You’re Probably Not Injured: Re-thinking How We Manage Athletic Pain

Course à pied

, by Matt Fitzgerald

Photography by: M2020

Athletes have long been conditioned to stop training when they start to feel pain. However, recent research suggests that perhaps the best treatment for an injury is... more exercise!

In his new book, Pain and Performance: The Revolutionary New Way to Use Training As Treatment for Pain and Injury, Flagstaff, Arizona-based strength coach Ryan Whited challenges conventional wisdom concerning pain and injury. Filled with intriguing new research, it teaches athletes that, in repetitive motion sports such as running, pain seldom equates to actual injury, and that the most effective treatment for most exercise-related pain experiences is . . . exercise!

An example is a 2017 scientific review published in the Journal of Orthopaedic & Sports Physical Therapy, which reported that, compared to rest, “hip and knee strengthening decreased pain and increased activity” in 673 subjects with patellofemoral pain (aka runner’s knee). Findings like these, combined with Whited’s hands-on experience with athletes at Paragon Athletics, the gym he co-owns with his wife, Betsy, have led him to develop an alternative to the medical paradigm for addressing pain, a self-management method he calls “Training as Treatment.”

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Issues with the existing paradigm

The problem with the existing medical paradigm, Whited argues, is that athletes often seek treatment for injuries that aren’t really injuries, over-relying on doctors and physical therapists in ways that are not without consequences. For starters, medicalizing pain deprives athletes of pain self-efficacy, or the belief that they can manage pain on their own, which is unfortunate because research has shown that high levels of pain self-efficacy predict better outcomes. Science has also shown that commonly used diagnostic language such as “imbalance,” “weak,” and “degenerative” foster a self-fulfilling sense of fragility in athletes, as well as kinesiophobia, or fear of movement.

Photography by: kovop58

What’s more, imaging and other techniques used to diagnose sports injuries are notoriously imperfect, as are many of the common treatments. For example, most meniscus tears are asymptomatic (an estimated one in twenty athletes has one without knowing it), but if you went to an orthopedist with knee pain and an MRI revealed a meniscus tear, it would almost automatically be flagged as the cause of your pain even though there’s a good chance it was preexisting. Worse, the most common treatment for meniscus tears is surgery, yet a 2013 study published in the New England Journal of Medicine found that patients who underwent a sham meniscus repair surgery were just as likely to get better as those who got the real thing.

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Re-defining aches and pains

Findings like these have led to the emergence of a new, biopsychosocial model of pain that defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The core idea here is that pain is complex and multidimensional, in contrast to the traditional view of pain as a simple and direct signal of significant tissue damage. Indeed, although we know that exercise is the most effective treatment for pain, it doesn’t work in the way that adherents to a strict biological conception of pain would expect. In particular, exercise reduces pain independent of its effects on tissue healing or strengthening, and often before these effects have time to manifest. Instead, it works through a number of less tangible mechanisms including increased pain self-efficacy and reduced kinesiophobia, descending analgesia (a drug-like change in brain chemistry that occurs during activity), desensitization (or reduced expectancy of and reactivity to pain), and a heightened pain threshold and pain tolerance.

Pain seldom equates to actual injury, and that the most effective treatment for most exercise-related pain experiences is . . . exercise!

Whited was intentional in choosing the name Training as Treatment for his method. In the medical paradigm, athletes train when they’re healthy, and when they’re injured they stop training and enter treatment. But athletes who work with Whited at Paragon Athletics learn that they are seldom truly injured and that pain is a normal part of the athletic experience. On top of that, no distinction is made between training and treatment. When athletes are pain-free, they train in ways that reduce the likelihood of pain interfering with their fitness development. And when they experience pain, they continue training, now with the goal of reducing pain and its limiting effects on fitness development.

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A four-step process when experiencing pain

The heart of Whited’s method is a four-step process that guides athletes forward when they are experiencing pain. Here’s a summary of the key steps:

1. Adjust your activity in your primary sport so that your pain remains at a tolerable level and doesn’t get worse over time. For example, avoid fast running to protect a sore Achilles or switch from outdoor running to elliptical running to reduce knee discomfort.

2. Temporarily suspend any strength exercises in your normal routine that cause a level of pain that feels excessive. Introduce one or more exercises that involve the painful area and don’t cause excessive pain. If your Achilles tendon or your knee hurts, use it, but get creative in finding ways of loading the area that feel helpful.

Elliptical trainers offer a suitable alternative to outdoor running. Photography by: NDAB Creativity

3. When the new strength exercises become easy and/or when your pain level decreases noticeably, replace one or more of the exercises you’ve chosen with others involving the painful area that are more challenging and/or stimulate a little more pain. When these exercises in turn become easy and/or your pain level decreases further, swap them out once more. While the specifics depend on the location, nature, and severity of your pain, in most instances, this process starts off with isometric movements, where you hold a muscle contraction, and terminates with explosive movements.

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4. At the same time you’re going through the process detailed in step 3, gradually reintroduce elements of your normal training in your primary sport as your pain allows.

One word of caution: Not all pain experiences can be successfully self-managed. If the pain results from acute trauma (e.g., you fall and hit your knee), or if it is accompanied by “red flags” such as numbness or weakness, incontinence, significant bruising or swelling, deformation (e.g., a bulge in your lower abdomen), seizure, loss of consciousness, confusion, or a gut feeling that something’s not right, seek medical help. As Ryan Whited is the first to admit, the fact that athletes have been taught to rely too much on doctors doesn’t mean we should never rely on them!

  • For additional guidance on the Training as Treatment method, pick up a copy of Whited’s book (full disclosure: I coauthored it!) or visit his website.