Pain Management in Three Steps: Mechanism, Trajectory, and Action

The degree of overlap between physical medicine and endurance performance is striking. At the root of each is pain management. With running, it is well known that pain is an inevitable part of the process, and with peak performance, pain is a given.

In physical medicine as in running, pain is information. It is neither bad nor good. As noted in one of our previous articles on pain physiology, pain is “a system output based on sensory input the brain perceives as a threat.” In short, pain is a protective output meant to keep us from harm.

Accepting that, pain it isn’t always an accurate indicator of actual danger. Slight issues can hurt a great deal. Major injuries often don’t hurt at all. This is also true for ultramarathon running: we may often feel extreme pain (or fatigue, or malaise) at, say mile 30, only to feel much better by mile 40, only to feel terrible yet again, at mile 50–all without changing anything.

So what gives? Which is correct?

• “No pain, no gain;” or
• “If it hurts, don’t do it.”

The answer: neither. It’s more nuanced than that. We need more data!

The two most common groups of patients I see clinically are:

1. Pain Ignorers. These folks ignore all pain, which often results in real tissue damage. These folks like to brag about their “very high pain-tolerance!”
2. Pain Freak-Outs. These folks stop in their tracks when they experience any pain at all.

Neither approach is sustainable. To patently ignore all pain is to drive off a cliff–real injury and long-term damage can be done. But to freak out and stop with every bit of pain? You will literally go nowhere.

As such, pain management is about helping navigate clients–patients and runners–through what the brain is trying to tell us. “Is this information actionable? Or is it something I can dismiss?” Counseling patients through a difficult injury and coaching runners through a tough ultra has tremendous similarity.

When experiencing pain, it’s important we assess three factors: mechanism, trajectory, and action.

Mechanism

If something starts to hurt, question number one should be, “Is there a reason?” For orthopedic pain, is there a mechanism of injury? Possible mechanisms include:

• Volume. Increasing activity volume (distance, time, repetitions) too quickly.
• Intensity. Activity is excessively intense (effort x time).
• Inefficiency. Activity is inefficient (running stride, posture).
• Trauma. Either acute or subacute (a fall a week ago that altered joint mobility or running mechanics, then see ‘inefficiency’ above).

For endurance-performance issues such as fatigue, nausea, bonking, or generalized pain:

• Hydration. Have you been over- or under-drinking?
• Nutrition. Has fuel intake changed (different fuels, different rates) or is somehow deficient?
• Pacing. Is the effort appropriate for your event and distance? Too hard? Too easy?

If there’s a known mechanism, there may a reasonable–and often actionable–threat to well-being (see below for ‘action’).

However, absent of a mechanism? The threat may not be real. For various reasons–ranging from aberrant ‘zaps’ of pain to generalized hyper-sensitivity–sometimes things hurt. Or, when racing, even when strategic execution is perfect, we can feel ‘low.’

But absent a logical mechanism, and when the symptoms are fleeting–they come and go in less than a few minutes or miles–the vast majority of the time, there is no real threat. The best course of action is to continue with caution.

Trajectory

When experiencing pain, it’s important to ask what is your body trying to tell you. Sometimes the best course of action is to stop, but just as often, pain is information to keep going! Anyone who has experienced ‘tendinitis’ knows that healing tissue needs remodeling stress, and it is often painful.

So if ignoring pain can make an injury worse, and failing to remodel can prevent healing… how do we know which is which? Part of the answer lies in its trajectory:

• What (and where) is the pain now?
• Where was it before?
• Where is it going?

Short-lasting, random pains–no matter how severe–are not a threat. They are blips on a radar, nothing more. Without a trajectory, they are simply random (aberrant, or hyper-protective) sensations. The same goes for mid-race malaise: short-lasting, transient ‘low points’ in a race mean nothing. Suffering isn’t ideal, but it’s not necessarily damaging.

Trajectory is everything. For orthopedic pain, tight structures can start out painful and get far worse over the course of a single mile. But that’s only a mile. Here is a typical dialogue between a patient and me:

Patient, “I had bad pain the first mile, so I stopped.”

Me, “Well, how do you know it wouldn’t get better in the second mile?”

For chronic, stiff tissues, pain nearly always improves after that first mile. Failing to push beyond that point is inadequate remodeling stress. Likewise, if we all stopped or dropped out of races after a short bad patch, or if the first several miles don’t feel great, no one would finish races.

A normal trajectory for stiff, healing tissue includes:

• < 5 minutes: moderate to no pain
• 5 to 10 minutes: worsening (and often severe) pain
• >10 to 30 minutes: little to no pain
• >30 to 60 minutes: pain gradually increases

At that latter point, when pain increases, this is time to take pause: is it time to take ‘action’ (see below), or time to stop? Otherwise, pain early in a run–even if severe–is okay, if it quickly goes away.

The same is true for ultramarathon suffering: any issue that goes away in a short amount of time is not a threat.

However, any issue–orthopedic or race–that starts out mild then gradually worsens represents a threat. This is a negative trajectory, and it will likely only get worse unless ‘action’ (again, see below) is taken.

The gray area is when things stay the same. For orthopedic injury, the key is to look at the bigger picture, beyond a single run, and toward a daily or weekly plot. Improvement is:

• same (low-level, consistent) symptoms while undertaking increasing activity
• same activity, less (day-to-day, week-to-week) symptoms

In ultras, if malaise stays at a low but manageable level, the key is to simply continue. Execute your pacing, hydration, and nutrition plan, and keep moving. If your issue is stable, each passing mile represents improvement toward your finishing goal.

Action

If you’re experiencing pain, have a mechanism, and have a progressive and negative trajectory, it is time to take ‘action.’ Like we say in our ultrarunning circles, “Solve your problems.” Drink, eat, salt, stop and fix that blister, or change your shoes. Or, slow down, cool off, or rest for a spell.

In physical medicine, it’s about changing yourself or your environment in response to the pain. All of my clients get a home exercise plan, not simply to stretch and strengthen, but for use as a pain-relieving tool kit. Like a running belt or hydration vest, they can go into that plan, utilize a technique, and often get symptom relief.

Moreover, efficiency is also a tool. If inefficiency is a mechanism, changing how we run can have powerful and immediate impacts on pain of both kinds. Optimizing efficiency–and having real tools to do so–is a powerful strategy.

That said, when you’ve used all the tools in your belt, but you still have symptoms, it is time to stop. For a sensitive (or emerging) injury, unremitting pain means we have met (but not always exceeded) tissue tolerance. Thus, the only course of action is to stop, rest, and try again later.

This, too, holds true for ultras. If eating, drinking, stretching, changing something, and resting fails to fix you, it’s simply not your day. Pushing on may get you to the finish line, but it’s a dangerous gamble that you may create more serious or prolonged damage as a result.

Below are two recent client case studies that highlight the challenges of pain management:

A 20-year-old male runner, ‘Andrew,’ came to see me for Achilles tendon pain. It began to hurt him in the early summer, and he tried to push through it, but when it worsened, he was forced to stop running. When he came to see me, we restored mobility, improved strength, honed efficiency, and put him on a progressive return-to-running plan. A month into his recovery, he messaged me to state that he had a setback. He wrote, “I had very sharp pain my Achilles!’ This worried him, and he took several days off running as a result.

Another client is ‘Maddy,’ a 50-year-old woman with sudden-onset right-foot pain. She has a history of foot sensitivity (including a diagnosis of arthritis in her big toe). While on vacation, she both ran and hiked much more than usual, which resulted in progressive stiffness and soreness in her lower legs and feet. Prior to her prescribed long run, her feet were hurting her significantly, which prompted some reservations about even starting the run. She went anyway, on a long, out-and-back route in a remote area. When the pain worsened, she continued on, as she had no options (other than to walk) to finish the run. As a result, she severely flared her foot, which included a trip to urgent care for severe pain.

Looking at these two cases, let’s break down their mechanism, trajectory, and action:

Given the conventional pain-management wisdom, it’s difficult to fault the decisions either Andrew or Maddy made. After these episodes, I spent time with both runners on the ‘mechanism, trajectory, and action’ approach:

• Because his symptoms were both familiar and severe, it’s understandable that Andrew was worried. However, since his symptoms were short-lasting (a sharp but come-and-gone stab), did not occur during running, and occurred during an otherwise normal, safe, healthy, low-stress activity (climbing stairs), his situation lacked both mechanism and trajectory. His better course of action would have been to test his Achilles with other activities (more steps, light hopping, running drills) in order to establish a trajectory before resigning himself to prolonged rest.
• Maddy has a history of chronic pain, including general hyper-sensitivity, and has often had to ‘work through’ symptoms in her training. However, her error in this case was failing to acknowledge the negative symptom trajectory during the week, as well as the significant mechanism of injury (which was obvious when tallying the vertical gain in her training log). That she had symptoms–and doubts–before even starting the long run is evident of an impending flare.

In summary, pain is information. That it’s not always accurate is a major challenge in both health and well-being and optimal running performance. But just as it makes my job a challenging (and fun) balancing act, so too is pain management in ultrarunning. Pain is inevitable in running and in life. Listen, reflect, and using your best judgment, act accordingly. You’ll ultimately do your best, and in the end, that’s all we can do.

Call for Comments (from Meghan)

• Can you apply this ‘mechanism, trajectory, and action’ approach to the last pain issue you experienced or are currently experiencing? What new perspective does doing so offer that situation?
• Have you ever experienced pain that didn’t seem to have a source, and that came and went without much warning? How about feeling an unexpected ‘low’ during an ultramarathon when you were executing your race plan well?