Running has dramatically increased in popularity during the coronavirus pandemic. With gyms and yoga studios shuttered for months, many people who have taken up running for the first time are now seeking advice and treatment for running related injuries and pain. Seasoned runners who regularly use hands-on therapy as part of their management plan are eager to see their healthcare provider again in person. Although running injury research has made great strides over the past decade, diagnosis and management remains an enduring challenge, and the number of runners seeking care is steadily increasing.
It’s more important to understand the person you’re working with than their diagnosis. Runners often resist taking time off even when it may benefit them in the long term. Running is their identity, their stress relief, their community and social life, and in a pandemic it’s more important than ever to maintain fitness for physical, mental, and emotional wellbeing. In these unprecedented times clinicians should use discretion and conduct a thorough assessment before prescribing a break from running, especially if the injury has not been formally diagnosed.
As someone who’s been running for 17 years and been a professional who works with injured runners for 8 years, you’d think I might have a clue about the topic. Yet our understanding of runners and the symptoms they present with remains a work in progress, and injury prevention may never be a realistic goal. Despite all this uncertainty, after a long, steep unlearning and relearning curve I’m cautiously optimistic about what we do know, and can share some thoughts that will hopefully be helpful for runners and clinicians.
The basic principles of training are still generally accepted: don’t increase mileage too much, too soon (10% rule), run at least 80% of your mileage at conversation pace (80/20 rule), plan recovery days every week, don’t ramp up too quickly following a break, individualize your training program based on your past history and injury risk, and plan a recovery week every four weeks.[1] We’ve also learned a lot about the role of adequate sleep, proper diet, and stress management in improving performance and decreasing injury risk. Anyone who has been in the sport for any length of time knows this stuff isn’t exactly groundbreaking.
So why do runners still get injured even when they do all the ‘right’ things?
Pain and injury are often conflated by laypeople and even some clinicians, and believed to be linear, causal effects of elusive ‘training errors’. We now understand pain perception as a complex, emergent, protective output of the nervous system that correlates poorly with tissue damage, and likely arises from a myriad of contributing factors, rather than a single root cause. A runner’s pain threshold is often lower than their tissue tolerance, and lower still if they’ve sustained an injury in the past. And the longer pain persists, the less likely it will correlate with tissue damage. While this experience can be frustrating, debilitating, and sometimes maladaptive, it has an important biological basis; all pain originates from the nervous system, which is more sensitive and reactive than the tissues in order to protect the organism from injury and death.[2] In the case of new, severe, or worsening pain, it is advised to see a healthcare provider to rule out sinister pathology, but once this is done it’s more accurate to reframe the pain as ‘sensitivity’ rather than injury.
If runners can learn to differentiate pain and injury, how should they proceed with their pain management?
Pain often persists even when damage has been ruled out, causing frustration, anxiety, depressed mood, and loss of fitness. It can feel isolating and confusing to see your friends all following the same sensible training program without ill effects.[3] Unfortunately we still don’t know much about why some people have more sensitive nervous systems than others, and the potential contributors (poor sleep, stress, etc.) that have been meticulously recorded in a training journal can only be speculated upon in hindsight.
This retrospective data collection does however provide a unique opportunity. Caveat: I don’t normally recommend that my chronic pain patients keep a journal to track their flares and triggers, as human nature dictates that this kind of reporting tends to be negatively biased, thereby exacerbating feelings of hopelessness.[4] But serious runners are huge data nerds - they have records of every workout they’ve done for the last few years, even decades. And they’re biased humans who tend to record instances where pain sidelined them or caused a negative outcome, while overlooking the times when they crushed a workout or race despite worrisome symptoms. They’ve likely been given conflicting patho-anatomical explanations by numerous providers, in turn causing hypervigilance and fear, and they need tangible, actionable advice that will promote resiliency and self-efficacy. When recording training sessions in their journal, runners should pay particular attention to the positive outcomes, especially in situations when they have a rational fear based on past experience that pain will sabotage their performance.[5] If positive outcomes are routinely omitted, the data is incomplete and not an accurate representation of the athlete’s strength, adaptability, and resilience.
Key takeaways:
1) Runners must understand that hurt does not equal harm, and pain is not necessarily something to be diagnosed, treated, and prevented, but rather managed, accepted, and even embraced. This is important for them to be able to reach their athletic potential.
2) Training data should include positive outcomes, especially when pain is a perceived threat to optimal performance, which will help reduce fear, promote self-efficacy, and teach them to tolerate uncertainty.
Runners are dedicated, hard working folks, and a challenging, rewarding population to work with. When they learn not to equate pain with injury, and start documenting their positive experiences, especially the unexpected ones, they may be surprised at the number of pain free, joyful moments they’ve had over the season. This will remind them of the reasons why they fell in love with running in the first place, and help them mentally detach from their rigid schedule.[6] They can learn to appreciate the long term benefits of taking a short break when needed, without dwelling on unknown or unknowable injury mechanisms. Running is worthwhile because it’s hard, and overcoming adversity makes a breakthrough even more satisfying. In the midst of a pandemic the stakes are higher than ever, and clinicians should teach and promote a healthy, sustainable approach to running, to enhance long term physical and psychosocial wellness.
References:
1) Running-Physio.com: 6 Common Training Errors and How to Fix Them https://www.running-physio.com/training-errors-video/
2) Melzack, R., Katz, J., (2012). Pain. WIREs Cognitive Science / Volume 4 / Issue 1. https://doi.org/10.1002/wcs.1201
3) Turner, J., Malliaras, P., Goulis, J., McAuliffe, S., (2020). “It’s disappointing and it’s pretty frustrating, because it feels like it’s something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy. PLOS ONE https://doi.org/10.1371/journal.pone.0233459
4) Task Persistence - The Least Used Coping Skill https://healthskills.wordpress.com/?s=Task+persistence+
5) The Naked Physio: Fear, Expectancy Violation, Symptom Modification, Generalisation. https://thenakedphysio.com/2018/10/29/fear-expectancy-violation-symptom-modification-generalisation/
6) De Jong, J., Balk, Y.A., Taris, T.W., (2020). Mental Recovery and Running-Related Injuries in Recreational Runners: The Moderating Role of Passion for Running. Int J Environ Res Public Health; 17(3): 1044. doi: 10.3390/ijerph17031044