by Zach Ripley, co-founder of AtoZrunning and Running Coach

Embracing Pain and Injury

I was just as distressed as you are about to be when I read the 2010 study from Current Sports Medicine Reports that indicated “40%-50% of runners experience injury yearly.” We already know that running pain and injury is common, but numbers like that make it sting.

If we’re counting any small strain or some such as an injury, perhaps it’s not a stretch (the study indicated anything that necessitated any interruption in training). What such news ought to be, though, is a call to action. 

If we run, we know these two things with certainty: pain and injury are inevitable, and despite all, the times between make it worthwhile. This examination will simply better equip us to deal with the pain when it strikes in a manner that decreases the disruption to our training.

Understanding Pain

In college, I used to be known for gingerly approaching my coach before practice to announce, “Hey boss, when I do this thing and move in this very particular way, this other thing hurts in this very precise spot.” Any guesses how said coach most often responded? 

Don’t do that thing. 

He was on point for calling out my absurdity. Unfortunately, this also seems to be the most common reaction from general doctors when approached by a runner with a running pain. Stop running for a bit, and it will stop hurting. Right?

Pain is more complex than that, though, and warrants some amount of reflection. We will present in this guide our basic approach to responding to pain, and in order to do that, we need to clarify what we mean by pain.

We are all familiar with such terms as soreness, tightness, aching, burning, stinging, and the like. Let’s apply a simple caveat here: pain is the body’s signal that something is amiss. That signal always means something. That doesn’t always mean it is an especially notable or significant something, but as runners, our first priority in dealing with pain is understanding to what degree notable intervention is needed. 

When considering whether a pain is notable and worthy of significant intervention, apply these parameters:

• Has it been hurting for 2-3 days in a row?
• Is it acute and asymmetrical (hurts on one leg but not the other)?
• Does it progressively worsen during activity?
• Does it hurt even outside of activity (sitting, standing, walking, sleeping, etc.)?

When these questions are affirmative, we know we have an issue that may benefit from further attention. Yes, it gets more complicated than this. Location matters, the specific nature of the feeling matters, and plenty of other things, but most of us do not have the luxury of complex diagnosis when it comes to the random pains of running. These are generally fairly effective filters for most situations.

Minimizing Risk

Before noting the process for responding to pain, reflect a moment on some fundamentals. Most of us prefer to either ignore pains until they blow up or treat every pain like it’s cause for an MRI and a surgery consultation. Without knowing exactly the balance, it’s safe to assume that a lot of the day-to-day discomforts we experience can likely be resolved by better general care. 

Wherever we are in the pain spectrum, we ought to be reminding ourselves to attend to those most basic needs:

• Nutrition, hydration, and sleep all contribute to how resilient our bodies are as well as how quickly and effectively they recover. Imbalance or shortcomings in these areas are sure to increase risk.
• Unimpeded movement is another basic necessity for the body, so things like simple regular myofascial release techniques go a long way (runners love their foam rollers, but things like graston technique and other more precise methods are often even more effective).
• Supple and pliant tissues tend to respond to exertion better, so consider something as brief as a gentle massage with an emollient to a tight area before activity.

With regular positive habits around such things, we’re reducing our risk of injury. And yes, we’ll talk about the general strength and mobility work that we all need in our routine. In a moment. First, assuming the pain is persisting despite such optimizations, we can readily assert that intervention is necessary.

Overcoming Injury

The process for addressing pain and injury (or possible injury) begins with identifying whether the pain is notable. Having done that based on the criteria above, we know that an adjustment is needed. This process is our four-step graduated approach.

Step 1: Jog easy for 2-3 days

The most important intervention we need in our repertoire is easy jogging. Set aside the yoke of, “I must follow the plan” and replace it with “I must remain healthy.” Easy jogging instead of a hard effort or even just scaling back an easy day to a minimal effort jog can make a big difference on both reduced stress to a potential injury as well as increased blood flow to an area that needs a little extra.

We know we are on the right track when the nature of the pain reverses, so after a day or two of jogging, progress should be notable. If indeed progress is made but the issue is still present, add a couple more days of jogging to see if it continues to improve.

After those few days of jogging, if the pain is minimal or gone, ease back into regular training (emphasis on ease back in).

If the pain is not improving or is worsening even or if it returns repeatedly after trying to ease back into training, it’s time for the next step.

Step 2: Rest for 2-3 days, then jog

When easy jogging isn’t helping, our next step back needs to be rest. For runners, rest doesn’t mean lay on your bed all day (although I suppose it also means that…). In this instance at least, we mean no running. That time can indeed be used in other ways, and one of them ought to be some TLC to the hurting area. Cross training in a manner that causes absolutely no discomfort to the concerned area is also a good move, but we shouldn’t go crazy. 

While off, if we’re doing the good work with things like nutrition, hydration, therapy, etc., we should see fairly swift healing if the issue is tissue-related. Having done that, we next try some light jogging for 2-3 days to be sure things are feeling good and the concern has improved. This then effectively moves us back to step 1, and we advance accordingly.

Therefore, as we jog, if the pain is diminishing or absent for a few days, we can begin easing back into regular training. However, once more, if the pain returns immediately or begins to worsen again, we need to think about advancing another step further.

By the way, this is also the stage in the process where we recommend you get some outside eyes on the issue. If a pain is bad enough that we have to take a few days off running, then it’s bad enough to have a medical examination that preferably involves a visit with someone who knows runners and running injuries. Sports medicine is always a good place to start. If you don’t have someone, we highly recommend Adam and his team at Endurance Rehab, and if you’re not in the West Michigan area, they do virtual injury screening as well! (No, we do not get compensated in any way for these recommendations.)

Step 3: Rest for 1 week, then jog for another

We tried a couple days off to no avail, so the next step up is a full week off followed by another week of minimal effort jogging. The week off is intended to be a maximum recovery time, so we reduce all activity levels and especially avoid ANY activity that causes irritation or discomfort to the pain area. If sitting in a certain way makes us sore later, we sit in a different way. 

Rest alone is rarely the most effective way to maximize recovery, though, so just as before, we increase all activities that improve things like blood flow and supportive nutrition. Depending on the pain (tissue vs. bone, etc.), certain micronutrients can be helpful in larger quantities. We do recommend care here, as overdoing nutritional supplementation can also have negative side effects. A little boost goes a long way.

Along with drinking lots of water and taking the vitamins and minerals, we attend to areas of tightness and weakness, spending time every day (if not two or three times/day depending on the nature of things) releasing, mobilizing, stabilizing, etc. Once again, though, we do nothing that causes irritation or aggravation.

After that week of rest, we use another week to jog back into training. We start with a day or two of walk/jog to build confidence and ensure pain-free activity. Then we try a solid jog. Then we add a little more time for a few days. By the end of that week, jogging needs to be totally pain free for at least 60-90 minutes. Once there, we are ready to ease back into full training, keeping hard efforts very light at first and avoiding extremes.

If we can’t jog pain-free or if we start back into training and the pain returns or persists, we’ve exhausted our options and need to move into the final step, the full injury protocol.

Step 4: Reset button – 2 or more weeks off and an injury protocol

This is the sad step but absolutely necessary if we can’t get back to pain-free running: a full stop in training and an injury protocol period of at least 2 or more weeks. What is an injury protocol? In these terms, it means 

1. seeing a medical professional (if not already), 
2. seeking diagnosis for the injury (something notable is wrong and needs to be clearly established if possible) by pushing for things like scans or specialist visits, and 
3. expecting a period of downtime and cross training.

We have something serious wrong, and we need to take it seriously. If it turns chronic (or already is), it can cast shade on years of running. None of us want that. 

This period of time is defined by rest until further notice (or at least 2 weeks) as well as a reset of season plans and goals. This doesn’t necessarily mean canceling the goal race, but there’s a good chance it does mean we need to set aside performance goals for now and focus on getting fully healthy and running pain-free. There’s no sense in contingency plans or what-if scenarios here either. We can’t start thinking things like “If I am back to training in 3 weeks, then I can get these efforts in still and be good by this date…” That is unproductive thinking.

Instead, we follow the following steps in terms of both our thinking and our actions:

1. Diagnose the issue and establish a plan for addressing the cause.
2. If possible, seek an alternative training option (cross training) that in no way risks the rehabilitation process but allows for aerobic activity of some sort.
3. Focus on rebuilding strength and stability.
4. When pain-free running is possible, very gradually increase to a full training load of easy jogging.
5. When a full training load of jogging is possible, revisit training goals and plans and resume regular training.

And perhaps it warrants mention that this tends to be the time when most runners go to the dark places: increased anxiety and agitation, isolation and cynicism, entertaining unhealthy habits. The most important thing we have to remember is that these things are very nearly guaranteed but almost always temporary.

While there does come a time for every runner when the running days end, we shouldn’t speed that along by making poor choices with our pain.

Isolating Malfunction

Beneath every pain is a negative stimulus, a cause of some form or another. Excepting such pains as are caused by obvious instigators (falling, stepping on something, fighting with the neighbor dog [again]), notable running pains usually demonstrate malfunctioning physiology.

Therefore, while a good pain and injury protocol makes a big difference in reducing chronic concerns and speeding a return to healthy training, few problems ignored vanish of their own accord. We’ve noted the need for consulting professionals who deal in running pains and injury. That’s an important step, but the purpose of such interactions should always be the identification of malfunction and restoration of sound function.

Let us not be content to live with “that bad knee” or “that creaky achilles”. Phil Wharton famously notes that in his twenties, he was told his scoliosis was so bad that he would never run again. Neither he nor his father were willing to accept that, and years later he would ultimately run 2:23 in the marathon and has been running for decades. How? They identified the malfunction and restored it.

Finally, remember that the malfunction is not always physiological. It can be poor training decisions, unhealthy life habits, and much more. If you listen to our podcast, you’ve heard us say (far too often) that all runners ought to be students of the sport. Learn about sound training practices and the science of movement. Learn about energy systems and the role of nutrition in function. Learn about motivation and the effects of stress. 

Then find the gaps and fill them, starting with acknowledging that pain means something, so attend to it.