Dealing with injuries as an athlete

At university, I undertook a short course on sports psychology, hoping to garner some insight into what makes pro athletes tick, and how the rest of us can improve our own psychology to improve our sport. The topic that stuck with me most, however, was talking about the effects of injuries on athletes, and not just professional ones. Since sports have strong mental as well as physical benefits, the stress and anxiety caused by injury can sometimes be almost incapacitating. Figuring out how to keep fears and potentially serious mental health problems at bay is both vital and complex.

While I’m no expert, I have an unfortunate amount of personal experience dealing with recurring injuries, namely IT band syndrome, caused by doing ‘too much, too soon’ in most athletes, but initiated and exacerbated almost solely by road running for me. My first physio told me to ‘stop running’, in favour of all other sports, which did nothing to help the actual problem, since I was always going to run, I just needed to know how. And so commenced 6 years or recurring injury.

After a huge flare-up during training for and running Tokyo marathon in early 2019, I worked with my second physio, Zoe, from Physio Motion (London based) to figure out the cause of my particular injury (weak glutes, poor running form to compensate) and work on those issues. Since then, I’ve been able to run two ultramarathons and 50+km weeks on trail (big for me – previously 5km would hurt) with no pain until recently, on a very tiring 10km road run around Bristol.

So, in my current mindset, I thought it might be helpful to share my top tips for dealing with injuries, both mentally and physically.

Get a diagnosis

For many people reading this, your injuries will be recurring, so you’ll have a good idea of what the pain is, and what it means. However, for many others, you’ll have a ‘lateral knee pain’ or ‘calf niggle’ and won’t know what’s gone wrong. Getting a diagnosis is vital to taking the right steps to recovery. Taking time off until it doesn’t hurt and then going straight back to what you were doing before doesn’t treat the root cause of the problem, so you might have the same issue again. Get a diagnosis and a plan to recover.

Know what’s gone wrong

This might be personal to me, but when things go wrong, I need to know why. Understanding the details of why something went wrong, what happened in the lead up and what I can do next time to avoid the same thing happening helps me feel in control of the issue. It also helps prevent it happening again. If I think about it, the recent cause of my flare up was: 2 weeks off followed by 3 very stiff road runs in quick succession, followed by a lack of stretching on top of 9 months without a regular or sufficient physiotherapy strengthening routine. Know your triggers and work to fix them.

Accept reality

If you are injured, the chances are that you felt a niggle before it turned into a full-blown injury. If you had taken a step back at ‘niggle’, it may never have turned to ‘injury’. So now you’re injured, it’s time to accept that reality. It may not be the reality forever, but for now, pushing through the pain doesn’t make you hardcore, it makes you stupid (speaking from experience). It also means your injury will likely take longer to heal and you’ll spend more time away from what you love. Accepting your current state means that it’ll likely last for less time.

Treat recovery like training

If you’re anything like me, you get pretty exciting when a new training plan comes your way, but groan at the idea of a physiotherapy/rehab plan. However, technically, a rehab plan is the same as any other training plan – it’s taking small steps to improve from the position you’re currently in, to the position you want to be in. Switching your mindset from ‘rehab is a chore’ to ‘rehab is training’ can help keep motivated. The more you stick to your rehab plan, the sooner you’ll be back to the training you love.

Enjoy the time off

When you know you can’t run/do the sport you love, it seems like all you want to do is that thing, but in reality how many times did you think ‘I wish I didn’t have to go on this run’ when you still could? Time off is a chance to take stock, recover both physically and mentally, and improve other skills too, be it in the gym or at work. You’ll be amazed how much free time you have all of a sudden! Again, this is about mindset – you can choose to resent the free time, or you can choose to do something productive with it (rest is also productive).

Speak to others

While being pragmatic is always best when it comes to injuries, sometimes speaking to someone else who can share your frustrations can make you feel less alone. Sharing tips and irritations can be helpful, and having a downright bitch about your injury every now and again can feel good. It’s unfair that I’m injured. I read my body well, I rest well, I eat well, I don’t do huge mileage, and yet here I am once again. It’s immensely frustrating. Once you’re done, pick yourself back up and get on with your rehab plan.

Go back slowly

At the end of your 6 weeks or 6 months, you’ll likely be trepidatious but excited to get back to running/whatever sport you love. However, these are the tentative first steps after months of recovery and work. Don’t go out all guns blazing, however fresh you feel. Work with your physio to plan your return to training. A 2km run is as valid as your previous 20km runs. Don’t let ego or excitement get in the way of a slow and sensible return to training – your body will thank you in the long run (so to speak)! And if anything, you should be finishing your sessions feeling like you want to do more.

This piece has been helpful to write for myself at least, so I hope it also helps a lot of you! Save it, share it, bookmark it on your laptop. 65% – 80% of runners get injured each year, so it’s likely that you’ll need this advice at some point, whether that’s now or in the future. Good luck with your recovery!

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Losing your period – amenorrhea and training

This piece is part 2 to last week’s blog post on how periods affect training. If you haven’t already, give it a read!

When it goes wrong

A topic I have spent some time (though probably not enough) discussing on my Instagram page, as well as on here, is overtraining and RED-s, or Relative Energy Deficiency in Sport. The condition has spent more time in the limelight recently, with high profile cases coming to the fore, and more people on social media opening up about their experiences too. However, unfortunately the topic is still shrouded in mystery and shame, meaning that every year more people are affected. Even worse, it’s often assumed that losing your period is a normal, even healthy side effect of training, and isn’t anything to be concerned about. This is a myth that needs to change

Exercise is a stressor to the body. For the most-part, it is a good stressor, leading to adaptive changes to make us faster, stronger, fitter. There comes a point, however, where the demands of a particular sport go beyond the recovery that is given, and beyond what the body can handle. There are many ways that this can happen, and the outcome is a cascade of physiological responses with serious, even life-changing, consequences. RED-s refers to a state where there is insufficient energy intake for the amount of training being undertaken, leading to reduced bone density, low energy availability and, among other things, hypothalamic amenorrhoea, or stopped periods. In the general population, around 2% – 5% of women are affected. Within athletes, the prevalence is much higher, at 3.4% to 44%. 

Somewhat problematically for diagnosis and recovery, there are many stories of athletes having their best seasons right before their body starts to shut down. This is because the effects of RED-s take time to come into play, and can be caused by the most innocuous-seeming deficiency in calories over a long period of time. However, this is an important issue as it is increasingly common even among for-fun athletes, even those of a ‘healthy’ BMI, and RED-s is quietly sidelining more and more people.

Periods are important. They show that your hormones are functioning as they should – it is impossible to function optimally as a human and athlete without the hormones your body needs.

RED-s, a condition that encompasses a number of symptoms, including menstrual irregularity

Why do people lose their periods?

Secondary amenorrhea is when you have experienced regular periods before, but then stop menstruating for 3 months or longer after that point. Functional hypothalamic amenorrhea (FHA) is a type of secondary amenorrhea, caused by low energy intake, weight loss, stress or a combination of these factors. Note: you do NOT have to be underweight and be training loads and have a really low calorie intake for this to happen. All of these make it more likely, but FHA can happen to anyone. It is also important to rule out other causes of amenorrhea, in case it is caused by some other factor. 

Losing your period as a side-effect of training should never be seen as acceptable. The idea that it’s a sign that you’re working hard is both harmful and wrong – you can train much better if you have a healthy cycle. 

Evolutionarily speaking, FHA in times of stress may have been adaptive. If you can’t support your own body and health, there’s no way you could support another life (i.e. a baby), so it doesn’t make sense to ovulate, as this is energy consuming. The downregulation of the body’s natural functions protects the brain and vital organs. However, there’s no questioning that it is a red flag that something is up, and in this day and age we are lucky to have the knowledge to protect ourselves against such outcomes. 

What happens when you lose your period?

FHA results from changes in the hormone GnRH, which in turn reduces luteinising hormone (LH) and eventually oestrogen availability. This has a number of negative consequences affecting the whole body, including bone density, cardiovascular health and mental health. The longer it continues, the greater the effects. Conditions such as osteoporosis, previously associated with post-menopausal women, also become more likely, due to the reduction in oestrogen’s protective effects on bone density. This in turn increases risk of injury such as fractures. Research suggests that athletes with menstrual irregularities are also likely to experience more injuries and recover slower from those injuries.

There can also be short and long-term consequences for reproductive health. Of course, if you are not ovulating, you cannot get pregnant (though this should never be used as a form of birth control!!), but there may be long-term impacts on fertility in response to chronic amenorrhea. However, when treated properly, the prognosis for future fertility is good

How can I get my period back?

This is a question I get asked a lot, and I am reluctant to give prescriptive answers, as I am not a medical professional. Generally speaking, reducing stress on the body and increasing energy availability are good places to start. Often the causes of FHA are not entirely physical, and seeking professional mental health help can assist too. 

These are some of the factors most important to optimising physical health:

  • Ensure you are allowing for adequate rest between training sessions. 
  • Reduce the number of very intense sessions per week, and space them out.
  • Make sure you are eating enough carbohydrates, fats and proteins. 
  • Avoid fasted training sessions. 
  • Get enough sleep – it is vital to recovery! 
  • Eat within 30 minutes of a training session. 
  • Reduce stress in other areas of your life where possible.

If you are unable to get your period back by yourself, after reducing exercise intensity and improving recovery, it is recommended to seek professional help as soon as possible. A specialist sports dietician should be able to help if you’re concerned or not sure if you need pointing in the right direction. 

Conclusions

With the increase in uptake of sports, and higher stakes especially in competitive sports, it is unlikely that conditions such as FHA and RED-s are going away any time soon, especially among young women. While we place pressure on men and women both to perform and look a certain way, regardless of actual health, it is vital to continue to educate athletes and coaches on the consequences of not treating our bodies well and with respect. 

Unless you’re actively trying to get pregnant, it can be easy to push issues such as FHA to the back of your mind, especially if the perceived immediate benefits are greater the perceived long-term risks. Ironically, if your primary concern is performance rather than long-term health, it will be difficult to become healthy and thus perform optimally. I’m hoping that by talking about it more and improving public awareness, we can start to encourage people to seek help when they need it, and hopefully reduce stigma while we’re at it! 

If you’d like to learn more about this topic, these podcasts were particularly helpful for me:

If you found this blog post helpful, please do share with anyone who might find it useful or share and tag me on Instagram! Many thanks to specialist Renee Mcgregor for talking me thorough these complex issues too. If you enjoy my posts regularly, please consider contributing so I can keep this page up and running (no pun intended).

Common Running Nutrition Mistakes

This is a guest blog post by Renee McGregor, a dietitian who I look up to for evidence-based information, especially in regards to running and nutrition. 

Renee is a leading Sports and Eating disorder specialist dietitian with 20 years of experience working in clinical and performance nutrition. She’s worked with athletes across the globe including supporting Olympic (London, 2012), Paralympic (Rio, 2016) and Commonwealth (Queensland, 2018) teams. She is regularly asked to work directly with high performing and professional athletes that have developed a dysfunctional relationship with food that is impacting their performance, health and career. On top of this Renee is the founder of Enspire clinic, a centre specialising in supporting individuals and athletes of all levels and ages, coaches and sports science teams to provide nutritional strategies to enhance sports performance and manage eating disorders. This is reflected in her work on social media too, priding herself on proving an educational hub for both the professional and everyday athlete. When not inspiring others with her incredible work, Renee can be found running the mountains and chasing the trails, most likely training for a crazy ultra-marathon!

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Everyone has an opinion about nutrition – why shouldn’t they? After all, we all need food to survive. However, there is a difference between anecdotal nutrition advice and actual nutritional science. On social media we are exposed to the former a lot more than the latter. What works for one person in a sample of n=1, may not work for another. Just the other day I was on a group chat where someone very boldly stated that their new vegan regime was the cause of their newly found energy and improved recovery. However, this was based on subjective information, which they had collected over a few weeks. Is this science? No – this is one individual’s personal experience with no information of what her diet had been like previously or even if any other aspect of her life had also changed which may have resulted in how she was feeling. Presently there is no evidence in the literature to suggest that a plant-based diet can improve an individual’s performance – such anecdotal evidence could cause more harm than good.

Nutritional science, and particularly sports specific nutrition, is actually quite complex. While many simply look at the impact of one particular nutrient or process on performance, this completely ignores the fact that the human body is run on an intricate system of endocrine, biochemical, immunological, physiological and psychological pathways that all work collectively.

Let’s take the keto diet as an example. This was a huge trend a few years ago and many still promote it with the idea that if we remove carbohydrate from our diet, then our body will use more fat for fuel and improve our performance but also our body composition. While on the surface this may seem to have some gravitas – take out carbohydrate and the body will have to find another fuel source to provide the body with energy – what has been completely ignored is the importance of carbohydrate intake on the hypothalamic pituitary axis, which is necessary to get adaptation from a training response. In addition, carbohydrate has a critical role in optimising immune function in those who are physically very active.

So, with this all in mind, here are some of the common mistakes often made…

 

Carbohydrates

Numerous studies have demonstrated that carbohydrate is the preferred fuel used by the body and is definitely the key to optimal performance. That said, many runners still have little understanding of how much they actually need in order to meet their requirements with many under fuelling.

As stated above, carbohydrate availability is particularly key for the hormonal cascade needed in order to see adaptation and thus progression. This means ensuring sufficient carbohydrate before, during if your runs are over 90 minutes and within 30 minutes of completing your session. While everyone’s physiology is slightly different, as a rule of thumb the requirements set are 5g/Kg BW of carbohydrate if you are running for 60 minutes a day, with this figure increasing for longer or multiple training sessions. In general, I do not encourage fasted sessions and the recommendations state that if you are going to include these, you should not do more than 2 a week and they should be no longer thank 60 minutes, at an effort of no more than 6/10. More than this and at higher efforts, potentially can result in chromic stress on your body leading to a depressed immune system, higher risk of injury and down regulation of your hormones, particularly your thyroid gland, oestrogen and testosterone, leading to further negative health consequences.

In practise, if you are training regularly, it is unlikely that you will ever have full glycogen stores and so it is essential to ensure that you consume carbohydrate at meals and snacks throughout the day. Aim to include nutrient dense carbohydrates such as oats, potatoes, whole grains, fruit and yoghurts at 3 meals (about a 1/3 of your plate) as well as including 2-3 smaller carbohydrate based snacks such as bananas, cereal bars, 2 slices malt loaf or 2-3 oatcakes with peanut butter.

One common observation I have seen is that many people view vegetables as carbohydrate, often displacing these for pasta, grains, bread and potatoes. While vegetables play a role within our diet and should be included, they are predominantly fibre which means they add bulk to the diet but not essential carbohydrate fuel.

 

Protein

There is a lot of hype around protein in the recovery phase, with many runners stressing about not getting enough to enhance recovery. Protein does play a role in the response to training and should be included in addition to carbohydrate, particularly immediately after. The general recommendations are that a recovery meal/snack/choice should provide 1.2g/Kg BW carbohydrate and 0.4g/Kg BW protein. So for someone who is 55Kg this would be 66g of carbohydrate and 22g protein and looks like a medium size baked potato with a small tin of tuna.

It is important to appreciate that the body will struggle to utilise more than 0.4g/Kg BW post training for muscle protein synthesis and adaptation. Any additional protein consumed will be used as fuel or stored as excess. Therefore, it is actually really important to spread your protein requirements out throughout the day. Aim for palm size portion of protein at 3 meals and then half this amount for snacks. This will ensure that your body always has an amino acid pool to draw from in order to repair and rebuild muscles, throughout the day, as well as preventing blood sugar fluctuations.

 

Sugar

With so much negativity around sugar, it is hardly surprising that many runners are equally concerned about their intake. While I would never advocate a high sugar diet, there are definitely times during training and competing, where sugar is the only option. During endurance events, such as a half or full marathon, the body will need an easily digestible source of carbohydrate to keep stores topped up so that running pace can be maintained beyond 60-90 minutes. Gels, jelly babies, sports drinks are all suitable options and they all contain sugar. So in this case, sugar actually enables and potentially enhances your performance.

 

5 Nutrition Staples:

  • Don’t be drawn to the latest fad – many runners will try almost anything to improve their performance. Focus on training and getting the building blocks of your diet correct first – this is going to have more impact than whether you are gluten free or not.
  • After a very hard training session and especially when you will be training again within 12 hours, taking on something like flavoured milk is an ideal choice to start recovery as quickly as possible. The combination of added sugar to the natural milk sugar causes insulin to increase in the blood. Contrary to what you might think, this is actually really important. Only when our insulin levels are raised, can we draw carbohydrates and protein into the muscles to start the recovery process.
  • Always practise your race day nutrition – the worst mistake you can make is to use what is available on race day without previously having tried it –this could have real negative effects on your performance.
  • Work out what is right for you – just because your training partner swears by a bowl of porridge every morning, this does not necessarily mean this is the right fuel choice for you.
  • You don’t have to eat less on your rest day – for most this will fall between two training days so it is the perfect opportunity to recover and then refuel. By being consistent with your nutrition, you will also allow for consistency with your training which allows for progression.

 

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Anon II

This piece is part of #mentallywealthy, a series of blog posts written by men and women who have suffered, or are suffering from mental health problems. The aim is to open up the conversation around mental health and give a voice to those suffering. To see more from this series head to the ‘Mental Health’ tab on my blog. 

It’s not about getting skinny; it’s not about looking a certain way. It’s about not being able to control the external world that surrounds me and so instead I control my internal world, or at least I think I am. Imagine waking up and taking 20 minutes to get out of bed because you feel too faint, too weak, too drained to carry yourself. Imagine having to start your day with the agonising thought of how much weight you’ve lost and having that determine your actions and self-worth for the day. Imagine having your twin sister have to bathe you at your worst point, witnessing your skeletal frame. Imagine having your little sister have to monitor your snacks and meals at school. Imagine having your parents and grandma cry at the sight of you and the thought that you may die in your sleep.

The worst point of my anorexia left me bound to a wheelchair and hooked to an NG tube. I became so frail I couldn’t walk, and I’d abused my body to the point where it couldn’t digest ‘normal food’ anymore. The internet glorifies anorexia in some way and the recovery alongside it. It doesn’t show you the god-awful side effects that come alongside it. An eating disorder is not skipping one meal, thinking you are fat or wanting to lose a few kilograms. It is a mental disease, one that controls your life and overpowers everything else that you once cared about. It transforms you into a different person, stealing your personality, happiness, friends and family and replaces them with fear, anxiety and loneliness. I have had so many occasions where I know I have an abundance of support around me but that voice in my head convinces me that I don’t need help and that it’s better to keep my struggles to myself. It doesn’t appear out of nowhere, it grows from so many different sources; for me personally being perfectionism, a fear of growing up and change, and living up to expectations. It drains your body, mentally and physically, and slowly but surely kills you … literally. Anorexia is the rotting away of your body, the emaciated skeleton you become, the complete withdrawal from life, the numbness of all feeling apart from guilt and crying. It is your fingers turning blue, your legs giving in whilst you walk, the endless hours of body checking and exercising, and nothing but emptiness seen in your eyes.

I have been suffering from anorexia nervosa for almost 7 years, in and out of hospitals, transferred multiple times between treatment teams and consultants. It terrifies me to think that all of my teenage years have been lost to this illness. I was diagnosed when I was 13 years old, and this year, I’ve turned 20. I never thought I’d reach this age and still have my eating disorder. Two seconds ago I was a teenager, just falling into the depths of anorexia, thinking I’d magically get better and be successful in life. Yet here I stand, 7 years later, still suffering, still counting every calorie, weighing myself multiple times a day and still consumed by my eating disorder.

I don’t know if I will ever recover, and if I do then when that’ll be. To anyone else suffering, You don’t have to be alone, find someone, anyone who will listen to you. Sure, there will be nights when you feel alone, some nights where you actually need to be alone but don’t leave yourself with no option but to be alone. Having someone there for you doesn’t mean they’ll understand what you’re going through, but just having someone to listen, to hold you whilst you cry, will give a sense of longing security. Don’t fall victim to your anorexia, don’t become part of the 1 in 5 who die from anorexia.

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