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“Deromanticising” the Image of Pain in Athletes

Derman, Wayne, MBChB, BSc (Med)(Hons), PhD

Clinical Journal of Sport Medicine: September 2018 - Volume 28 - Issue 5 - p 415–416
doi: 10.1097/JSM.0000000000000655

Division of Orthopaedic Surgery, Surgical Sciences, Institute of Sport and Exercise Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa; and

IOC Research Centre, Pretoria, South Africa.

Corresponding Author: Wayne Derman, MBChB, BSc (Med)(Hons), PhD, Stellenbosch University, Cape Town, South Africa.

The author reports no conflicts of interest.

Pain is officially defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such.1 As health care practitioners involved in Sport and Exercise Medicine, we are taught that pain is an expected part of sport. Indeed, we are led to believe that it is not possible to achieve success at the highest level of sport, unless we have experienced pain in significant quantities. We hear from our athletes, utterances such as “Pain is nothing compared to what it feels like to quit, this is your moment, celebrate the pain,” and “pain is just weakness leaving your body.” Thus, the elite athlete has an almost romantic notion of pain being an inevitable career long partner. As clinicians, there is the paradox that although the athletes we care for are expected to go through pain, we are asked often to relieve that burden, we are asked to get the player through that pain and back to sport as soon as humanly possible, and we are often asked to achieve the impossible. Yes, few of us are ever trained in pain management in our training as doctors, physiotherapists, or strength and conditioning professionals. Too often, we rely on pharmacological interventions as sole interventions to relieve the pain when nonpharmacological measures could suffice, and other times, our management is insufficient leaving our athlete with a greater chance of longer-lasting pain. We, therefore, need a balanced approach to affective, holistic, and timeous pain management in our athletes. We need exposure to the realm of specialist pain management strategies for use and adaptation in our work as health care practitioners in our athletic patients.

It is for this reason that the International Olympic Committee commissioned a consensus meeting in Lausanne in 2016 that led to a Consensus statement and number of important publications regarding pain, which were published in November of 2017.2,3 In preparation for this consensus meeting, the invited experts were asked to review various topics in the field of pain management as they relate to use in the athletic population. This special edition of the Clinical Journal of Sport Medicine is a culmination of the preparatory reviews on these specific topics for appraisal by the panel for, and inclusion into the consensus statement. Included in this collection of articles for this special edition on pain are also a number of interesting original research articles.

In the first article of the edition, Harle et al provide a systematic review of analgesic management of pain in various sporting events on the global stage. The authors document the wide prevalence of use of these agents and based on the widespread use of nonsteroidal anti-inflammatory drugs (NSAIDs) and urge clinicians and policymakers to carefully assess their current recommendations for NSAID use and express the need for adherence to a more unified consensus-based strategy for multidisciplinary pain management in elite athletes. Novel findings regarding the use of analgesics in community-based endurance events are described by Rotunno et al who detail the patterns of analgesic use in relation to other medical factors in more than 76 000 race entrants. The authors show that more than 12% of recreational runners use analgesic agents before and/or during races. Factors associated with analgesic medication use were history of injuries, exercise-associated muscle cramps, and numerous chronic diseases. Sebak et al follow with a retrospective case series of long-term follow-up of professional rugby league athletes who had received local anesthetic injections before or during a match to aid return to play. It is of interest that given the choice over again, most athletes would choose to have the injection all over again.

Mataava et al then present a narrative review on the use of nonsteroidal injections in the management of pain, while Herring et al review the use of corticosteroids in the management of pain in athletes. The group of articles on pharmacological agents is completed by Grobblaar et al, who review both pharmacological and nonpharmacological interventions in the management of pain in persons with physical or sensory impairment.

It is clear from this group of articles that pharmacological management of pain is only a single modality of intervention, and a more holistic approach by team medical staff and other health care practitioners working with athletes is required. The other elements in the biopsychosocial model of pain are often overlooked, and we need to be reminded by our athletes that their pain is complex. As Wilt Chamberlain so aptly describes “All of the sudden, my right leg caved in. I crumpled to the floor in pain. The doctors weren’t sure I'd ever be able to play again…and even if I did recover physically, the psychological scars of so traumatic an injury might never heal” A rational for holistic and comprehensive management is described by Moseley et al who present a clinical model for managing chronic persistent pain in the athlete.

No collection of articles on pain management would be complete without a review on the potential role and limitations to the use of medical cannabis in the athlete population. In the present review, Ware et al tackle the issue of the influence of Cannabis on the health and performance of athletes. Finally, this special issue is completed by Zideman et al who have identified potential gaps in the existing research and documented the areas that the Consensus identified as key to further research. It is clear that pain management particularly in the athlete population is an important and evolving sphere of interest and will in the future attract many young researchers to study this complex area. I trust that you will enjoy reading the present collection of articles in this special edition of the Clinical Journal of Sport Medicine.

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1. IASP. IASP terminology. 2017. Available at: Accessed June 19, 1018.
2. Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51:1245–1258.
3. Hainline B, Turner JA, Caneiro JP, et al. Pain in elite athletes—neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Med. 2017;51:1259–1264.
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