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The Psychology of the Injured Runner

Let me begin this piece by shedding some light on my own injury. After all, it was the inspiration for this two-part blog (the commitment to which I’ve been regretting since I published part one...) so I owe it at least a little credit, right?

It all started at Heaven & Hell in September last year. An 88km mountain run consisting of four laps, each lap of 22km providing a staggering 1900m of ascent and descent. As if that elevation change wasn’t enough of a challenge, the majority of it took place off-trail. The full story of this run deserves a blog post of its own, but in short, my right knee let me know about 56km in that it was severely unimpressed with my choice of goal race for the season. I stubbornly informed it that we hadn’t come this far just to come this far, and therefore we would be finishing. Surprisingly, I was able to continue training post-race and complete the 40km Otter African Trail Run six weeks later without knee pain. This I mistakenly took as a sign of full recovery and November saw me lining up for 100km of Skyrun. Finally, just 20km from the finish of Skyrun, my right knee locked up completely and I had no choice but to hike to the finish. I didn’t know it then but that long night marked the beginning of a six month forced recovery period and my time as The Injured Runner.

If you read Part 1 you’ll recall my discussing the physical process of dealing with an injury, from the first nagging of a niggle right through to the MRI results and surgical correction quotations. Although I mentioned that injury diagnosis is not an exact science, at least the process, from physiotherapy right through to orthopaedics, is based on physical examinations, specialists’ opinions and pen-on-paper type of stuff. But what of the mental aspects of managing an injury? Does anybody even realise what “no running” means to a runner? Or the danger that a non-running runner poses to society? I suspect not.

Running is typically a multi-purpose activity for athletes. The most common reasons include as a source of exercise, weight management, competition, social interaction and stress relief. So although running injuries are physical in origin, athletes’ experiences of and responses to injury are largely psychological. It therefore follows that the physical management of an injury and success of rehabilitation requires what has been termed a “biopsychosocial” approach. This model systematically takes into account biological, psychological and social factors, as well as their complex interactions, in understanding health and illness. At the core of the oft depicted biopsychosocial Venn diagram is “well being.” So what psychological and social factors affect the well-being of the injured runner?

Psychologists have identified three key challenges in dealing with sports injuries. These include negative mindset, poor compliance with rehabilitation, and pain and fear of re-injury. Understanding the feedback loops between these factors is fairly straight forward. Most athletes inevitably suffer some degree of depression when they cannot run. This negative mindset is not optimal for recovery, as psychological stress is known to delay wound healing, and a running injury is no different. Additionally, without a positive mindset it is very difficult for any athlete to execute a full rehabilitation program correctly. Enter poor compliance with prescribed rest, strengthening or stretching, which in turn slows the recovery process and feeds negativity. Pain and fear of re-injury also causes a constant state of tension and anxiety, especially as return to training becomes imminent, adding to the negative mindset throughout the rehabilitation process. And so you have it – a rapid downward spiral of well-being.

The fear of pain and re-injury is an interesting concept which had not occurred to me before writing this article. The natural human instinct is generally to avoid pain, although runners tend to have a strong culture of “just pushing on” and embracing discomfort. This is especially true in the early stages of injury, but even the most stoic athlete is likely to feel anxious about a possible flare-up after months of battling with injury. The fear-avoidance model explains how some individuals experience more extreme worries about pain or risk of re-injury than others, and how this perception can negatively affect performance. It is in essence a self-protection mechanism that is often directly proportional to the severity of the injury, and regardless of whether it is founded in truth or perception, it can significantly hinder a return to former fitness and performance levels.

So how do you go about managing these challenges and restructuring your life around the absence of that endorphin-releasing daily activity in order to expedite your return to running? Well, firstly you’re going to need to adopt a multi-faceted approach and interrupt the negative feedback cycle in as many ways as possible. Secondly, bear in mind that you’re not aiming to cure your injury, merely manage it. And thirdly, remember that each of us is unique and it can take months of patient experimentation to rediscover your own state of mental balance without running. Because the whole psychosocial process is so interconnected, I’m going to discuss a combination of personal as well as scientifically recommended interventions to improve the injured runner’s well-being, in no particular order.

One of my personal coping strategies is to include some form of structured movement in my schedule. This serves the dual purpose of a mental boost for the day, and a muscular warm up for my rehabilitation exercises. Swimming is my go-to running replacement. Many people find lengths of the local pool so tedious that they can’t bring themselves to swim, but persevere and you may just discover an ultra-like calmness of mind in that underwater world. See it as a period of active recovery for body and mind where nothing and no one can bother you, unless you choose to surface. The other activity I enjoy is cycling, but it often engages similar muscles to running and is therefore more likely to induce pain than swimming. Your preferred movement can be anything from surfing, paddling, climbing or yoga to simply walking, just as long as it is pain-free. As well as the mental benefits, any activity will also help you maintain basic physical conditioning and core strength. And this is one of the reasons that I’m a big believer in cross-training for any athlete I coach. When you’re the injured runner you have a back-up activity.

Education is a key element of rehabilitation compliance. Studies have shown that levels of adherence tend to wane over the course of long recoveries, but equipping yourself with sufficient knowledge and understanding will help you see it through. Be proactive in seeking information from medical professionals and additional resources. The more advice and support you have, the less anxiety and tension you’ll experience. Be process-oriented and focus on reaching regular, intermittent markers of progress in order to eventually achieve the desired outcome. Remember that exclusive focus on the end-goal can distract from the necessary steps to get there.

Goal setting is often recommended as a simple method for remaining process-orientated during injury recovery. Studies have shown that facility-based treatment is significantly more successful than home-based treatment, likely due to a coach, personal trainer or physiotherapist having specifically formulated outcomes for each session. If you are managing your injury at home, identify a number of realistic goals that you wish to achieve on your path to full recovery and ensure that each one complies with the SMART acronym. They should be specific, measurable, action-oriented, realistic and time-based. Keep written records of your progress each day to track changes, because no matter how small, achieving your goals will aid you in sustaining motivation and optimism.

The social setback of injury is significant for many athletes, especially road runners who often train with a club. Instead of allowing yourself to fall into social isolation though, make a point of joining your normal pre- or post-run activities. It may be as simple as a warm-up jog or a midweek coffee, or seconding for a friend at an important race. By staying active in your community you can share your story and progress with others, benefit from the emotional support of friends, and ward off negativity for longer.

Let me drop in a quick analogy here. Managing an injury and it’s recovery is really just like running an ultra. You start by following a plan and doing your training, because you just know it needs to be done. Then before the race, you educate. You gain as much information as possible about the course, the terrain and the aid stations. If possible you enlist the help of a crew along the route, and the more experienced they are the better. But you also enlist the support of your family and friends along the way, because you need all the back-up you can get, and you also don't always want to talk about running. You then break the full distance down into manageable sectors which you memorise and as you reach each target during the race you congratulate yourself. You speak kindly to yourself, visualise only success, but always remain focused on the journey – the process. You realise that thinking about the end prematurely can lead to distraction, disappointment or even a DNF. So you execute your premeditated race strategy to the best of your ability, forgive any minor mishaps, and continue with a positive mindset. And eventually, after many lows and highs and lower lows and higher highs, you do reach that elusive finish line.

They say every cloud has a silver lining. The silver lining of my injury has been providing my body with a full off-season and the rest it needed after a few consecutive seasons of hard training and racing. While undergoing rehabilitation, seek ways to improve as an athlete other than through fitness gains. Most of us are guilty of neglecting certain facets of running which have the potential to maximise our performance. See a prolonged period of recovery as an opportunity to capitalize on increased time and energy availability and to develop as a runner. Consider options such as strengthening your core, examining running techniques more closely, improving your diet, or learning mental performance strategies.

This brings me to the real mental game of injury management – the power of the mind... “Embrace the power of the mind!” I do not dispute the power of the mind by any means, I’m just not a fan of the associated terminology. Imagery, visualisation, meditation... I prefer awareness and mindfulness. But at the end of the day it’s irrelevant, as long as you find one that works for you. Imagery uses imagination and typically removes you from your current mental space. In contrast, meditation centres awareness on one’s present state of self. But both are forms of relaxation which can be utilised to aid in stress management, calm the mind and create a more positive outlook. Like any training, however, mastering the mind takes time so practice daily and build up your efforts slowly.

All the above psychosocial interventions may seem somewhat overwhelming, especially if you are dealing with your first significant injury as an athlete. For me, a few points in particular stand out so I created my own acronym to guide me through the process of rehabilitation and recovery. It’s UNDO, and rather fitting I'd say.

U – Understand

Educate yourself in order to better understand your injury and the recovery process.

N – Nurture

Look after your injury by complying with the rehabilitation plan.

D - Do something else

Swimming, cycling, yoga, meditation, gardening. Make a point of replacing your allotted running time with another enjoyable activity. Don't become obsessed with the injury.

O – Objectives

Set realistic goals – biological, psychological or social – and acknowledge your achievements as you attain them throughout the process.

I want to conclude with a single word which encapsulates the success of return to running after injury. Resilience. Resilience means being flexible and adapting to change. It means maintaining focus, motivation and perspective during difficult times. It means resisting pessimistic thoughts and emotions. Resilience is optimism, hope and belief. We are all resilient in different ways, but it is the characteristics of resilience that give each and every one of us the psychological strength to overcome the challenges of being The Injured Runner.

There are still questions and topics on injury I wish to cover. Injury prevention. Return to training. How much fitness do you lose during recovery? And where I am in my process of returning to running. Dare I commit to a Part 3?

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