Over-treatment, and inappropriate treatment, of pain in athletes

Prof. Peter O’Sullivan recently discussed the over-treatment of athletes here. Recent cases such as the treatments for low back pain used by Tiger Woods have highlighted the emphasis on biomedical factors  in sports rehabilitation. The article is posted below.


Sporting people with non-traumatic musculoskeletal pain are perhaps one of the most ‘medicalised’ and ‘over-treated’ groups of patients. This is often driven by pressure from the athlete, the club, the coaching staff, the media and the health care professional, to get the athlete back to their sport as soon as possible.


Pain and imaging drives intervention 

There is a persistent belief that musculoskeletal pain in an athlete is caused by ‘tissue damage’ or ‘injury’. Easy access to imaging for musculoskeletal pain conditions commonly reinforces and validates this belief. So called ‘abnormalities’, such as disc degeneration, disc bulges, annular fissures, labral tears, rotator cuff tears and bursal thickening are highly prevalent in the pain-free population. On the basis of such imaging, invasive interventions such as injections and surgery are frequently prescribed. This practice is in spite of evidence that imaging, while very sensitive to detect changes in tissue morphology, is a poor predictor of pain and disability, and efficacy for these interventions is limited. Physical therapies such as massage, manipulation and needling are commonly prescribed to the treat the symptoms of pain in spite of only short term effects on pain and disability.


A need to look elsewhere

In contrast, contemporary evidence supports the view that non-trauma musculoskeletal pain in athletes is closely linked to other factors such as training volumes, sleep deficits, emotional distress, co-morbid pain and nonspecific health complaints (e.g. feeling run down and fatigued).This highlights the complex interplay between physical loading, mental health, tissue sensitivity, allostatic load and immune system factors. Pressure to train hard, play hard and get back to sport often escalates this process.


An alternative approach

So where does this leave the clinician dealing with an athlete with non-trauma musculoskeletal pain? Instead of referring them for MRI scan or ultrasound (which will invariably identify some abnormality), how about first enquiring about their stress load, training volumes, lifestyle habits, and screening for their mental health and general health, which may be far more revealing. Reassuring them about the body’s resilience, and that pain does not equal damage, helps build their confidence. The pain they are getting may mean that tissue is sensitised and they need to back off a little, preserve their sleep, learn to relax, normalise the way they  move, maintain healthy lifestyle habits and optimise their whole health. There is evidence that these interventions are effective in reducing pain and disability in
athletic populations. While this may be a hard story to sell to the athlete and the coach – it is evidence based. Changing athlete expectations requires cultural change amongst all involved. More is not always better – that is more treatment, more training, more massage, more imaging and more injections. Sometimes we need to back off to allow the body to restore its homeostasis and recover.

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