Pain, pain … go away?

As a physical therapist, I usually get two questions from runners experiencing pain: 1) am I hurting myself? and 2) Do I have to stop running?

These are important questions to ask and the honest answer is that it depends. 

To get answers, a good place to start is to have a simple framework to understand the type of pain you’re experiencing. 

Pain is a feedback system in our bodies that gives us information about what is going on. Pain can signal us to issues with training load, how we’re coping with our current life stresses, or if we need to devote more time to recovery.

A common scenario for runners is this: you start training and everything is going great. You’re excited, motivated, and you feel really good. Running is fun.

Then the weeks of training start piling up. What once seemed like an early morning or after work thrill is now starting to interfere with your other responsibilities. Your body is starting to feel sore with no end in sight. Running is hard. 

Then, it happens. 

Pain. Not just soreness, but true pain. Running is … confusing. 

This is when the questions of “Am I hurting myself?” and “Do I need to stop running altogether?” arise in your mind. 

The first thing to acknowledge is that not all pain is the same. With some running injuries, like tendonitis, can heal even when you’re experiencing some pain. Other injuries, like bone stress injuries, will only get worse in the presence of pain. 

For example, pain that is worse in the morning, gets better as you move throughout your day, and worsens again late in the day is common behavior for tendon pain. Think of the achilles or hamstring tendons. This pain is annoying and uncomfortable, but it doesn’t have to stop your running. It should, however, change your training approach because your body is telling you it’s overloaded.

While working with a skilled physical therapist, you can continue to run with careful monitoring of your tendon pain. Your PT will help you find the “sweet spot” with running, meaning the amount of running you can currently handle without majorly aggravating your pain. From there, you can perform graded loading exercises to repair your tendon without totally scrapping your running goals.

Keep in mind that you will most likely have to alter your running plan, so it’s important to have a flexible mindset around training. It’s also important to rate your pain daily to track how it is trending. Tendon pain between 0-3/10 (0 is no pain, 10 is the worst pain you’ve ever felt) is considered acceptable and safe for tendon pain.

You can’t throw caution to the wind with tendon pain, but you can make gradual and systematic changes to your running and therapeutic exercise plan that will address your injury.

The biggest take away of tendon pain? Proceed running with monitoring and caution. Be flexible and patient.

Then, there is pain that feels like a deep ache. It is mild at first, but worsens when you run. This pain typically feels better in the morning and worse throughout the day as you’re on your feet. You might be able to touch a small painful spot on your shin or foot, or it may feel deep inside your hip joint or low back. At worst, this deep ache wakes you up at night. This type of pain is bone pain, a major red flag and a hard stop for running.

Achy bone pain occurs when the load of running exceeds your bone’s ability to repair itself. The bone starts to break down and pain occurs. Bone injuries exist on a spectrum from a mild stress reaction to full-fledged fracture. No matter where you fall on this spectrum, all running must be stopped immediately.

The difference between a mild and severe bone injury is the time off associated with it. Mild bone injuries will mean less time away from running while a bone fracture means significantly more time, anywhere from 6-8 weeks of complete rest if you’re healing well. Then, you’ll need a gradual and highly monitored approach back to running. It’s not just a “take-time-off-then-resume-running-as-normal” scenario. It will take time to get back to where you once were with running.

Depending on the affected bone, you could even need to use crutches or a walking boot to off-load the bone for a while. This is why it’s so important to address this type of pain right away when you first feel it. If allowed to continue, the pain, injury severity, time off running, and time getting back to running is much longer and more painstaking.

The biggest take away of bone pain? Stop. Running. Now. Get it checked out by your PCP or PT. Then your PT can help you make a plan back toward running while addressing the many reasons the injury may have occurred. (See RED-S posts here, here and here for more.)

Most of all, you need to interpret what your pain is telling you. Pain and injury can happen even with the best laid training plans. Factors like life stress, sleep duration and quality, nutrition, and degree of athletic identity can affect how your body will respond to training and can even influence pain intensity.

As you can see, the questions of “Am I hurting myself?” and “Should I stop running?” depend on many factors, including the type of pain you’re experiencing. To truly know when to stop running and when to push onward, visit your trusted physical therapist who can give you insight into your pain, guidance about what to do next, and will collaborate with you to make a long-term plan that prioritizes your health and running goals. 

Katie Noble is a Doctor of Physical Therapy, a journalist, and a runner. She enjoys empowering and supporting female runners with evidenced-based education.