Pain is the most com­mon rea­son peo­ple seek health­care. Acute or new pain aris­es from in­jury or dis­ease and will usu­al­ly re­solve once the in­jury has healed or the dis­ease is cured. Oc­ca­sion­al­ly, pain con­tin­ues even af­ter the in­jury has healed and this is known as chron­ic or per­sis­tent pain. It is a very dis­abling con­di­tion which is not well un­der­stood.

There are many types of per­sis­tent pain. How­ev­er, the most com­mon is low back pain and this af­fects at least one tenth of the world’s pop­u­la­tion. The caus­es of chron­ic pain are not al­ways clear and of­ten in­volve a com­bi­na­tion of phys­i­cal, psy­cho­log­i­cal, and so­cial fac­tors.

Phys­i­cal caus­es of pain usu­al­ly be­gin with acute or overuse in­jury. Com­mon acute sport­ing in­juries in­clude ham­string strains, an­kle sprains, an­te­ri­or cru­ci­ate lig­a­ment tears and groin in­juries.

Dif­fer­ent sports will have a high­er oc­cur­rence of these in­juries. Groin in­juries are com­mon in Amer­i­can foot­ball and hock­ey, while ham­string strains are com­mon in sprint­ing. Overuse in­juries in­clude con­di­tions like stress frac­tures, ten­nis el­bow and carpal tun­nel syn­drome. These are caused by long-term repet­i­tive move­ment of the body part, high train­ing load, par­tic­i­pat­ing in en­durance events, in­creased train­ing vol­ume in com­pe­ti­tion sea­son, and high­er num­ber of years of par­tic­i­pa­tion. In some in­stances, per­sis­tent pain may de­vel­op af­ter cor­rec­tive surgery, as in the case of nerve pain in the groin fol­low­ing her­nia re­pair.

Al­though the un­der­ly­ing mech­a­nisms of in­jury are dif­fer­ent, acute and overuse in­juries may be­come chron­ic painful con­di­tions that are dif­fi­cult to treat and can in­ter­rupt or end an ath­lete’s ca­reer.

Peo­ple who ex­pe­ri­ence per­sis­tent pain are of­ten frus­trat­ed be­cause they may spend months or years try­ing treat­ments which do not re­move the pain. Med­ical ex­am­i­na­tions and in­ves­ti­ga­tions may not show a clear cause for the pain. For ex­am­ple, some­one with chron­ic low back pain can have nor­mal re­sults on spinal X-rays, CT scans or even MRI. When phys­i­cal caus­es of chron­ic pain are iden­ti­fied, they of­ten in­clude un­der­ly­ing fac­tors such as os­teoarthri­tis (joint de­gen­er­a­tion), lig­a­ment in­sta­bil­i­ty (com­mon in an­kles and knees), ki­net­ic chain ab­nor­mal­i­ties, mus­cle im­bal­ance (groin pain and ham­string in­juries), chron­ic in­flam­ma­tion (ten­donitis), chron­ic nerve ir­ri­ta­tion (neu­ro­path­ic or nerve pain com­mon in wheel­chair ath­letes and am­putees), sleep dis­rup­tion, in­ad­e­quate nu­tri­tion, and calo­rie in­take.

Oth­er pos­si­ble risk fac­tors which may pre­dis­pose an ath­lete to de­vel­op­ing per­sis­tent pain in­clude the spe­cif­ic team po­si­tion in which they play (which may in­volve awk­ward pos­tures and repet­i­tive move­ments and high forces), high body mass in­dex, fam­i­ly his­to­ry, age­ing, com­pe­ti­tion and ex­pe­ri­ence lev­el, and mus­cle weak­ness.

Ap­pro­pri­ate and ear­ly mul­ti­dis­ci­pli­nary treat­ment and re­ha­bil­i­ta­tion are es­sen­tial in re­duc­ing the risk of de­vel­op­ing per­sis­tent pain. A com­pre­hen­sive care plan might in­clude anal­ge­sia, in­jec­tions, ex­er­cise re­ha­bil­i­ta­tion, elec­tri­cal and ther­mal modal­i­ties, ki­ne­sio tap­ing, or­thotics, mod­i­fi­ca­tion of train­ing rou­tine, and cor­rec­tion of faulty move­ments.

When pain does not re­spond to phys­i­cal or phar­ma­co­log­i­cal ther­a­py, pa­tients may wor­ry that there is a sin­is­ter cause for their on­go­ing pain. In the ab­sence of se­ri­ous un­der­ly­ing caus­es such as can­cer, and with cer­tain­ty that tis­sue heal­ing has oc­curred, psy­choso­cial fac­tors should not be over­looked. Psy­cho­log­i­cal fac­tors in ath­letes in­clude the ex­pe­ri­ence of pain it­self, dis­tress, low and neg­a­tive mood, and stress. Anx­i­ety and fear are known to in­crease per­cep­tion and in­ten­si­ty of pain, while pos­i­tive mood and emo­tion­al states can re­duce the ex­pe­ri­ence of pain. Oth­er psy­cho­log­i­cal and be­hav­iour­al pre­sen­ta­tions which in­crease the risk of in­jury are ag­gres­sive­ness, be­ing too cau­tious dur­ing play, and hid­ing the pres­ence or sever­i­ty of an in­jury.

So­cial fac­tors in­clude pres­sure to re­turn to play even while still in­jured, lifestyle, and sleep dis­rup­tion. Re­turn­ing to play too ear­ly could be due to so­cial pres­sure to per­form, fi­nan­cial in­cen­tives, or even a self-per­cep­tion of in­vul­ner­a­bil­i­ty. The ad­di­tion­al con­cern with re­turn­ing to play too soon is that the ath­lete is now at high­er risk of sec­ondary in­juries, there­by in­creas­ing the risk of de­vel­op­ing per­sis­tent pain.

Ath­letes may al­so have pro­tec­tive psy­choso­cial fac­tors, such as ac­cess to bet­ter health care, health­i­er lifestyles (no smok­ing, al­co­hol, or sub­stance abuse), sup­port­ive team mem­bers, and bet­ter men­tal re­silience to cope with pain. Ad­e­quate men­tal health sup­port in the ear­ly stages of in­jury will help to pre­vent the pro­gres­sion of pain from acute to chron­ic. Ther­a­pies such as cog­ni­tive be­hav­iour­al ther­a­py, mind­ful­ness, stress man­age­ment strate­gies and pain ed­u­ca­tion are ben­e­fi­cial in the pre­ven­tion and man­age­ment of per­sis­tent pain.

Per­sis­tent pain is not al­ways pre­ventable, and in many cas­es is not cur­able. Pa­tients and ath­letes may spend years seek­ing a cure to re­lieve their suf­fer­ing on­ly to be­come frus­trat­ed and even an­gry. In the acute and sub­a­cute stages of an in­jury, all caus­es of pain should be iden­ti­fied and treat­ed to re­duce the like­li­hood of chron­ic pain. De­lay­ing prop­er treat­ment of acute in­juries in­creas­es the risk of chron­ic pain, so do not pro­cras­ti­nate in seek­ing med­ical ad­vice when an in­jury oc­curs dur­ing sport.

Ce­cile Hosang is a phys­i­cal ther­a­pist and as­sis­tant lec­tur­er in the Fac­ul­ty of Sport. She is al­so a pain spe­cial­ist.