“Pain manifests itself in strange ways” (Ammon McNeely).
Writing about the same subject, Stu Littlefair recommended “if you want to avoid mistakes, talk to a man who's made them all”. I’m your man. In 1984 I climbed reasonably well, for the time, trained enthusiastically but non-specifically, typical of the time, and developed elbow pains, like others at the time. Of course I ignored them. I had no money and thought I had to continue working as a cleaner. Stopping climbing was inconceivable. The pains got worse and eventually I stopped working and even climbing. As climbing was my entire world, this left me fed-up and a bit lost.
I had investigations which showed nothing and treatments, conventional (eccentric exercises, ultrasound, arm braces, neck mobilisations) and alternative (acupuncture, osteopathy), which did nothing. This left me even more fed-up. The pains started in my right elbow but, after six months of not climbing, moved to my left as well. This was bizarre and worrying. Everyone told me to rest but this didn’t seem to help. Things got so bad I drank halves as a full pint was too painful to lift. I moved back in with my parents and away from the climbing world, I didn't want to be around climbers, so lost contact with most of my friends.
Eventually, after eighteen months of not climbing, I started doing other things. I took a part-time voluntary job, studied for an A level - dictating the exam as holding a pen was painful - and went to college. I found a new group of friends and got into the early rave scene. Some waving arms in the air may have occurred. The pains slowly eased and, cautiously, I started climbing again. Since I didn’t know any climbers where I now lived, I soloed easy routes. The pains improved quickly and were almost gone within three months of restarting climbing.
This behaviour was understandable with my knowledge at the time but represented a succession of mistakes in how to manage an injury, followed by an inadvertently well-designed rehabilitation programme. It was also a clear illustration of how pain is only distantly related to pathology and how psychological and social factors are strong influences on and are influenced by pain. This is acknowledged in the world of pain rehabilitation but less so in sports injuries. Reading articles or discussions about climbing injuries, the implicit or explicit assumption is that pain is a representation of tissue damage or pathology. It isn’t. This disconnect, and it’s implications, is what this essay is about.
Most people understand pain as a signal sent from the damaged bit, via nerves, to the brain. Pain represents damage and more pain means more damage. This is wrong. Pain can be severe with little or no tissue damage, as in muscle cramp. Conversely there can be marked damage with very little pain, like my friend who ran a marathon with a fractured metatarsal, unknown to her until the following day. This video of Ammon McNeely after his BASE jumping accident is fascinating if you are interested in pain or gruesome if you are normal. His leg is shattered but his main emotion seems to be disappointment and he doesn’t behave like someone in agony. He described the pain as “only 8 out of 10”. How could it not be 10 out of 10, his bloody leg is half hanging off? Numerous studies on tendon and other soft-tissue injuries show a poor relationship between pain and pathology. Many people have pathology without pain or, like Ammon, less pain than you might expect. Others have pain without apparent pathology or, like me, much more pain than would be expected from minor pathology. Why is this?
People with tendinopathy have altered pain thresholds: mechanical stimuli become painful at less force. is painful. There are many examples of this in other musculoskeletal pains. Treating one tendon in people with bilateral tendinopathy can result in pain reduction in both tendons. Functional MRI scans, of brain blood-flow, show changes in brain activity in people with many kinds of pain. Normal MRI scans show brain structure changes in people with persistent pain. All this suggests the central nervous system works differently in people experiencing pain: through experiencing pain their pain perception changes. The nervous system does not simply transmit pain signals from the periphery to the higher centres of the brain. Pain is modulated and can even be generated by the central nervous system and, in turn, pain influences the central nervous system. This can be a positive feedback loop as I found to my cost.
Rather than a simple indicator of tissue damage, pain is best understood as one of a number of responses to a perceived threat. Tissue damage is usually a clear threat but is not the only factor that defines the magnitude of that threat. The meaning of the pain is important. Fear about pain makes people more likely to develop a painful problem. Deliberately increasing people’s anxiety about a painful problem increases their pain. Describing a painful problem in terms of serious pathology increases pain and decreases willingness to move. The greater the threat, the greater the pain. Minor tissue damage that is a major threat - it stopped me climbing, the most important thing in my life - can be very painful.
Pain with recent injury is an evolved response, clearly beneficial in the short term, it stops us doing further damage to ourselves. Other threat responses include changes in how muscles work and how we move. Having tense muscles means being better able to run away from the sabre-tooth tiger that has just taken a lump out of you. We limp or change how we move in more subtle ways. Many of the psychological and social effects of pain are also advantageous. It is sensible to be somewhat fearful of pain and avoid seemingly damaging activities. Social withdrawal is an extension of this. Usually these responses resolve as pain does, unfortunately they don’t always and most of these responses become unhelpful if they are persistent. Constantly tense muscles can themselves become painful, continued limping makes other joints and muscles sore. Social withdrawal can lead to long term depressive illness, which in turn makes everything more painful. Then there is the influence of pain on how the central nervous system itself processes pain.
The central nervous system is very plastic, highly adaptable. It's how we get better at things with practice, how we wire a boulder problem. A central nervous system that has a lot of practice at feeling pain adapts to get better at feeling pain. The adaptations can be in hardwear - neurones making new branches and connections - or in softwear, different areas of the brain becoming active in pain processing. The aim of this rewiring and functional reorganisation is to make the central nervous system more efficient at pain processing. Pain thresholds become lower, sometimes to the point where non-damaging mechanical stress - gently stretching or prodding the area - can be felt as pain. This applies both to the painful part, but also to other areas. This is probably why my left elbow started hurting as well as my right, despite not doing anything damaging to it. Lingering tenderness after an injury is often put down to scar tissue, it’s at least as likely to be a neurophysiological effect.
What does all this mean for how we deal with painful problems?
It is useful to differentiate between recently started pain and persistent pain that has been around for a few months when soft-tissue healing will normally have completed. These pains behave differently and should be managed differently although often they are not. Many athletes under-rest at the early stages of an injury, then are over-cautious with persistent pain, particularly if they have experienced set-backs like treatment failure. I did both to a spectacular degree.
Take recent onset pain seriously, modify your activity, the pain is trying to tell you something. Since pain itself can influence pain processing in the longer term, it makes sense to manage new pains effectively. Taking simple painkillers, or even NSAIDs, might not be so bad after all. Ice may not be having a profound anti-inflammatory effect but it’s a great analgesic with few side-effects. Stop altered pain processing starting to occur. Address local pathology and associated biomechanical defects (If they exist, there are many false positives). How to do this are extensively covered elsewhere and I'm not going to discuss them here. Briefly, some mechanical load is probably a good thing but both complete rest and too much activity are likely to result in longer recovery times. This is usually attributed to improved healing of soft-tissues under appropriate load and there probably is some truth in this. Be particularly careful when you are climbing: adrenaline, endorphins, movement, happiness and social context is a powerful analgesic cocktail and it is easy to overdo things. I still sometimes make this mistake.
There is an additional possible benefit of movement on pain that is less discussed. Here I am speculating a little but my guess is that, just as threat produces alterations in movement and pain, movement is capable of producing alterations - reductions - in threat and thus pain. Moving something without bad things happening is a good way to reduce a threat associated with movement. Do lots of pain-free movement, especially of the painful area. Yoga might help. Surfing might help. Swimming might help. Weightlifting might help. Waving my arms in the air to music might have helped me. Perhaps this is how training antagonists helps?
General exercise is helpful too. Go running, dancing, anything that is fun and makes your heart beat faster. Aerobic exercise boosts endorphins and endocannaboids (analgesic substances, similar to Morphine and Cannabis, present in the blood stream but reduced in people with persistent pain). It can also help low mood, indirectly raising pain threshold. This might help a bit in recently developed pain, it’s more important in persistent pain and it’s another thing I did, inadvertently, to help break out of my elbow pain vicious circle.
Remember that persistent pain no longer represents damage. If you have a long-standing problem, some pain when you move is probably normal. Try to recognise your old friend aches and pains grumbling away and learn to distinguish between them and upstart new tweaks you need to pay more attention to. This is easier said than done, I mistake new for old and old for new to this day.
Acknowledge if you are unhelpfully anxious or very low, particularly about your injury, this is likely to amplify your pain. Try to normalise your mood, doing whatever it takes to help this. Feeling fed-up and pissed-off for a while at losing 6 months of training is a completely normal reaction. Withdrawing from friends and most social activities is not helpful and was a major reason why my problem persisted as long as it did. Others, for the best motives, supported me in this withdrawal. It’s sometimes hard to see this when you’re in it. Getting out and getting a life again was one of the most important things I did to get on the road to recovery.
The crucial moment of my recovery was getting back into easy trad. climbing. This could have gone wrong if I had done too much too soon but, luckily, I paced myself. I didn’t start too eagerly, but neither did I stop, as I had in the past, immediately things started to hurt a bit. Easy trad. involves lots of pain-free movement. It makes me happy and less anxious. I spent the first two years of my climbing career happily bumbling up v.diffs and severes, it is when I became who I am now, so easy trad. has extremely powerful positive associations for me. It works on climbing injuries every time for me. It might be completely wrong for you, but you should now know what you need to do instead.
[This was mostly written a year ago but erick's post reminded me of it and I thought an expanded version of my reply to him might be of interest to some]
Writing about the same subject, Stu Littlefair recommended “if you want to avoid mistakes, talk to a man who's made them all”. I’m your man. In 1984 I climbed reasonably well, for the time, trained enthusiastically but non-specifically, typical of the time, and developed elbow pains, like others at the time. Of course I ignored them. I had no money and thought I had to continue working as a cleaner. Stopping climbing was inconceivable. The pains got worse and eventually I stopped working and even climbing. As climbing was my entire world, this left me fed-up and a bit lost.
I had investigations which showed nothing and treatments, conventional (eccentric exercises, ultrasound, arm braces, neck mobilisations) and alternative (acupuncture, osteopathy), which did nothing. This left me even more fed-up. The pains started in my right elbow but, after six months of not climbing, moved to my left as well. This was bizarre and worrying. Everyone told me to rest but this didn’t seem to help. Things got so bad I drank halves as a full pint was too painful to lift. I moved back in with my parents and away from the climbing world, I didn't want to be around climbers, so lost contact with most of my friends.
Eventually, after eighteen months of not climbing, I started doing other things. I took a part-time voluntary job, studied for an A level - dictating the exam as holding a pen was painful - and went to college. I found a new group of friends and got into the early rave scene. Some waving arms in the air may have occurred. The pains slowly eased and, cautiously, I started climbing again. Since I didn’t know any climbers where I now lived, I soloed easy routes. The pains improved quickly and were almost gone within three months of restarting climbing.
This behaviour was understandable with my knowledge at the time but represented a succession of mistakes in how to manage an injury, followed by an inadvertently well-designed rehabilitation programme. It was also a clear illustration of how pain is only distantly related to pathology and how psychological and social factors are strong influences on and are influenced by pain. This is acknowledged in the world of pain rehabilitation but less so in sports injuries. Reading articles or discussions about climbing injuries, the implicit or explicit assumption is that pain is a representation of tissue damage or pathology. It isn’t. This disconnect, and it’s implications, is what this essay is about.
Most people understand pain as a signal sent from the damaged bit, via nerves, to the brain. Pain represents damage and more pain means more damage. This is wrong. Pain can be severe with little or no tissue damage, as in muscle cramp. Conversely there can be marked damage with very little pain, like my friend who ran a marathon with a fractured metatarsal, unknown to her until the following day. This video of Ammon McNeely after his BASE jumping accident is fascinating if you are interested in pain or gruesome if you are normal. His leg is shattered but his main emotion seems to be disappointment and he doesn’t behave like someone in agony. He described the pain as “only 8 out of 10”. How could it not be 10 out of 10, his bloody leg is half hanging off? Numerous studies on tendon and other soft-tissue injuries show a poor relationship between pain and pathology. Many people have pathology without pain or, like Ammon, less pain than you might expect. Others have pain without apparent pathology or, like me, much more pain than would be expected from minor pathology. Why is this?
People with tendinopathy have altered pain thresholds: mechanical stimuli become painful at less force. is painful. There are many examples of this in other musculoskeletal pains. Treating one tendon in people with bilateral tendinopathy can result in pain reduction in both tendons. Functional MRI scans, of brain blood-flow, show changes in brain activity in people with many kinds of pain. Normal MRI scans show brain structure changes in people with persistent pain. All this suggests the central nervous system works differently in people experiencing pain: through experiencing pain their pain perception changes. The nervous system does not simply transmit pain signals from the periphery to the higher centres of the brain. Pain is modulated and can even be generated by the central nervous system and, in turn, pain influences the central nervous system. This can be a positive feedback loop as I found to my cost.
Rather than a simple indicator of tissue damage, pain is best understood as one of a number of responses to a perceived threat. Tissue damage is usually a clear threat but is not the only factor that defines the magnitude of that threat. The meaning of the pain is important. Fear about pain makes people more likely to develop a painful problem. Deliberately increasing people’s anxiety about a painful problem increases their pain. Describing a painful problem in terms of serious pathology increases pain and decreases willingness to move. The greater the threat, the greater the pain. Minor tissue damage that is a major threat - it stopped me climbing, the most important thing in my life - can be very painful.
Pain with recent injury is an evolved response, clearly beneficial in the short term, it stops us doing further damage to ourselves. Other threat responses include changes in how muscles work and how we move. Having tense muscles means being better able to run away from the sabre-tooth tiger that has just taken a lump out of you. We limp or change how we move in more subtle ways. Many of the psychological and social effects of pain are also advantageous. It is sensible to be somewhat fearful of pain and avoid seemingly damaging activities. Social withdrawal is an extension of this. Usually these responses resolve as pain does, unfortunately they don’t always and most of these responses become unhelpful if they are persistent. Constantly tense muscles can themselves become painful, continued limping makes other joints and muscles sore. Social withdrawal can lead to long term depressive illness, which in turn makes everything more painful. Then there is the influence of pain on how the central nervous system itself processes pain.
The central nervous system is very plastic, highly adaptable. It's how we get better at things with practice, how we wire a boulder problem. A central nervous system that has a lot of practice at feeling pain adapts to get better at feeling pain. The adaptations can be in hardwear - neurones making new branches and connections - or in softwear, different areas of the brain becoming active in pain processing. The aim of this rewiring and functional reorganisation is to make the central nervous system more efficient at pain processing. Pain thresholds become lower, sometimes to the point where non-damaging mechanical stress - gently stretching or prodding the area - can be felt as pain. This applies both to the painful part, but also to other areas. This is probably why my left elbow started hurting as well as my right, despite not doing anything damaging to it. Lingering tenderness after an injury is often put down to scar tissue, it’s at least as likely to be a neurophysiological effect.
What does all this mean for how we deal with painful problems?
It is useful to differentiate between recently started pain and persistent pain that has been around for a few months when soft-tissue healing will normally have completed. These pains behave differently and should be managed differently although often they are not. Many athletes under-rest at the early stages of an injury, then are over-cautious with persistent pain, particularly if they have experienced set-backs like treatment failure. I did both to a spectacular degree.
Take recent onset pain seriously, modify your activity, the pain is trying to tell you something. Since pain itself can influence pain processing in the longer term, it makes sense to manage new pains effectively. Taking simple painkillers, or even NSAIDs, might not be so bad after all. Ice may not be having a profound anti-inflammatory effect but it’s a great analgesic with few side-effects. Stop altered pain processing starting to occur. Address local pathology and associated biomechanical defects (If they exist, there are many false positives). How to do this are extensively covered elsewhere and I'm not going to discuss them here. Briefly, some mechanical load is probably a good thing but both complete rest and too much activity are likely to result in longer recovery times. This is usually attributed to improved healing of soft-tissues under appropriate load and there probably is some truth in this. Be particularly careful when you are climbing: adrenaline, endorphins, movement, happiness and social context is a powerful analgesic cocktail and it is easy to overdo things. I still sometimes make this mistake.
There is an additional possible benefit of movement on pain that is less discussed. Here I am speculating a little but my guess is that, just as threat produces alterations in movement and pain, movement is capable of producing alterations - reductions - in threat and thus pain. Moving something without bad things happening is a good way to reduce a threat associated with movement. Do lots of pain-free movement, especially of the painful area. Yoga might help. Surfing might help. Swimming might help. Weightlifting might help. Waving my arms in the air to music might have helped me. Perhaps this is how training antagonists helps?
General exercise is helpful too. Go running, dancing, anything that is fun and makes your heart beat faster. Aerobic exercise boosts endorphins and endocannaboids (analgesic substances, similar to Morphine and Cannabis, present in the blood stream but reduced in people with persistent pain). It can also help low mood, indirectly raising pain threshold. This might help a bit in recently developed pain, it’s more important in persistent pain and it’s another thing I did, inadvertently, to help break out of my elbow pain vicious circle.
Remember that persistent pain no longer represents damage. If you have a long-standing problem, some pain when you move is probably normal. Try to recognise your old friend aches and pains grumbling away and learn to distinguish between them and upstart new tweaks you need to pay more attention to. This is easier said than done, I mistake new for old and old for new to this day.
Acknowledge if you are unhelpfully anxious or very low, particularly about your injury, this is likely to amplify your pain. Try to normalise your mood, doing whatever it takes to help this. Feeling fed-up and pissed-off for a while at losing 6 months of training is a completely normal reaction. Withdrawing from friends and most social activities is not helpful and was a major reason why my problem persisted as long as it did. Others, for the best motives, supported me in this withdrawal. It’s sometimes hard to see this when you’re in it. Getting out and getting a life again was one of the most important things I did to get on the road to recovery.
The crucial moment of my recovery was getting back into easy trad. climbing. This could have gone wrong if I had done too much too soon but, luckily, I paced myself. I didn’t start too eagerly, but neither did I stop, as I had in the past, immediately things started to hurt a bit. Easy trad. involves lots of pain-free movement. It makes me happy and less anxious. I spent the first two years of my climbing career happily bumbling up v.diffs and severes, it is when I became who I am now, so easy trad. has extremely powerful positive associations for me. It works on climbing injuries every time for me. It might be completely wrong for you, but you should now know what you need to do instead.
[This was mostly written a year ago but erick's post reminded me of it and I thought an expanded version of my reply to him might be of interest to some]
