Case 1:
A builder accidentally jumps down onto a 7-inch nail.
With the nail protruding through his boot, the man is rushed to hospital in such excruciating pain that on arrival he needs an injection to sedate him.
On carefully cutting away the boot, doctors are surprised to discover that the nail has actually passed between the man’s toes, missing his foot completely.
The agonizing pain he felt at the time of the accident was solely down to his mistaken perception of injury, and not actual injury… – Fisher et al., British Medical Journal,1995
Case 2:
A construction worker visits the dentist complaining of a toothache that has been bothering him for a while.
Dental X-Rays reveal that the man had unknowingly shot himself in the head with a nail gun six days prior.
Despite the extreme nature of the injury, the man’s unawareness of what had happened at the time lead to a mistaken perception that he was just suffering from a bit of toothache, with pain far lower than we would expect. – USA Today, Associated Press, 2005
So… why are we talking about accidents with nails?
Well, both of the medical reports above are excellent illustrations of how pain and injury are not the same thing.
They can appear at the same time (and very often do) but it is not a prerequisite.
You can experience a lot of pain with just a little injury (think how much a paper cut hurts) or even no injury (nail through the boot incident or phantom limb pain).
You can also experience a lot of injury with little or even no pain (think of soldiers on a battle field or the nail gun incident).
And this has serious implications when it comes to us understanding and dealing with running related injury (or pain!).
A little bit of history
Despite the clarity emerging from modern pain science research, the average runner (and many of the therapists who treat him/her) still regard pain as a direct product of injury:
The more you hurt, the more serious the injury.
As a result, many of the ways we deal with pain (or pay others to do so) are outdated and potentially ineffective.
Blame for this can go back to the 17th century philosopher, mathematician and scientist Rene Descartes who in 1664 introduced the concept that pain travelled from irritated body parts to the brain (in his illustration a naked man with his foot in a fire).
Descartes’ proposition was revolutionary at the time, given that prior to that the recommendation for dealing with pain was ‘pray to God for forgiveness.’
His theory stood unchallenged for some 300 years until pain science pioneers Ronald Melzack and Patrick Wall started asking questions in the 1960’s like ‘if pain travels from tissues to the brain, how is it that soldiers who have suffered amputation still feel pain in the limb that is no longer even there? (phantom limb pain)’.
To cut a long story short, Melzack and Wall helped us understand that Descartes actually got it wrong.
Pain does not travel from tissue to brain; there is no such thing as pain nerves or fibres.
Pain is an output from the brain, based on sensory information it is continuously receiving from multiple sources.
This sensory information includes not only mechanical changes in peripheral temperature or pressure (e.g. holding your hand near a fire) but also what we see, smell, hear, memories of past experiences, beliefs, emotion, stress, etc. (hence why our man with the nail in his boot was in such agony despite there being no actual tissue damage).
To put this into a runner’s perspective:
Let’s imagine you go over on your ankle whilst running.
Mechanoreceptors (sense changes in pressure and texture) and thermoreceptors (changes in temperature) send messages to the brain of potential danger (nociception) but it is the brain that decides whether / how much it will respond to these messages.
If you have a history of ankle sprains, the brain may decide that the threat is big enough to warrant some evasive action, so it sends out a sharp shot of pain.
However, if you have no history of ankle sprains and have no great cause for concern, the brain may decide to ignore the messages from the sensory receptors and you will continue running pain free.
Pain is a perception
This is not the same as saying pain is ‘all in your head’ or ‘in your imagination’.
All pain is very real, it’s just we need to appreciate that the source is not just tissue damage, there may even be no tissue damage.
Understanding that pain is multifactorial can help a runner examine more ways of reducing and ceasing pain rather than just focussing on just ‘treating’ the body part that hurts.
Pain is our most highly sophisticated form of defence, it’s the way our nervous system protects us.
Pain is the brain’s best guess at what is going on in the world around us, so if we want to reduce pain we need to consider anything and everything that could be increasing the brain’s perception of threat.
Although many of the common running related pain issues (ITB pain, patellafemoral pain, Achilles pain) do probably involve some irritation on a tissue level, it is nevertheless important to bear in mind that factors such as fear, worry, negative expectation and concern (even on a subconscious level) can increase system sensitivity and cause an elevated output of pain.
Research shows that poor nutrition and lack of sleep are two other major factors that can amplify the perception of threat.
The structural explanations that many runners attribute as the source of their pain e.g. poor posture, mal-alignment, degeneration, imbalances, tight or weak muscles are often not only wrong, but can also increase perception of threat and system sensitivity.
With the huge amount of either poorly expressed or downright wrong information that runners have access to these days via social media, books, dvd’s, fellow runners or therapists, many running related pains may have become amplified by already established cognitive beliefs, particularly if the pain is persistent i.e. longer than 3 months.
‘Injury’ an obsolete word
Though we are still a long way from understanding how pain works, what we do currently know means that on many levels the word ‘injury’ is becoming a rather obsolete word.
By referring to everything as a ‘running injury’ we perpetuate the erroneous and outdated belief that all pain derives from a ‘tissue issue’.
This in turn leads to an overdependence on structural treatments for pain (manipulation, massage, stretching, etc.) which though may temporarily help reduce symptoms generally fail to ignore the many other factors that we now know can influence pain and promote effective, long term recovery.
There is no magic wand for managing or treating running-related pain.
However, a good start is runners and therapists understanding that pain is multifactorial, meaning we always need to examine and address the biological, psychological and social factors, or ‘biopsychosocial’ for short.
Once serious pathology has been ruled out (if in doubt, always get checked out) and physical objectives noted (strength, proprioception, flexibility, mobility, etc.) assessment should always take into account the following :
- Lifestyle: how is your sleep, nutrition, level of physical activity?
- Personal beliefs: what do you think the problem is? What have you read, been told, etc.?
- Understanding of pain: why do you think it hurts?
- Previous experiences: have you had this pain/injury before? How did you deal with it?
- Psychological factors: are you worried, anxious, stressed? Is anything in your life adding to this?
Having a better understanding of how pain works is not a magic bullet to make it go away but it will give runners a far better tool kit for self management in times of pain and reducing the risk of future reoccurrence.
When you seek the services of an injury professional, be confident to ask them for more information. If they only seem interested in focussing on the body part that hurts, direct them towards this article.
Pain is a sign of defense not defect; it is our ally, it protects us; we need to learn to work with it as opposed to treating it like the enemy.
Happy Running!
Matt Phillips is a Running Injury Specialist & Video Gait Analyst at StrideUK (http://www.strideuk.com/) & Studio57clinic (http://studio57clinic.co.uk/). Follow Matt on Twitter: @sportinjurymatt
