Does Pain Equate to Injury? Maybe Not.

You’re running along one day and your left heel becomes sore. It’s not too bad, so you complete the run. When you run again, the pain returns, and it’s a little worse this time. It’s still tolerable, though, so you complete this run as well. But in your next run the heel pain is even worse, so you decide to bail out and take a few days off.

Are you injured? Maybe, maybe not. For decades, doctors and scientists equated pain with injury. The idea was that the sort of “pain experience” I just described was always caused by damage to the tissues in the painful area, and that such damage constituted an injury by definition. But the latest science suggests that the story is far more complicated. Pain and injury are only loosely coupled, in fact, and it is not at all uncommon for runners and others to have significant tissue damage in a particular area yet feel no pain and to feel pain in an area that lacks significant underlying tissue damage.

In a 2006 study by researchers at the Karolinska Institute in Sweden, comprehensive testing was performed on 80 patients diagnosed with patellofemoral pain syndrome (PFPS), among the most common injuries in runners. Twenty-nine of these runners were found to have perfectly healthy knees as judged by standard imaging tests and another 29 had no measurable damage but above-normal levels of “metabolic activity.” Even among the minority of patients who did have observable degrees of tissue disruption, there was no consistent pattern to the damage.

That’s one example of pain existing largely in the absence of injury. There are also many examples of injury existing without pain. A study appearing in Physical Therapy in Sport reported the results of ultrasound imaging of the Achilles tendons of high-mileage runners who had no history of pain in that specific area. Nearly half of these asymptomatic individuals were found to have significant pathology in at least one tendon. If one of these runners had developed Achilles pain and gone to their orthopedist and undergone an ultrasound, it is very likely that the pathology revealed by this test would be fingered as the cause of the runner’s pain. And the doctor who did so might have been dead wrong.

Redefining Pain

Based on the latest science, the International Association for the Study of Pain revised its official definition of pain last year to the following: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” In other words, pain is a certain kind of feeling. When damage to the body is felt, it is felt as pain. But the same feeling can occur at other times, such as when an injury has fully healed but we still fear using the affected part of the body.

So, what does this mean for you as a runner? It means that, except in cases of acute, traumatic, or obvious injury, such as stepping in a pothole and feeling something explode in your knee, which subsequently swells up to the size of a softball, you should treat pain as pain and make no assumptions about whether you have an injury and, if so, what it’s called. The idea that getting a diagnosis is a crucial first step toward recovering from a running “injury” is so ingrained that it may seem almost heretical to suggest that, in most cases, it has no practical benefit for treatment, and in many cases it does more harm than good, specifically by causing runners to feel fragile and physician-dependent. But researchers are increasingly warning clinicians against what has been described in one recent scientific paper as “too much medicine” in physical therapy practice, “an umbrella term that includes overdiagnosis, misdiagnosis, false positives, diagnostic overmedicalization, and overdetection.”

I myself am a past victim of too much medicine. Many years ago I went to see an orthopedist about a nagging pain in my right knee. No amount of rest seemed to help it, so my doctor recommended arthroscopic surgery. When he opened me up, he found that the knee’s cartilage had deteriorated — a condition known as chondromalacia. So he filed the cartilage down all nice and smooth, sewed me back up, and told me that my problem was fixed and I’d be running pain-free within a week or so.

He was wrong. When I started running again, the pain returned. Chondromalacia was not the source of the pain, and smoothing out my knee cartilage fixed nothing. Eventually, I overcame the pain on my own by patiently yet persistently using the knee through a mixture running, bicycling, and strength training, doing as much as I could without making the pain worse, and making progress in a halting, two steps forward, one step back manner until the pain was gone and my training once again unlimited.

Self-Managing Pain: You are In Control

The formula for working through athletic pain that I developed heuristically for myself 15 years ago is now on its way toward becoming standard practice among forward-thinking therapists and trainers. Folks like Greg Lehman, a Canadian physiotherapist and author of the free e-book Recovery Strategies: A Pain Guidebook, and Ryan Whited, a Flagstaff-based personal trainer with whom I am currently coauthoring a book on self-managing athletic pain, are steering athletes away from “medicine” and empowering them to regard pain as a normal part of the training process that most athletes can work through on their own (or with the help of a trainer or coach) most of the time.

The exceptions are cases where you experience one of the following “red flag” symptoms or signs: numbness or weakness, significant bruising or swelling, incontinence, confusion, seizure, loss of consciousness, or a gut feeling that something’s wrong. In all other cases, you should feel confident that the athletic pain you’re experiencing is not injurious in nature and it’s okay to work through it in a sensible, mindful way. In practical terms, this entails resting only when — and no longer than — necessary; continuing to run, though no more and no faster than you can without exceeding a tolerable level or discomfort; and doing strength exercises that involve the affected part of the body, beginning with simple isometric movements (think balancing on your toes in the case of Achilles tendon or calf pain) and progressing gradually to ballistic movements (think jump roping).

The message here is not that it’s “all on you” to solve the pain issues you experience as a runner. By all means, get help when you need to from qualified trainers, coaches, physical therapists, and — as a last resort — physicians. Just try to seek out professionals who are up to speed on the latest pain science and don’t let anyone take away your control of the process. You are the boss of your pain.