Pain, Injury, and Rehabilitation

Originally published in Los Angeles Sports & Fitness, January/February 2014.

Injuries happen. If you play sports long enough, you will hurt something at some point. It is part of the game. I coach basketball, so ankle sprains are the most common injury. What happens when we sprain an ankle? When we land on someone’s foot, we feel pain. However, according to Dr. Adrian Luow, pain is a construct of the brain. When we land on someone’s foot and sprain our ankle, the proprioceptors and nerves in our ankle signal danger, not pain. As Dr. Luow said during his presentation at the Boston Sports Medicine and Performance Group (BSMPG) conference in May 2013, pain is a decision by the brain, and it is determined by how you think. The pain that we feel in the ankle is really a perception of threat. 

Several years ago, I coached high-school girls basketball. Several of the players had never played basketball or any competitive sport previously. During the first week, one of these novice players turned her ankle. I happened to be watching her at the time. It did not appear to be anything out of the ordinary; just a minor misstep. However, as a novice athlete who had never experienced something like this, her brain registered the threat, and she felt scared. She fell to the ground. She refused to stand up. She crawled toward the sideline, almost in tears, and a teammate ran to get ice. After icing for the rest of the practice, her teammates had to help her to her car. She missed two weeks of practice.

Toward the end of the season, a different girl who had been playing basketball for years, came down wrong during a game. She completely turned her ankle. She was going for a rebound, so I was watching her as it happened. It appeared to be a far worse injury. It looked painful. She fell to the ground, and the officials stopped the game. She hobbled to the sideline, but refused attention from the athletic trainer. After a minute or two, she walked off behind the basket. She walked on it for a couple minutes and returned to the bench. She informed me that she could return to the game, and she did.

The differences in outcomes were stark. In our macho sports world, we would attribute the differences to toughness, especially with females. The first girl was soft or lacked toughness. In a sense, she did, but not in the way that we tend to think about it. More than toughness, she lacked experience. The second player had twisted her ankles previously. She knew that she would be okay. She had experienced the sensation previously. When she felt the sensation from her ankle signaling the threat, she fell in a heap and hobbled to the sideline. However, after the initial shock, she chose not to feel pain. She walked on the ankle and realized that the danger had subsided. She made this choice because she had experienced these sensations, whereas the first girl had never felt the sensation of turning an ankle. When her proprioceptors signaled danger, she had no experience to know that she the danger would subside. She panicked. She felt pain. As Dr. Luow added, thinking about pain creates more pain. Because of the novelty of the injury, she was unable not to think about the pain, which only heightened the pain. The second player was concerned more with returning to the game, so she did not think about the pain, and the pain went away.

Because pain is a construct of the brain, the absence of pain has nothing to do with the health of the joint. In both instances, there was trauma to the ankle. In both instances, when the initial threat subsided, the feelings of pain diminished. Once the feelings of pain subsided, the athlete put pressure on her foot and started to walk. When she walked on the foot, and there was no pain – the danger had been removed – she felt like she was 100%, and she resumed normal activities. The only difference between the two was the time frame – one took two weeks, whereas the other took minutes.

Regardless, neither ankle was 100% when she returned to walking and playing. Because pain occurs in the brain, it is not connected to the health of the ankle. Also, as expert physical therapist Bill Knowles said at the BSMPG conference, injury causes a disruption in the central nervous system (CNS). As Knowles added, even when the biology of an injury has healed, an athlete may not be prepared to resume activities because of the CNS.

Between the trauma of the injury and the immobilization during the recovery — whether explicit (brace, boot) or implicit (limping) — an athlete returns to training with an ankle that is less than 100%. Stability has been reduced due to the trauma, and range of motion has decreased due to the immobilization. Returning to training may or may not improve the stability and range of motion — a lot depends on the training. To be certain of a 100% return, an athlete should engage in some ankle rehabilitation exercises.

Beyond the rehabilitation to improve stability and range of motion, and return the ankle to its pre-injury health, an athlete must redevelop the correct motor pattern. In basketball, I work with players with previous injuries who believe they are fine even though I can identify an old injury without knowing any history of the athlete. Due to an injury, and often a lack of rehab post-injury, the normal motor pattern is altered. As an athlete practices and plays with the altered motor pattern, like my player who returned to the game immediately, she reinforces that altered pattern, just like a player practicing any skill over and over to perfect it. After a period of time, the altered pattern becomes the normal pattern to the athlete. She has adapted to an altered motor pattern due to the lack of stability or reduced range of motion. Even if the athlete returns to rehab to increase stability or range of motion, the new motor pattern is likely to persist. Once she returns the ankle to its pre-injury health, she has to re-learn the skill. In basketball, this primarily is focused on shooting, though landing from a jump, stopping on balance, and other skills can be modified by injury and must be re-learned. One factor related to the high incidence of noncontact ACL injuries in girls basketball players is previous ankle injury. It could be that athletes adopt new motor patterns for landing from a jump due to the ankle injury, and this new pattern is suboptimal for protecting the knees. Therefore, relearning the optimal motor pattern – or the pre-injury motor pattern – may prevent a further more severe injury in the future.

Motor patterns develop through repetition. An injury can change a motor pattern, and with enough repetitions, the new motor pattern can become the habitual motor pattern, even when the pain of the injury has subsided and the biology of the injury has healed. The missing piece from injury rehabilitation often is recovering the optimal motor patterns, especially sport-specific patterns. The rehabilitation from an injury is not complete until the athlete returns to the same or an improved skill performance.

By Brian McCormick, PhD
Coach/Clinician, Brian McCormick Basketball
Author, Cross Over: The New Model of Youth Basketball Development
Director of Coaching, Playmakers Basketball Development League

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