Updated: Mar 29, 2021
Injury is not a word most of us have ever questioned. There is a lot written and studied about pain - what it is, where it comes from, what causes it - but injury is... well, injury.
So before we go any further... how do you define injury? Is it something that is painful, in which case... is a headache an injury? Or is it something that is damaged, in which case, how do we classify the high percentage of asymptomatic cases of meniscus tears, disc bulges, and osteoarthritis?
In the same way that pain can occur with or without injury, injury can occur with or without pain. This might seem counter-intuitive; we are often told that pain is a signal that the body is in danger, and although it's relatively easy to wrap our heads around the fact that these alarm systems can go awry (much like the burglar alarm that randomly goes off due to faulty wiring, or the airport metal detector that is set at too high a sensitivity and beeps at bra underwires), it's much less easy to explain how we can get injured and not have any pain. I'm not going to attempt to explain this - one easy explanation in some cases is the lack of pain receptors in certain tissues, which would explain why I felt absolutely no pain when my anterior cruciate ligament tore all the way through - but I use the point to illustrate why pain and injury are two distinct things.
I wouldn't be saying anything new or revolutionary in pointing out that calling an injured knee a "bad knee", or throwing alarming-sounding medical jargon around, are hardly conducive to comfort and optimism in recovery. But I have observed and thought about a few things in my time as a movement coach and massage therapist (and as a human with a body that has occasionally been injured and in pain) that are a little more about attitude than taboo words.
Many years ago, one of my clients stated that they wouldn't deal with physiotherapists anymore, because every time they saw one about a chronic pain condition, they were asked, "What did you do?". My client would reply they hadn't done anything to aggravate their issue, to which the physio would insist, "Well, you must have done something to flare it up". I have no doubt the physiotherapist didn't mean to sound accusatory - and said out loud, there are ways to make that statement sound less aggressive - but it's easy to see how someone already exhausted from chronic pain, frustrated at the unpredictable recurrence, already having built their life around managing the pain and preventing flare-ups, would feel particularly aggrieved at this attitude.
In fact, in took me years before I came up with a suitable response to my aunt's half-joke that I should quit whatever activity had caused me pain or an injury. Now, I point out that even people who sit all day and don't do any sport get back pain, so I'm not actually worse off for having gotten injured running/lifting/cycling/doing various martial arts. There's this prevailing view that an injury is an abberancy, someting that happened because we made bad decisions, or were the victims of someone else's bad decisions, and that by being more careful we can avoid such misfortunes in future.
The unpopular truth is that our bodies are constantly undergoing some degree of breakdown and remodelling. Outside of one-off events like falls or collisions, problems arise when the rebuilding of tissues doesn't keep up with the breaking down process. Sometimes, perhaps often, this is the cause of an inadequate work-rest balance; training too much or too hard, recovering too little. While this can sometimes be preventable, it's not always easy or even possible to spot the signs, let alone do much about it - what happens if you suffer from insomnia, or work a high-pressure job that just demands that you put in some extra hours, but you are also an elite-level athlete who needs to put the training hours and intensity in?
This blog post isn't a self-help article, and even if it were, there's no magic formula for avoiding injury. But then, what do we even consider to be "injury"?
The definition of "injury" is "hurt, damage, or loss sustained" according to Merriam-Webster; "damage done to a person's or an animal's body" according to Collins; "Harm or hurt. To harm, hurt, or wound" on Medicinenet.com; and many similar iterations. While clearly not incorrect (after all, who am I to contest the dictionary), this seems incomplete and unhelpful from the point of view of sports injuries.
We've already established that pain and injury are not the same thing, and if we know that damage is almost always happening within the body in some way, at what point does the damage count as an injury? When it causes pain or loss of function? Perhaps - but what about age-related muscle breakdown (sarcopenia) which is associated with loss of function, and frailness? A person who has lost muscle mass due to inactivity may suffer a lot of the same symptoms as a person who has partially torn a muscle. Is someone who lives with chronic neck tension from using a computer all day, resulting in radiating pain down the arms or up into the head and face, less injured than someone who has a degenerative disc in the cervical spine, but little to no pain?
One personal example that really moved this discussion of what "injured" means to the forefront of my mind: I caught myself referring to myself as injured, following my knee surgery; "I can't do X, I've injured my knee". While that was undeniably true during the seven weeks between the rupture of my ACL and the reconstruction of it, surely I couldn't call myself injured after the surgery... though, arguably, I felt less able, and experienced pain for the first time... and the harvesting of hamstring muscle fibres to graft into a new ligament left me with what can technically be described as a hamstring injury (and in fact, to this day, 17 months post-op, that is still the area that doesn't quite behave as it used to). I switched my wording to "I am recovering from an injury", in the hope of warding off the creation of an "injury identity" - when someone identifies so strongly with an injury state that they shackle their own recovery by being too cautious to rehabilitate the injured area. A classic example is lower back pain or injury: whether or not the injury or pain occured due to a lack of strength in the lower back or supporting muscles, at some point that injured lower back will need strengthening; but many people are nervous about deadlifts or other exercises that specifically target their backs, or, often, about any sensation in the lower back (like the feeling of those muscles actually working!).
At the other end of the spectrum, I do see a lot of reluctance to acknowledge injury. Many people will experience recurring pain in a joint, sometimes to the point that they can't perform an exercise or movement at all, but when I try to dig deeper into the symptoms and causes - asking if they can describe the pain, point to where they feel it, tell me how and when it comes on - they tend to wave these questions away, or laugh awkwardly at me taking things too seriously. I do not mean to disparage any of my clients who have done this: we are products of the society around us, and clearly something is giving us signals that certain pains and injuries are not valid. Furthermore, this is compounded by a trend in therapy to not give a client or patient a name for their diagnosis, if it can be avoided, or to only use lay terms. While I agree with the need to demystify pain and injury, there is a risk of minimising injury, in a way that can be detrimental to a client's mindset in recovery.
In fact, I have experienced this myself. I have suffered many aches, pains, niggles, and restrictions that I have struggled to get myself to properly address: the maybe-broken maybe-stress fractured toe that doctors looked at and went "That's not right" but then shrugged off when the X-rays came back clear (stress fractures don't show up on X-rays, and nor does soft tissue damage); the neck that went "crunch" and caused me pain and stiffness for months, but that an X-ray showed to have no vertebra displacement or disc issue; the wrist that clearly suffered tissue damage when it got aggressively bent backwards in jiu jitsu, swelling up rather alarmingly over the next few hours and preventing me from using that thumb (I had just embarked on a 24-hour Grapplethon, so yes, I kept going). Part of my reluctance to seek treatment was the dismissive attitude of many healthcare professionals, part of it was my own naivety. I didn't understand that although damaged tissues heal, they don't go back to how they were before; a filled pothole in the road might allow your car to drive over it again, but you might still hear or feel the change in texture of the road surface - you certainly will if you cycle over it - and over time that tarmac won't respond to changes in weather the same way as the original road surface. I am not sure people believe me when I say this, but my ACL rupture and reconstruction was genuinely the easiest injury I've had to deal with (it helps that it never hurt!): there was a clear cause and effect, nothing was going to just heal on its own, and there was a pretty set timeline for milestones to hit along the recovery journey (there is also an estimated date for return to full-contact sport - about 12 months from surgery - but that's a very grey area: I was cleared about 6 months post-op, but 11 months later I still have some work to do; we all have different starting points and different end points in mind).
I believe there are several factors at play that may explain our dismissive attitude towards injury.
At the deepest level, our (modern, Western) society glorifies hardship and sacrifice - a leftover of puritanical times, perhaps, or simply a byproduct of capitalism - but not for its own sake: there is supposed to be a payoff (hence my link with capitalism: you work hard, you get paid, you are happy because you have money to buy nice things with). So it's not that we just want to suffer for the sake of it: we want to suffer just enough that we get some sympathy or some other reward. If we choose to, we can then brush off that proffered sympathy to demonstrate just how tough we really are, and bank sympathy credit for further down the line when we really need it.
At the same time, this glorification of hardship relies on our belief that we are not worthy of pleasure, love, or anything else that makes us feel good. If exercise is easy, it's not doing enough (also said as: "no pain, no gain"). If we enjoy our training session, we weren't trying hard enough. I'm not pointing fingers here: I catch myself doing this all the time. Just today I wondered if the bike session I did had been worth doing, because it was enjoyable; last week I berated myself for only choosing the yoga classes I knew wouldn't take me too far out of my comfort zone; any time I don't feel exhausted by Friday, I wonder if I should have tried to drum up some new business to fill a few more hours during the week. Every week I will have a new excuse for why I don't feel wholly satisfied at my efforts, a new example of something that was "too easy".
And because things aren't supposed to be enjoyable, a legitimate reward is not having to do those things: we deprive ourselves of food until we reach a goal weight, then go back to our pre-deprivation habits; we concoct some strict and aggressive training programme for ourselves, reminding ourselves of how good we will feel when it's done; we work ourselves into the ground all week so we can properly enjoy the weekend.
What does all this have to do with injury and the language we use to talk about it? Here's how I see it: say we force ourselves to go to the gym 5 days a week to do some hard exercise we don't enjoy; we start to experience some pain or discomfort during this exercise regime; we acknowledge it, maybe tell someone else, but deem it not serious enough (because we are not worthy of feeling our best, because exercise is "supposed" to hurt, because pushing through the pain shows just how dedicated we are); we push through and eventually end up forced to stop, often because someone else has told us to - now, we get the reward of stopping exercise, whilst also having proven to ourselves that we really did give it our best shot, we weren't weak, we didn't want to give up. We reap all the rewards: we have shown that we are tough, we get sympathy, and we get to stop the exercise we never wanted to do in the first place. So we can't openly admit that we are injured - that would make it too real. That would mean we'd have to do something about it, something that would perhaps have no purpose other than making ourselves feel better. I say "we", but maybe it's just me...
If you don't believe me, consider a conversation I had with a member of my family recently. They were telling me about how they've been managing their lower back pain, and I said something about pilates. They responded, "Well, that's all well and good, but I won't be doing pilates when I'm 80". They had no response to my genuine question, "Why not?".
I believe that sort of relationship with and between suffering, hard work, pleasure, self-worth, and reward is what has given the concept of injury this foreboding importance. It has become a big, serious thing; a moment of reckoning; a decision to make. It's not just a fact of life, a spectrum in which we almost constantly operate. If we all knew how to manage symptoms of injury, if we were better versed in the language of our bodies (pain, stiffness, tension, crackling, creaking, clunking, numbness, weakness... the list is infinite), if we believed we had a right to do what feels good for us, we would seamlessly adapt and adjust in order to keep going as efficiently and comfortably as possible.
If I allowed myself to write such a long post and go off on so many tangents, it wasn't to end it with a quick fix or a practical solution. If my rambling post made anything clear, it's that these beliefs and attitudes are complex, and deeply ingrained in all of us. Moreover, they get reinforced at every level (I have heard of a consultant suggesting to a patient that the patient's pain wasn't worth dealing with, as the consultant was younger than the patient, yet experienced the same pain; the inference being that the patient should be grateful to "only" have that level of pain at their age). The world, and its attitudes towards bodies, isn't going to change overnight or within one generation, but it won't change at all if we don't start doing something about it. Only when we acknowledge and accept a problem can we start to build a path towards a solution; so we can only recover from an injury if we acknowledge it in the first place. How can we do this if we don't learn to speak our bodies' languages, and practice tuning in?