Decades of research into injury recovery times has shown that there are five psychological factors that influence how soon injured people get better. Strangely, these factors play a bigger role in recovery times than how severe the injury was, and they are things that we can control. I’ve interviewed injury and pain psychologist Caroline Marlow PhD to learn what injured people need to be aware of and what they can do to recover from injury sooner. Remember, if you need help with an Achilles injury, you're welcome to consult one of our team via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.
In this article:
Watch the video of the interview:
The role of psychology in Achilles injury recovery times
Nobody wants to be injured or in pain. Everyone wants to get better as fast as possible. However, the things that help us to recover better and faster from Achilles injuries (and all other types of injury) aren't necessarily the things that we first think of. But even more interestingly, the things that do predict recovery are things that we can control.
Over the last five or so decades, a body of “return-to-work-research” has been developed. It looks at what helps injured people return to work sooner rather than later and at what the best predictors are of whether somebody stays work-disabled after getting injured.
Quite counterintuitively, no physical or medical predictors of return to work or prolonged work disability have been found. It doesn't matter how severe your symptoms are, it doesn't matter how the injury happened or what the injury is; those are not reliable predictors across injured people of when they will actually recover and get back to work.
We already know that tissue damage and pain don't marry up very well. The amount of tissue damage doesn't necessarily indicate how much pain you’ll have, and the severity of the pain likewise doesn't necessarily indicate how much tissue damage there is. This means that some people might have pain which would lead them to think that they haven’t recovered as well as they actually have.
Along the same lines, the return-to-work research has found that there are five psychological factors that are useful for predicting how soon someone who has been injured will return to work and/or whether they will suffer prolonged work-disability.
Now, returning to work may not be the main priority of everyone who is injured; it may be returning to sport, to be able to drive again, or to be able to play with your kids. However, it would be prudent to take note of this research and see what we can learn from these five factors.
The good news is that these five psychological factors are things over which we have a certain amount of control.
1. Recovery expectations
This would be your prediction, your belief about the likelihood of recovering from the injury within a certain period of time.
Why is this important? We know from the research that people who have low recovery expectations are less likely to engage in recovery behaviour, less likely to keep their appointments with medical practitioners, and also less likely to adhere to their rehab programmes.
Find a practitioner you can trust and pick their brains
How can an injured person use this to their advantage? The first thing to do is to find a physio, an osteopath, a consultant, a GP, that you can really trust with the information that they give you. Ask them three questions: “When should this heal?”, “How much pain would you expect someone with this to feel now and into the future”, and “What can I do now and in the future to speed up my recovery?”
So, make sure you come away from the consultation knowing what the medical professional thinks is possible, with some understanding of how any structural concern might relate to pain, and also what you can do about it.
When we're injured, sometimes we very much focus on what we can't do and not on what we can do. So, please think about what you can do, and follow your practitioner’s rehab advice.
Use trusted information sources
Social media is very much a source of information for people right now. There are lots of sites where people understandably talk about their injury-related problems, and those can often be quite unhelpful if you are trying to recover from one yourself. Caroline says she has seen quite a few of her patients falling into this trap.
Everybody is different, and therefore it's not necessarily always helpful to listen to other people's stories, particularly if they are negative ones. If they’re positive, fantastic. But generally, social media channels don't tend to give us that kind of information.
So yes, do look for information, but please use trusted sources. There's lots of good information on the Treat My Achilles website and on Caroline’s website and social media channels. Also, depending on the type of injury, there are many charities, hospitals, and accredited medical practitioners and researchers that can be reliable sources of information.
So, use all the reliable information you can find to help you form a realistic expectation of when things will be back to normal for you.
2. Confidence that you can cope
The second factor is your confidence in being able to cope with the symptoms and the limitations that your injury may bring. We know that the more confident people are, the fewer sick days they have and the faster they return to work.
Figure out what makes you feel safe
The first step is to give some thought to what you can do to control your symptoms. Again, everyone is totally different with this. When Caroline helps people, she asks them to think about "What is it at that moment in time which makes you feel safe?" That might be resting your injury, it might be applying some heat to it – whatever is appropriate for you at that particular stage of your recovery.
But think about other things as well. What else can you do to your environment to make you feel safe? Is it nice music? Being warm? Whatever it is that works for you, is really helpful at this stage.
Learn from yourself and others
Think of a time that you've coped with a challenge before. What lessons can you learn from that, and what can you apply to your current injury situation? Even if you haven’t had a serious injury before, you will have had examples of where you've coped with something which seemed difficult at the time.
Ask people around you how they have coped with injury or other tough situations, and see whether you can implement that.
Set small goals and keep a record
Set small, achievable goals and keep a record of when you’ve achieved them. It’s very easy to not notice or forget that we are further along our recovery journey than we were maybe a week or a month ago. Having some kind of record which shows that, “Actually, we are doing okay” and ”I’m coping” will help. It could also be useful to write down what you did to help you cope, and then use this strategy again.
Ask for support
Across all kinds of unfortunate life situations that people find themselves in, social support is the one thing which comes through as best able to help you.
Many of us tend to be wary of asking people for help, but people are often very keen to help. Be as specific as you can be in asking for the support that you want. And then obviously, also show that you are doing your bit. People tend to get fed up with helping when they think that they're doing everything and you're not doing anything.
Think across a range of people. There's lots of people in your life who can probably help you in very different ways. Together, they can give you much more support than you probably think you can get.
Avoid meds and alcohol to help you cope
Many people reach for the medicine cabinet when they’re injured to help them get through the pain. Relying on pain meds and/or alcohol is not advisable.
Go and see your GP to discuss alternatives. And if you do decide to come off medication anyway, please make sure you talk to a doctor so that you can do it in a controlled way.
Catastrophising is when we think the worst – often over and over again – about the pain and the injury, and how it is affecting us, both now and in the future. Examples are doubting whether we will be able to get back to work or focusing on how the injury might affect our finances. The more we worry about these types of thing, the more it sets us against recovering effectively.
Why is this important?
Pain behaviour: The more we catastrophise, the more we do pain behaviour. That might be things like wincing more or protecting the area which is in pain more. Maybe we move less and/or we tense up more. All these kinds of things working against you recovering.
Pain medication: Often, people who catastrophise take more pain meds. Pain meds are becoming more and more controversial. Yes, sometimes they can help in the short-term. But increasingly, research is showing that pain meds aren't so useful in the long-term. So be wary of getting into a cycle where you're taking more and more pain meds.
Staying in bed: The third thing which people who catastrophise tend to do, is to stay in bed, bed-rest, for longer periods of time. Moving is really important for our general fitness and our general health, but also, of course, for helping recovery. This is because being immobile leads to further deconditioning, which can lead to more injury and more pain down the line.
Disengaging from support: People who catastrophise tend to engage less with the support and the interventions that they've been given.
To summarise, the more we think negatively about our pain, our symptoms and the consequences of that, the more it leads us to do things which aren't helpful.
So, what should we do instead?
Be aware of what you say to yourself
This sounds a lot easier than it is, but what we need to be aware of what are the kinds of things that we're saying to ourselves. Stop for a second, pay attention to it, and see if you can actually challenge that. Is that actually the truth?
This is particularly relevant when you start anticipating what's going to happen in the future – it doesn't necessarily need to be like that. See if you can challenge it, either with information from a trusted health professional or from your own experience.
And then, of course, the ideal situation is if you can then replace that negative thought with something which is more positive, something like, "What if?" “What if I do this? Maybe something can be better?” What can I control?”
Stay in the present
When we are injured and in pain, it’s very easy to think back to a time when we were not injured, or even think forward to what might be if the pain or injury continues. Aim not to do that. Instead, try to stay focused on the present, and really focus on what you can do right now and throughout the rest of the day to keep you moving forward successfully.
4. Feelings of loss and blame
An injured person might be thinking, “It’s not fair that I haven't been able to play with the children over the last couple of years", or "It doesn't seem right that I haven't been able to work and now I’ve been overlooked for an important project.”
Also, some injuries happen because of external factors. Maybe you slipped on something which shouldn't have been there, so you want to blame other people.
The research has shown that injured people who experience such feelings are less likely to be confident that their treatment is going to work; this can delay their recovery. It can also cause emotional distress and lead to things like delayed PTSD and depression.
If you feel that you have something along the lines of trauma and depression, obviously seeking clinical support for that is very important.
Dealing with feelings of loss and blame can be quite a complex thing to work through. However, if you keep focusing on loss or blame, it consumes the emotional resources that you need to focus on and do the things which are going to help you recover. So again, it's coming back to what is important for you to recover right now. What can you actually do?
So, sometimes we need to work to accept that time or opportunities have been lost, and understandably this isn’t easy. Something that may help is to compartmentalise difficult situations relating to your injury, such as legal proceedings. Try to have set times of the day or the week in which you deal with these, as opposed to letting it drift and letting it gnaw at you all week long.
5. Health beliefs
Health beliefs are the things that we believe to be true in relation to our health, our injury, and how we actually recover.
As this article has already implied, there are quite a lot of myths out there about health, pain, injury, and recovery. We have to work our way through these and find reliable information instead.
Here are some examples:
“I’m a slow healer”
It's very difficult when you have an injury and you can't see inside yourself to know actually whether you're healing or not. What I tend to recommend that people do, is to have a look at things they can see. If you cut yourself, does that heal well? So, look for obvious signs that your body is capable of healing.
“Scans and X-rays will always show what's wrong”
Unfortunately, this isn't the case. Hopefully, the more we talk about how our psychology and our thinking affects pain, injury, and recovery, the clearer it will become that not everything can be shown on a scan.
“The medics need to fix me”
We know now – through quite a lot of research – that the more that people take control of their recovery, the better they do actually recover. Unfortunately, people often get caught in a situation where they're being pushed from one appointment to another, one specialist to another specialist, because of this desperate need to find someone to “fix” us.
That isn't always very helpful, so at least do the things that you can control whilst you're going through that situation.
“All the injury needs is rest”
In the old days, if you hurt your back, you'd be in bed for weeks. But that really isn't the advice anymore. A trusted physio will be able to tell you the kinds of activity and rest patterns that you can do to help you.
“No pain, no gain”
This is a myth we still encounter, especially in sports. Caroline says she was talking to someone the other day and they were talking approvingly about how “the older a generation has a ‘tough it out’ mentality”. These kinds of things aren't necessarily helpful, as when you pushing through pain, you might do more damage, or increase our protective responses that will induce more pain.
So, if you ever think something is true about your injury, just stop and think for a second: “Hang on. Is that necessarily the case? Is there evidence out there to support this?”
How we can help
Dr Caroline Marlow can be contacted here for psychological advice on injuries and pain.
Need help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.