The sixth in a series of posts about what makes runners uniquely equipped to run. This post explores why it hurts. . . and how to make it stop.

“Being a distance runner is about handling pain. If you can’t manage pain, you probably won’t end up as a distance runner.”

KARA GOUCHER, American long-distance runner

There are many ways to categorize pain, but a broad definition would be acute vs chronic. Acute pain comes on suddenly, has a limited duration, and is often caused by damage to tissue (bone, muscle, organs). Chronic pain lasts longer and is more resistant to medical treatment, such as with long-term illnesses like osteoarthritis.

1 of 3 graphics from totalinjury.com: How the Brain Responds to Pain

WHY IT HURTS

Recurring pain is normally caused by:

• mechanical injury, such as a fall or twisted joint;
• repetitive micro trauma, as with overuse injuries that cause stress to the tendons or bones, or micro tears to the skin, as with calluses or blisters; or
• muscle imbalances – weak glutes, overdeveloped quads, or not having a strong core, for example.

The medical community says “pain is what you say it is” because pain is subjective. A person’s general health, previous experiences, stress, anxiety, depression, and motivation can influence how we perceive pain.

Soreness vs Pain

Muscle Soreness

Everyone gets sore with intense exercise. Pain from sore muscles is usually felt the next day and comes from microscopic tears in the muscle fiber. Rebuilding of the muscle damage creates larger, stronger muscles.

If soreness seems especially severe and lasts for several days, it’s probably delayed onset muscle soreness (DOMS), and may be a result of performing new exercises at a relatively high intensity. Studies suggest theories to explain the mechanisms of DOMS, including lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation and enzyme efflux.

Muscles build up resistance to DOMS with multiple sessions, but new runners who can’t shake the burn after a day or two can try massage or light exercise. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.

Reference: Cheung K, Hume PA, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Med. 2003;33:145–164

Sharp Pain

A sharp pain during exercise – in contrast to muscle soreness – can be indicative of an injury. This type of pain can be located in the muscles or joints, and may linger without fully going away even after a period of rest. Runners should not push through a sharp pain since it can exacerbate the injury.

ATTACK AND HEAL

The body’s response to injury is inflammation, which is designed to attack and heal. The early stages of inflammation enlist the immune system to protect the body and control infection. Like pain, inflammation is categorized as acute or chronic.

John Hunter (1728–1793, London surgeon and anatomist) was the first to realize that acute inflammation was a response to injury that was generally beneficial: “But if inflammation develops, regardless of the cause, still it is an effort whose purpose is to restore the parts to their natural functions.”

Increased blood flow to the area causes redness and heat; the accumulation of fluid causes swelling, pain is due to the release of chemicals that stimulate nerve endings, and loss of function is a combination of factors.

Inflammation is part of the natural healing process; without it wounds and tissue damage would never heal. Reducing inflammation may be necessary in some cases where inflammation has caused further inflammation – becoming self-perpetuating, which may lead to chronic inflammation.

When joint tissues have not been given adequate time to fully regenerate between workouts, they may become chronically inflamed and/or degenerate to the point of serious injury. Overuse injuries, such as runner’s knee, develop in this manner. It’s the harder than normal workouts that cause significant tissue damage and post-workout inflammation. For this reason, most training programs increase duration and/or intensity more slowly to allow the body the necessary time to recover and adapt.

Note: Scientists at Emory University School of Medicine in Atlanta, Georgia, found in a study that poor sleep quality, and short sleep durations are associated with higher levels of inflammation.”which in turn increases the risk of developing heart disease and stroke.” What drives the inflammation in the first place is still a mystery.

Pain Management

Physiologists at the University of Wisconsin used spinal injections of a powerful painkiller to block lower-body pain in a group of cyclists; the cyclists actually got slower. They initially felt great and started out faster than normal, but then faded. Without the feedback of pain, they couldn’t pace themselves properly. Training to live with pain: What we can learn from Olympic athletes 

Everyone reacts differently to pain, which means how each person manages their pain will also be unique. Complicating each approach is the fact that injuries themselves react differently to treatment therapies. Following is at least a partial list of pain management therapies, in no particular order.

Ice or Heat? If the injury is sudden and acute, ice is preferred for the initial two or three days post injury – 20 minutes each two to three hours until the ‘heat’ comes out of the injury. Ice will also reduce inflammation and provides pain relief by reducing the blood flow to that area. (A bag of frozen vegetables, such as peas or corn, is an excellent way to ice an injury.)

Heat should be avoided in the first 48 hours as it encourages bleeding. Once the ‘heat’ is out of the injury, heat packs can be used to stimulate blood flow, which will aid healing, help muscles relax and ease the pain – 20 minutes a few times a day using a heat pack, or alternatively take a warm bath or hot shower. Heat stimulates sensory receptors to block the transmission of pain signals to the brain.

Post Exercise: Ice, Heat, or Both? Although light exercises or gentle stretching may be equally effective in reducing pain after a hard bout of exercise or race, ice baths, or cold water immersion, has long been a popular interventional strategy (the ideal temperature range seems to be between 50 and 59° F for 10-15 minutes).

There is some reasoning that the benefit has less to do with the temperature of the water than the immersion itself, however, and the deeper underwater the body is, the better (in other words, jumping in a lake or swimming pool is even better than soaking in a tub).

Read more:  Ice, heat or a little of both? How do you recover from a hard workout?

Tart Cherry Juice: Researchers have found tart cherries reduce a type of inflammatory activity in the body by about 38% (Naproxen, a powerful NSAID, provides a 41% reduction). Long-distance runners drinking cherry juice before marathon-level events have less muscle damage and up to 1/3 less post-event soreness compared to those who did not drink cherry juice. Students given 12 ounces of tart cherry juice before and after strenuous resistance training suffered only a 4% reduction in muscle strength the next day, compared with a 22% loss in exercisers drinking a placebo.

1 of 5 graphics from RunnersWorld “Where it Hurts”

Meditation: studies show that meditation increases immune function, decreases pain, decreases inflammation at the Cellular Level, decreases anxiety, depression and stress, increases grey matter of the brain and cortical thickness in areas related to paying attention, improves focus and memory (see all the studies at psychology today.com.) Lebron James, Kobe Bryant, Misty May-Treanor and Kerri Walsh are a few of the athletes that meditate to improve their game.

Breathing and mindfulness practices can have powerful effects on athletic performance. Breath control can influence core muscle activation instantly and improve respiratory function in as little as two weeks, with benefits increasing exponentially with pranayama training. Mindfulness enhances endurance, behavior performance, and executive functions within five weeks. Breathing and mindfulness promote relaxation and better cognitive function reflected with enhanced performance. Read more here.

Strapping tape vs supportive tape: taping can stabilize and support the injury, provide pain-relief via de-loading of the vulnerable or painful structures, and facilitate normal movement, muscles or postural patterns.

• Rigid strapping tape is commonly referred to as ‘sports tape’ or ‘athletic tape’.
• Elastic strapping tape can be used when less rigidity or support is required.
• Kinesiology tape is an improved version of elastic sports tape that acts to dynamically assist muscle function.

Massage: Massage has been utilized in the treatment of illness and injury for thousands of years by health care practitioners as a treatment for reducing stress, pain and muscle tension. Nonetheless, research has generally failed to demonstrate massage significantly contributes to the reduction of pain associated with delayed onset muscle soreness, enhances sports performance and recovery, or plays a significant role in the rehabilitation of sports injuries. The most successful treatments combined a massage therapy program that also included stretching, walking, swimming, aerobics, strengthening exercises, and education on posture and body mechanics. (Reference: The Role of Massage in Sports Performance and Rehabilitation: Current Evidence and Future Direction – Jason Brummitt, MSPT, SCS, ATC  North American Journal of Sports Physical Therapy)

Three forms of massage are frequently reported in sports medicine literature: effleurage, petrissage, and deep transverse friction massage (DTFM).

Massage therapy modalities can include Swedish, Deep Tissue, Sports Massage, Trigger Point Therapy, Thai Massage, Thai Herbal Compresses, Hot Stone, Lymphatic Draining Therapy, Shiatsu, Cupping, and Reflexology, among others.

Acupuncture: Dating back more than 2,500 years, acupuncture is based on the premise that there are more than 2,000 points in the human body connected by bioenergetic pathways, known as meridians where Qi, or energy, flows. When a pathway is blocked the disruptions can lead to imbalances and chronic disease.

In various studies, acupuncture has proven beneficial in the treatment of chronic health conditions, and has been found safe for children. It works, in part, by stimulating the central nervous system to release natural chemicals that alter bodily systems, pain and other biological processes.

Proprioception / Balance Exercises: These exercises teach your body to control the position of a deficient or injured joint. A common example is the use of a balance or wobble board after an ankle sprain. Unpredictable movements provoked by the balance board re-educates the body to react without thinking, restoring natural balance and proprioceptive reactions.

Stretching: In its most basic form, stretching is a natural and instinctive activity. Considered a form of exercise, stretching improves the muscle’s felt elasticity and achieves comfortable muscle tone. The result is a feeling of increased muscle control, flexibility, and range of motion.

There are five different types of stretching: ballistic, dynamic, SMF stretching, PNF stretching, and static stretching. (Read about each one here.)

Athletes stretch before and after exercise in an attempt to reduce risk of injury and increase performance, although these practices are not always based on scientific evidence of effectiveness, and depending on which muscle group is being stretched, some techniques may be ineffective or even detrimental. A study in 2013 indicates static stretching (vs dynamic stretching) weakens muscles, or “stretch-induced strength loss,” which you would want to avoid too close to exercise or competition. (Note: other studies have found that reducing the amount of time a static stretch is held (say 15 seconds instead of 30) is beneficial to some individuals pre-exercise.)

Muscle “tightness” results from an increase in tension from active or passive mechanisms. Passively, muscles can become shortened through postural adaptation or scarring; actively, muscles can become shorter due to spasm or contraction. Regardless of the cause, tightness limits range of motion and may create a muscle imbalance – which we have learned will eventually lead to acute or chronic pain. (Source: International Journal of Sports Physical Therapy)

Static stretching is more effective than dynamic stretching for those recovering from hamstring strains, and they seem to recover faster by performing more intensive stretching than less intensive stretching, and a gentle, static stretch relieves the pain associated with a sore Achilles’ tendon. Patients with knee osteoarthritis can also benefit from static stretching to increase knee range of motion. Researchers have shown that 12 months of stretching is as effective as strengthening exercises or manual therapy in patients with chronic neck pain.

The effectiveness of stretching is very individual, but most research concludes a routine of regular stretching, especially as you age, is beneficial in overall conditioning, can alleviate pain, and will improve muscle strength over time.

Injuries are often more painful at night because of the body’s reduced blood flow. Light stretches before bedtime will increase blood flow, and can help alleviate pain. It’s not necessary to stretch the injured area. Performing simple movements, such as swinging your arms or performing any variety of extension stretches will encourage bood flow.

Yoga & Pilates: Pilates is a form of exercise that focuses on the activation of the deep core muscles, while yoga is a mind-body workout that combines strengthening and stretching poses with deep breathing and meditation or relaxation. Both exercises will improve flexibility, core stability, overall body strength, postural alignment, balance, reduce the chance of re-injury, and help correct muscle imbalances that created the pain initially.

Bergamot: Bergamot essential oil reduces the feeling of pain in the body by stimulating the secretion of certain hormones which lessen the sensitivity of nerves to pain. Massage a few drops into the affected area for temporary relief. (Read more.)

Arnica: dating back to the 1500s, Arnica is used topically for bruises, sprains, muscle aches, wound healing, joint pain, inflammation and swelling from broken bones. Arnica is available in gels and creams, but should never be applied to an open wound or taken orally, except in an extremely diluted form.

Aspirin: A standard (325 mg) or extra strength (500 mg) dose is an effective pain killer and also works as an anti-inflammatory, making it a possible treatment for rheumatoid arthritis, osteoarthritis, lupus, and mixed connective tissue disease. (People at increased risk of bleeding should avoid aspirin. Contact your health professional to discuss possible contraindications before beginning any pain management therapy.)

Over-the-Counter Pain Relievers include:

• Acetaminophen (Tylenol)
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn)

Both acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs also reduce inflammation. (Inflammation is a necessary part of the healing process, and reducing injury-related inflammation may not always be an effective treatment therapy.)

Acetaminophen (Tylenol) works on the parts of the brain that receive the “pain messages.” NSAIDs relieve pain by reducing the production of prostaglandins, which are hormone-like substances that cause pain.

Using NSAIDs increase the risk of heart attack or stroke and have also been known to cause stomach problems. (Source: webmd.com)

One study on the effects of Ibuprofen on skeletal muscle showed that taking ibuprofen during endurance training canceled running-distance-dependent adaptations in skeletal muscle.

Another study confirmed in the laboratory that the use of NSAIDs after exercise slowed the healing of muscles, tissues, ligaments and bones.

During the first 2 to 3-days of an acute injury, taking a NSAID is advised, but once you exceed this window, general advice is let the body do the work. No evidence shows that a NSAID will provide benefits during a run or race, and may hinder.

A list of possible side effects of NSAIDs can be found at nhs.uk.

A Montane athlete, Marcus Scotney, had a potentially life threatening experience following the 2014 Iznik Ultra in Turkey. Read an interview following that event with UK’s key specialist on kidney function, Dr Richard Fluck, regarding the impact of NSAIDs and Sport.

Note: People given a placebo for pain control often report that the pain ceases or diminishes.

 

This post is meant for informational purposes only. It is not intended to provide medical advice. Please consult a physician to discuss your specific pain/injury, the treatment options most appropriate for you, and to ensure there are no contraindications in the treatment options you may adopt.

Read more:

Before You Take Ibuprofen, Try This (Time.com)

Ibuprofen and Running: Anti-Inflammatory Drugs Hurt Your Training

What Are the Best Anti-Inflammatory Spices? Outside Online

How Exercise Works (HowStuffWorks)

RUNNERSWORLD: articles related to stretching for runners

Stretching: The Truth (New York Times)

Main Types of Chronic Pain (verywell.com)

Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise

Best Essential Oils for Pain: EssentialOilExperts.com