A Player’s Guide to Pain

Here’s the ultimate conundrum (pun intended):

• No one wants to get injured.

• Most players don’t do nearly enough off-field work to prevent injury, and even if they do tons of work, accidents happen.

• When something hurts, you want it to stop right away and not come back. Oh, and you don’t want to miss any points.

Sound familiar? I get tons of questions about pain from flatballers: How do I know when to stop and when to push through? What should I do when it’s this kind of pain versus that kind of pain? How long do I wait before I try doing the thing that hurt me in the first place? Shouldn’t I wear a brace to keep my ankle stable? Ice or heat? How long will I be sidelined? My first reaction to these questions/comments has always been to tell people that I’m not a doctor or a PT – I’m a strength and conditioning coach, which means I deal with people when they’re healthy, and if they’re injured, I send them to somebody else who’s trained to deal with injuries. That being said, I do believe that there are a lot of things we (as players and S & C professionals) CAN do to address pain, and that by using a few tools and some sensible progressions we can often heal ourselves. When in doubt, however, or if these interventions don’t solve the problem, go see a doctor. Or if you’re lucky enough to live in Seattle, go see my friend Deb (Cussen) Scheibe, DPT (Doctor of Physical Therapy) and former Team USA member. Her clinic does an amazing free 15-minute sport screen that will tell you whether you need to see a doctor, PT, or orthopedist.

Knowing about pain and what to do when you feel it is a big step towards minimizing how it affects you. Pain is a sign that something is wrong – it’s usually a symptom of a problem and not the problem itself. If you play through pain, you can end up really injuring yourself either by moving oddly to protect the painful area, or stressing the painful area to the point where it takes you out. I want to give you a sense of the different types of pain you might experience while playing ultimate, and give you some tools and strategies for alleviating pain on the sideline (hint: the TL:DR flowchart is at the bottom of the article).

First of all, let’s look at the types of pain you might have to deal with::

Acute Pain – results from an identifiable incident (i.e. “I planted and something weird happened to my hamstring.” “I bounced my head off the ground on that layout.”)

Developing Pain – starts as something small or nagging, but gets worse with game-like movements (“My calf has been bugging me since that track workout…it warmed up fine but now that I’m sprinting it’s starting to tighten up again.”)

Chronic Pain –  often resulting from structural damage and scar tissue, but can also be a sign of an injury that’s not fully rehabbed or a result of poor movement patterns (“My knee always starts bugging me about an hour into practice. I’ve gotten used to popping a couple ibuprofen and just dealing with it.”)

Pain can take you out of a game or practice – identifying the kind of pain you’re experiencing can help you figure out what tools to use in addressing it. The tricky part is that pain is a subjective sensation, defined by the International Association for the Study of Pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Simply speaking, when you experience pain, you almost always will have a hard time thinking clearly or rationally. That’s why my first advice to anyone who comes off the field with pain (no matter what type) is the same: find a teammate or someone to sit with you, sit or lie down, and try to breathe and calm yourself. You need an outside perspective about what’s happening (hence the other person), and you need your nervous system to become quieter so you can accurately report sensations and give feedback (to yourself or others) about the state of your body. What you do from there depends to some extent on the resources you have available. Here’s some types of sideline care and how they help:

Athletic trainers: If you’re at a tournament or an event where there is a trainer on staff, score! That’s the best place to go if there’s any indication you might have suffered structural damage (you heard/felt something “pop;” there’s bruising; something went in a direction it’s not supposed to, there’s swelling) or there’s a possibility you might have a concussion. They can perform tests to rule out or diagnose serious injuries, and tape up limbs that need extra structural support or compression. When in doubt, go to a trainer, or the doctor or an emergency room if there’s no trainer available.

Pro Tip: When it comes to ankles, too many players tape up on a tourney day as “ankle insurance.” Fully rehab your ankle issues as soon as possible and stop playing taped – artificially-created ankle stability reduces your ankle mobility and will, sooner or later, cause issues further up the chain. Something has to move when you jump and run – if your ankle can’t, your knee will, and you don’t want knee problems added to the pile.

Massage therapists: Pretty self-explanatory. If you’re lucky enough to have one at a tournament or even on staff with your team, you can let them do for you what you would otherwise do for yourself with other tools! The only downside is that they’re not usually on the sideline at your game – traveling to and fro and time spent in massage might keep you out of the game longer.

Lacrosse balls: These are a great low-cost tool for getting back on the field quick. If you have possible structural damage or a really sore spot, you can roll out the tissues adjacent to the problem (like this one for low back pain) – this will allow for more blood flow through the stressed-out site and keep everything around it from seizing up. If the pain isn’t severe, more of a muscle twinge or hamstring tweak, you can roll directly on the tissue, tacking down a painful spot and move the nearest limb around  This is one of my go-to’s when I’m on the sideline with a team during a tournament – you’ll see me hand this to someone and tell them “Go do XYZ for three minutes and then come back.” When they do, they often hand it back and say, “That feels better, thanks!” and start warming up again.

Pro Tip: Using the lax ball to open up tight areas pre-game/practice is a great way to reduce the incidence of injury. Imagine a knot in a piece of rope – if you stretch it and move it from the ends, does the knot loosen or get tighter? Remove the muscle adhesions before you warm up and definitely before you play!

Foam rollers: These are great for identifying problem areas that might be contributing to pain. It’s less painful to foam roll than to use a lacrosse ball, so it’s a good choice if you’re in enough pain that you have a hard time breathing normally or feel stressed. You can alter your pressure easily by resting some body parts on the ground. I have most of my players with knee issues use the roller like this for pretty instant relief.

Pro Tip: An injury in one place can often adversely affect the tissues/structures surrounding it or compensating for it – use the foam roller to keep the areas around the problem from seizing up and causing more pain/movement dysfunction.

Voodoo X bands: My new favorite sideline tool! These are pretty brilliant, fairly inexpensive, and super helpful for several reasons. They provide compression, which is good for stability and helps bring down swelling, especially when combined with movement. KStar developed and sells X bands, and demos them as an alternative to icing and rest for ankle sprains. They also help realign joints and tissues – wrap the band around a tight muscle group tightly, then perform about a minute’s worth of exercises that tax that muscle group – when you take the band off, new blood rushes in and flushes out the stressed tissues.

Pro Tip: This technique and equipment are new, and more research needs to be done to establish a protocol. I’m still experimenting with them myself, but I’ve found them to be a very quick and effective way to free up tight areas. I sent one with UW Element when they left for Nationals after I used it on them constantly at Regionals!

Mobility/Stretching/Release: Always a good option if musculature is gripping or seizing up. Make sure you soften it up first with soft tissue work. Tons of videos on my YouTube channel, and also Tim Morrill’s!

Pro Tip: The low back is one of the first things to tweak if you have super tight hips and/or underactive glutes – try this great stretch to loosen things up (thanks, Tim)!

Ice: The use of ice as the go-to for addressing injuries has been under fire in several articles lately (here’s one). Many professionals and doctors have abandoned “RICE,” including the man who originally developed the protocol in 1978 (Gabe Mirkin). Ice is used to reduce pain and swelling, but it’s often overused, and not combined with movement and other methods for speeding recovery. So how much ice is enough, and why is it important to control inflammation?  According to Deb, PT extraordinaire, “Inflammation is a normal tissue response and part of the healing process. But if it’s severe it can be detrimental, and even dangerous (i.e. in the case of compartment syndrome). Use it short term after initial injury (first 24-72 hrs) to keep the inflammatory process in check, and then as needed to decrease pain control and muscle tone. The logistics: Direct ice no more than 15 min out of every hour, and keep skin protected with layer between it and the ice.” Reducing normal amounts of swelling is now thought to be counter-productive to the healing process (Tim McKnight). There’s some interesting methods getting attention from the athletic and medical community at the moment, including Dr. Hartzell and Dr. Shimmel’s alternative treatment for ankle sprains.

Pro Tip: Ice’s best use is probably as a pain control, allowing the nervous system to calm down, and to controll excessive swelling. Remember, though, that pain is a symptom that something is wrong – you MUST be able to perform athletic movements without pain before you consider returning to play. If it’s still cold to the touch, you might not have an accurate sense of the damage – warm it allllll the way back up before decide whether or not to go back in.

Ibuprofen: Ah, Vitamin I. I’ve heard so many jokes about this that it’s really not funny anymore. I think there’s a time and place for it, but it is waaaay overused in the ultimate community to mask pain so players can keep playing. It deadens your awareness of discomfort and makes it more difficult to diagnose an injury or to tell when you’ve passed the threshold into a serious danger zone. As Deb says, “Pain also influences the nervous system, and playing through pain will upregulate the sympathetic nervous system which has various physiological effects.” In my opinion, the only time to use it is for issues like headaches (from sun glare, hangover or a non-concussive layout) and for managing a long-term issue with an amount of pain that’s constant (you need hip surgery, you’re not going to hurt yourself further by playing, but you can’t play without pain).

Heat: Hard to come by on the sideline, but worth a mention. It’s great for increasing blood flow, which speeds the healing process (an alternative method to RICE as coined by exercise physiologist Paul Catanzaro is METH: Movement, Elevation, Traction and Heat). It can also calm your nervous system down after a shock (like a huge layout). But honestly, you’re producing quite a bit of heat just by playing, so it’s better used in the hotel room at night.

There’s a whole other article to write about recovery, but I’ll address two hot issues here – the first is, to ice bath or not to ice bath? My experience has shown it to be beneficial in aiding muscle recovery on tournament nights and after hard practices, but some research has shown that active recovery and cold water (not freezing water) immersion is just as beneficial, and without the potential icy side effects I mentioned earlier. The debate rages on, and more studies are needed. A last word from Deb on the subject: “Theoretically it will control the diffuse inflammation from a day of impact and muscle strain. It will also help with pain (soreness) control. I suspect there’s a strong psychological effect as well, which can become a real physiological effect with how it positively impacts the nervous system.” The other question I always get is the hamstring question – how do you know when you’re safe to return to play? There’s a HUGE incidence of hamstring re-injury (or injuring the other leg) in our community. Here’s an easy hamstring rehab protocol I recommend – again, though, when in doubt, go see a doctor. And test that hamstring out in drills on the sideline where you’re paying attention before you jump back into play. Enjoy the flowchart – I’m open to all comments and suggestions for revisions of it. This is just a first pass at a team med kit addition! :)