How to mentally handle an injury part deux
If you didn't read the blog before this one, suck it up and spend nine minutes reading it before reading this one. It's gonna go better for you. And buckle your seatbelt because this one is longer than that one. If I'm expected to fix your broken ass, then I have a lot to say. As always, NONE OF THIS is medical advice and I am not a doctor. If you need medical advice, go directly to a doctor. Do not pass go, do not collect $200.
In the last blog, I suggested finding a way to align your mental injury recovery with your physical injury recovery. You can get into all kinds of emotional trouble when they're mismatched, and I prefer to limit my emotional trouble to agonizing whether I have to wash my hair today or not.
Let's return to our physical rehabilitation list and turn it into mental rehabilitation. As a reminder, this is the standard physical therapy order of operations for injuries, but no one ever suggests you try it for your brain too. NOW YOU CAN. You need to therapize your brain in order to handle injury recovery. Here's how to do it:
1) Do everything to understand the source of the pain.
From my experience working as a trainer, this is one of the most valuable and most-ignored steps in the process. Figure out your injury's personality. (Yes, injuries have personalities. Some are assholes and some are fucking assholes. It's important to know what you're dealing with.)
I can't tell you how many people have said to me, "My knee hurts," and I say, "Cool, where?" and then they indicate a thirty inch rectangle between their rib cage and second toe. I get that they legitimately might not know, so that's fine. But then these same people come back to me with a confident internet diagnosis of their problem.
Them: I think I know what's wrong with my knee. It's a medio-lateral ligatendon full separation herniation.
Me: That sounds serious. What about arthritis?
Them: Other option is a brain tumor.
Diagnosing and understanding are two different things. Self-diagnosing is a disaster but self-understanding is crucial. Here are three ways to better understand your injury.
The How It Happened:
Did you twist your knee? Fall on it? Hyperextend it backwards? Didn't do anything but it suddenly woke you up in the middle of the night? Been running for ten years without a problem and suddenly there's a problem?
Understanding the start is a huge help to your providers. If there wasn't any kind of catastrophe, that's ok. If you had had some sense that it wasn't perfect, that's useful also. (Did it click a lot? Did it feel weaker than the other one? Was the range of motion changing? Were there any sudden shifts, like a knee buckling when you stepped down or a shoulder popping when you put a jacket on? Clicks and pops don't necessarily mean anything is wrong, but in certain joints they can give information.)
The How Has It Changed:
Many people can identify whether something hurts or not, but cannot identify if the pain has changed since they first noticed it. Is it getting better? Is it getting worse? Was it agony for three days and then nothing since then? Has it been the exact same pain for six weeks no matter what position you're in?
This is a big one: how often do you have it? Pain sucks so much it can seem like it's always there. But is it?
If you say, "My elbow always hurts," and I say, "Ok, so you feel it right now while you're talking to me?" and you say no...I don't mean to be a dick, but then your elbow doesn't always hurt. That's useful information. True nonstop pain is bad. If your elbow is badly aching while you're standing talking to me, that suggests something more serious that you might want to get checked out asap (like fractures, sprains, infections, inflammations like gout, bludger attack, etc).
The opposite is true too. If you say, "My elbow doesn't hurt anymore except for when I open the fridge door," your elbow does still hurt. This matters because of mental expectations. If you mentally decide that your elbow doesn't hurt anymore, but then it continues to hurt when you open the fridge door, you've set up a mental-physical mismatch. Every time your elbow hurts when you open the door, you're gonna get mad about it, because it's "supposed" to be healed. Your elbow is better, but you don't get to say it doesn't hurt anymore if it does.
Be clear about when and how your pain appears and disappears and you'll have a much easier time navigating it.
The How Does It Behave:
Does your knee hurt going up stairs but not down stairs?
Is your back fine when you touch your toes but crippling when you try to arch backwards?
Does your foot hurt when it lands on the ground or does it hurt when you push off the ground?
Each movement is mechanically different. Pain in your knee going up the stairs is often originating from a different part of your knee than pain going down the stairs.
Knowing how your pain behaves helps you figure out how to move safely while recovering. Injuries are rarely so crazy that you can't do any exercise at all. If you can't squat but you can deadlift, Bingo! Your leg day will still be both hellish and effective, like having nuns for teachers.
The more precisely you can identify what does and doesn't hurt, the more confident you'll feel in your modified workouts. Don't be dumb, but don't be afraid either.
And speaking of moving safely...
2) Back off from activities that exacerbate the current level of trauma. (And add others.)
If running hurts your foot, stop fucking running. This concept is lost on people. I'll say, "Dang, that foot is still a problem? Why are you about to go running?" And the person says, "I knowwwwww..." and then walks away. They knowwwwww, but they're still lacing up their sneakers five times a week.
Most people will keep running on a hurt foot until the foot hurts so much that it forces them to stop. Why do we do stuff that hurts? Firstly, because you hope it's just going to go away. Spoiler alert: it usually doesn't. Secondly, because the thought of stopping is painful in and of itself, and no one wants to ever add emotional strife to their life. We already have to make complex decisions about washing hair.
But being in pain is emotional strife too, so we might as well fix it. The alternative is a way, way longer healing process. The minute you commit to healing your body properly, understand that your mind must go with it.
If you stop running but spend every day thinking about how you should be running, you're creating chaos for yourself. It would be like a cat knowing she shouldn't jump into the dryer but then doing it anyway because it's the warmest spot in the house and she wants to be warm more than she wants to not die. Your fluffy ass is gonna end up cooked. When you decide to stop an activity that hurts, you need to mentally stop the activity at the same time. When your feet stop running, your brain needs to stop running too.
Being injured doesn't mean putting yourself into a mental body cast. You might have to experiment, but you can nearly always find some version of exercise that works while you're hurt. If you can't come up with something on your own, ask for help. A knowledgable friend, a gym employee, even googling "exercise you can do with a broken arm" returns more than 44,000,000 results.
Or, pick up another hobby. Many studies have shown that replacing one valued activity with another valued activity shows long-term benefits in terms of positive affect, self-esteem, and general psychological distress. I don't care if you start competitive dog grooming. Just find something to do. Spending three months in front of Netflix doesn't count, I don't care how good The Crown is. You'll be royally fucked when you start trying to move again.
3) Make liberal use of whatever accessory modalities make you feel better.
When it comes to healing joints, you might try ice, heat, ibuprofen, massage, and wraps to help you manage the immediate pain. This is how it works for mental therapy too. You'll need to find something to help you manage the immediate emotional pain. By all means cry, burn eucalyptus candles, mainline girl scout cookies and chicken nuggets, watch Center Stage a hundred (more) times, throw pity parties, or skip work to play with your dog. Accessory modalities are great for helping acclimate to your new injured surroundings. Who's the best goddamn dancer in the American Ballet Academy? YOU ARE.
Do remember that when it comes to physical healing, accessory tricks like ice and massage are temporary measures. You'll naturally do them less and less as you feel better. It's not like your ankle heals and anyone is like, "Hey, I think I'm gonna ice my ankle for fun tonight." Same goes with your mental therapy. Playing hooky and stress eating are temporary measures, so don't go face first into a box of donuts and then never be seen again. That won't solve your injury and it won't solve your mental pain. And for god's sake don't become someone who burns eucalyptus all the time. (I automatically distrust anyone who burns candles.) But when your leg hurts like hell and you're cuddling some Bombay Sapphire, I say make it a double highball.
4) Start movement as pain allows.
OK, this is when we get to neural clamshells and emotional squats. When you start physical therapy, you start from the very beginning. Pointing and flexing your foot or isometrically squeezing a ball. Same with your mental therapy. Start gently. The first few days of injured reserve (IR) are a good time to just chill. Put your phone down and let your mind wander. Sleep. Sleeping is worth ten million clamshells.
As you get into your IR groove, you can start finding all the movements which don't hurt. Here's the key: write programs for the type of training you usually ignore. Diligent core work, mobility training, flexibility improvement, meditation, strength training, agility work, etc. Whatever you're always saying, "I should do more..." is the thing that ought to be in the spotlight now.
Two reasons for this. One, doing the stuff you usually ignore probably means you'll get the most bang for your buck. If you never do mobility and then start doing a ton of mobility, you're going to see visible improvements fast. It's going to make you a better athlete, hands down.
Two, new stuff comes with a clean slate. The I Used Tos are an emotional coffin. You'll get buried in them. If your main exercise is cardio, you're way better off finding an IR workout program that has nothing to do with cardio. It cauterizes that demoralizing "I used to be good at this" feeling, because you won't have tons of previous experience to compare it to. Working on stuff you usually ignore means you can't unfavorably compare it to your normal capabilities.
NB: Your workouts must be pain-free.
When your feet stop running,
your brain must stop running too.
I can't emphasize this enough: Improving any aspect of athleticism will make you a better athlete. Try getting excited at the thought of learning something new, rather than depressed that you're not doing the same old stuff. You might think meditation is bullshit, but just wait until you're running again and find yourself on an endless slog of a hill in the driving rain with a 20mph side wind. How do you think people find a way to run through that kind of situation? That's right, they're meditating. The Little Engine That Could was a fucking meditative mastermind.
(By the way, The Little Engine that Could is a glorious piece of feminist literature. The dutiful girl train needs help bringing her toys to all the boys and girls on the other side of the mountain. Some men's rights activist trains, Preston and Bobby, who cross the mountain every fucking day, are all, "I'm important do you know who I am," and "If women want equality, they should do it themselves subreddit subreddit." Then a small girl train who has literally never once done the job that she is being asked to do is like "Sure, I'd love to help! I'll stop setting up Jimmy's Ph.D. thesis defense party and proofreading Chris's new resumé and having drinks with Matt because he's in emotional crisis, and we'll figure out a way to get up that hill, right as rain!" And then together the two women lift each other up and deliver toys to Preston and Bobby's children which the men take credit for and the entire world as everyone knows it continues to exist.)
5) Gradually add more advanced exercise back into your training plan.
Ah yes. Recovery! The part when you're almost healed again and everything is champing at the bit for the gates to open. There are just two important things here:
1) Be patient. Almost healed is not healed.
2) But don't be afraid to try.
Physical therapists tell you to gradually add exercises back in as tolerated, but what does tolerance mean? You should tolerate the pain or you shouldn't tolerate any pain? What if it feels fine at the time but hurts like hell tomorrow? What if it feels 100% great but your doctor doesn't want you doing anything for another month? This is mental therapy. Without it, recovery can turn into a wasteland of uncertainty.
Adding exercise as tolerated is bound to be trial and error. In general, bodies are clear. If they didn't like what you did, they're going to let you know. If they're ok with what you did, you'll feel just the way you did when you started, which is the goal.
I yelled at you three paragraphs ago to never move into pain. That's true, but you can (and sometimes have to) move into discomfort. Understanding the difference between discomfort and pain is a vital skill. Discomfort is like cooking with cilantro. It may feel tight, nervous, restricted, or slow, but you are able to get to a good place eventually. Pain is like cooking with truffle oil. Sharp, aggressive, overwhelming, and makes you want to vomit instantaneously. The only way to understand the difference is to experience it for yourself. As long as you have permission to try the move that you're trying, don't be afraid to give it a go.
If you try something and it sets you back, that's ok! It won't ruin everything. It's like online dating. Sometimes your body sends you a dick pic. Swipe left, but don't delete the app forever.
6) Return to sport.
Once people are healthy again, the hardest thing I have to teach them is how to trust their body again. This is mental therapy 600 level graduate seminar.
My father's ankle surgeon said to him, "If I reattach your Achilles and then you go sit on the couch all day because you're afraid to use it, I'm going to be really angry about it."
This pretty much sums it up. It's ok if your return to sport takes a long time. But it's not ok if your return to sport never happens because you're scared to return at all. In my experience, what makes people trust their body again is:
1) Good range of motion.
If your knee only bends 50% of the way, of course you don't want to go skiing on it. Your knee might explode. If you're feeling scared, make sure you've got command of your range of motion first.
2) No evidence of weakness.
Your shoulder is fine opening the fridge door but quakes every time you put dishes up in the highest cabinet? Yeah, I don't blame you for not wanting to go back to softball. Build strength in the overhead range before reaching out to snag a long fly ball. Joints can be extremely strong in one range of motion and extremely weak in another. It doesn't mean your shoulder is useless. It just means it needs overhead strength.
3) The ability to move fast.
Speed is the defining characteristic of athletes. There are tons of people who can shoot a basketball. There are not tons of people who can do it at a full sprint. Or from the floor.
The faster your joint can move, the more you'll trust it. Speed is the last gate to be unlocked in injury recovery, so feel confident that if your ankle can do some sprinting, it's in good shape overall. But do it in this order: Mobilize, Strengthenize, Speedenize. You sprint on a weak ankle and guess what you're never gonna be Steph Curry.
Hooray! You're better!
Well, eventually. There's a lot of pain territory that a blog can't get into, or that I'm not qualified to get into. (Who am I kidding I know everything.) Pain can be long-lasting and insidious. Keeping your mental game focused and patient can be excruciating. But I can say this: It. Will. Get. Better. I can't say how long it will take, but it will get better. The nervous system, which is wholly responsible for your pain, is just as plastic with injuries as it is with memory, learning, and all other functions that can always be changed. The nervous system can learn to escalate injuries and it can learn to de-escalate injuries, and BOTH OF THESE CAN HAPPEN WHETHER THE INJURY CHANGES OR NOT. As I have frequently discussed in these blogs, pain is a poorly-understood process. But we know very well at this point that mechanical tissue damage is only a small part of being in pain.
That's why mental therapy has to accompany your physical therapy. Simply expecting your ankle to hurt can make it hurt more. Expecting it to hurt less can make it hurt less. Imagining your worst day of your life can make it hurt more. Going Tinkerbell style with happy thoughts can make it hurt less. A bad day at work can make it hurt more. Playing with a puppy can make it hurt less. On and on and on. As with all things in life, your mental state matters.
The nervous system can learn to escalate injuries and it can learn to de-escalate injuries.
But no matter what else is going on, your best shot at defeating chronic pain is to be optimistic, proactive, and mentally resistant. In a laboratory version of Les Miserables, researchers looked at rats who were exposed to an aggressive intruder into their lair. After several intrusions, the invaded rats were split into two categories. Those who submissively rolled over, and those who assumed an upright posture of resistance. The submissive rats of the bourgoisie were shown to have high levels of pro-inflammatory molecules in their brains and bodies. This made them, like humans, more prone to depression.
But what about you, the rat who assumed a resistant upright posture? The rat refusing to roll over for the establishment?! The rats fighting on the barricades were found to have significantly lowered levels of inflammatory markers, and less prone to depression. Fighting back made the rats feel better and fare better. Fighting back will make you feel better and fare better! You will not submit to the painarchy! No one can avenge Eponine for you! YOU MUST DO IT YOURSELF!
WHEN THE BEATING OF YOUR HEART ECHOES THE BEATING OF THE DRUMS, THERE IS A LIFE ABOUT TO START WHEN TOMORROW COMES! (Oh, hello Eddie Redmayne.)
Now, stop feeling sorry for yourself, get your brain together, and go become a better athlete. See you out on the court.