are always more marathons. Be a smart athlete.

What should a runner do when pain, illness or injury has disrupted training and meant that less training than ideal has been completed during the training programme (reduced training volume)?

• Consider using  a short duration step taper or exponential fast decay progressive taper  if there is decreased overall training volume pre-taper (Kubukeli et al. 2002), the latter has been shown to still lead to 3.95 to 4.1% performance gains on pre-taper performance (Zaradas et al. 1995, Mujika & Padilla 2003, Banister et al. 1999). Step tapers are often considered not to be as effective but if it means you can settle down or inflamed tissue or pain before race day then you may be good to go on the day as a result of a week's rest beforehand.

There’s nothing like data to inform training (it should be science-based after all). However, even within science there is individual variability and some subjects form outliers falling outside the common responses. Having said that 95% of athletes will fall quite close to the research results (within two standard deviations in statistical terms). So use the science to make the right decision for you.

The more you have trialled different tapering approaches the more you will know how they affect you; the less you have the more you should start from a scientific start point. And when training volume has been reduced pre-taper you may need to think differently – very little, if any, tapering research has been done on rehabilitating athlete’s, but we’ve all seen a big race where an athlete has had less than ideal preparation but performed well on the day (the higher the mileage you’ve done in the past and the more you’ve maintained high levels of conditioning the more likely this is).

Enjoy running – train smart – successful athlete’s adapt to adversity.

Be realistic , confident & ambitious, but not over-ambitious. Race day will lift you but preparation is key.

There's increasing scientific debate about how best to manage a new soft tissue injury. Please also read my 2022 blog on this topic. Below is some explanation of some of the principles you may want to include in managing a new injury. 
 
Protection – Try to protect the injured body part. For example, wearing  a good sports brace, don’t overuse the injured limb, even use a crutch for a few days if you are limping badly. There is good scientific evidence that this is ideal early management for a new injury.
 
Optimal Loading  – Many people think you have to completely rest a new injury; this is not the case. As soon as you are able to it is a good idea to load the injury gently within tolerance (so not wincing in pain, moving very abnormally, guarding it, or limping!). Gradual loading of soft tissue injuries has been show to promote a faster healing rate than complete rest, just don’t load it too much too soon. Let the pain levels and the quality of your movement guide you.
 
Ice – There's some fresh debate about whether it's best to cool new injuries. Please read my 2022 blog to understand this more. If you do decide to cool a new injury, take a packet of frozen peas, wrap them in damp tea-towel, and apply to the injured body part. Use a pack of peas big enough to cover the painful, swollen part and a bit more. National Guidelines have stated that you can ice an injury for up to 30 minutes at a time but no longer; commonly 10-15 minutes is used. If applying ice-packs always have at least an hour’s gap between one ice pack ending and the next beginning.  Icing a soft tissue injury as soon as you can after injuring is proposed to reduce the amount of cells that die as a result of the trauma and therefore limits the total amunt of tissue damage. The ice pack reduces the bleeding and swelling and means that the injury may be less extensive than it otherwise would be. There is now some debate as to whether long term tissue strength may be not quite as good however. After 48-72 hours the rationale for using ice packs for longer than 8-10 minute applications decreases, unless you think you are causing new swelling by loading it too much too early.
 
Compression – There is low level evidence that applying a compression bandage to an injured body part reduces swelling and helps push swelling away from the injury site. If it is too tight you will get pins and needles or cold, numb peripheries (hands or feet) . Remove the compression if this happens! Compression garments can also be used but need to be good quality purchases to provide enough compression to make a difference.
 
Elevation – Rest the limb supported above the rest of your body (and above your heart preferably) for periods during the first 24-72hours. Again, there is low level scientific evidence that this helps to drain swelling away from the area and reduces bleeding in the early phases. This combined with compression can help your body clear swelling from a limb.
 
72 hours after injury is a good time to see a sports physiotherapist to identify what type of injury has occurred, for specific diagnosis, & to build a tailored program for the injury.

​Identfying the exact type of pain problem you have is key to optimal management.
 
Pete Jowsey MSc MMACP MCSP HCPC                                                                                                    www.pjphysio.co.uk

Sooner or later in any sport worth its title ‘sport’ athletes pick up some kind of soft tissue injury. What you do in the immediate hours and days following dictates how quickly you get back to training and your best. And that all starts with understanding the four phases of soft tissue healing.


                                                  

    The 4 Phases in Soft Tissue Injury Healing:

• the Bleeding phase – this typically lasts 0-2 hours; then as the internal bleeding reduces the body moves into,
•  the Inflammation phase – this typically lasts 24 to 48 hours for a milder injury but can be up a week plus for more extensive injuries. This is when the injured body part swells and that throbbing aching pain dominates.
• the Repair phase –  the body starts to lay down scar tissue to patch up the torn fibres (the damaged cells); this stage typically lasts a few days to a few weeks (depending how bad the initial injury was) as the body rebuilds the injured part. When the tensile strength is strong enough you as the athlete tend not to notice the injury anymore; however,
•  the Remodelling phase – goes on for many months as the new tissue becomes more and more well organised, performs better biomechanically and becomes better structured.

Pete Jowsey MSc MMACP MCSP HCPC                                                                                                   www.pjphysio.co.uk

There's been a lot misreported about Andy Murray's 'shoulder injury' & the magical effects of the physio. Based on what Andy said in the post-match interview & how the physio treated it here's a 'physio-eye view'.

Andy reported that the pain was near his scapula and his shoulder felt tight serving. He was not pictured gripping his shoulder joint  but over the back of the upper trapezius, into the right upper thoracic spine region. His physio manipulated his mid to upper thoracic spine joints, performed similar thrust techniques on the rib angles where they join the thoracic spine as well, and applied some brief trigger point pressure to his upper traps muscle (although this may just have been assessment) and his lats muscle under the armpit. We need every plane of movement available for the tennis serve action, and correct balance of muscle forces as we throw the racket head through the ball.

The manips increase the spinal joint glide (needed for the mechanics of serving); drop the tone in over-active muscles (especially in any guarded muscles running from the scapula to the thoracic spine). The 'few good cracks' Andy reported are 'cavitation'- nitrogen bubbles bursting within the spinal joints. The manips also stimulate the brain to release powerful non-opioid pain relieving chemicals into the bloodstream, using nor-adrenaline pathways - increasing muscle recruitment - part of our fight-or-flight system.  And a little trigger point pressure to be sure the upper traps & lats muscles have let go.

Not so mystical! Not quite 'healing' (as nothing was torn or damaged).

Nevertheless the effects were 'magic' - pain reduced or gone, moving well, great muscle control, focused & able to be on his game - the difference between losing 6 games in a row and winning 5 on the trot. Game-set-and match, Murray! 

Well reasoned & well applied physio makes the difference. That's what you pay your physio for! 

Now to prepare well for the last 16.

#it'snottheshoulderthistime      #knowyourmanips

Exercise stresses your body. You don’t have to be an Olympic medallist. You may just love taking part, do it for social participation, general health, fitness goals, or wellbeing benefits. Your body needs the right amount and types of stresses.

Here’s 6 simple steps you can take to protect your health when exercising:

1. Warm-up

 A 10 minute warm-up of gradually exposing our body to increased heart rate and increasing range and speed of joint movement prepares your body effectively. Warm-up makes a difference to how our tissues perform. You are less likely to injure tissue if you warm up in this way. 

2. Think of the intensity of your exercise

How many times do you perform your exercise? What speed? If using weights, how heavy? How many hills are there in your program? Downhills count too for runners! Change training variables gradually. 

3. Strengthen your thigh muscles

Do a few simple strengthening exercises for the quadriceps twice a week. For example, squats or lunges. This gives you stable, well supported knee joints.

4. Look after your back

Work on posture, flexibility, and having core muscle control. We live in a world of sitting – try to break it up regularly.  Simply standing up and sitting down again every 30minutes has a marked benefit in changing tension on tissues and improving circulation. Walk and stand more.

5. Schedule recovery time

Have 2 days a week where you don’t do strenuous exercise.  This allows your tissues to recover, adapt, and strengthen. Training is the stimulus. Recovery is where your body changes. 

6. Be structured & consistent

Approach sport and exercise in a structured and consistent way and you’ll really experience the benefits. Stress your body in a good way!

Call me to discuss anything in this article.