I am a physical therapist who specializes in treating 1) runners and 2) people with chronic pain. I used to think of these as two very separate categories. But with time and clinical practice I’ve realized the continual overlap and similarities between these groups. Time and again, I continue to apply pain science education – the hallmark of treating chronic pain – to runners and running injuries.
A principle to improving chronic pain is understanding how pain works and can affect the human body. It’s also important to understand that not all pain is harmful and should stop all exercise. This message can be hugely beneficial to runners, who are bound to experience pain due to training at some point. It’s imperative to be able to interpret our body’s signals and respond accordingly, rather than ignoring it or panicking.
What is chronic pain? By definition, chronic pain is pain that has been bothering you longer than 3 months. But the patients with chronic pain who I treat have usually been experiencing pain for years. Chronic pain is often felt in the spine, but it can be felt in any part of the body, especially areas of past injury. Chronic pain doesn’t always correlate with activity, meaning it doesn’t necessarily get worse with exercise but it often makes a person feel afraid to move normally..
In this article, I’ll discuss how runners can benefit from the principles of pain science.
The body is an ecosystem. Runners are often subject to the idea that asymmetries in their bodies are the causes of pain, like leg length differences or pelvic misalignment. It’s not as simple to say that the body needs to be in alignment and you’ll run efficiently and feel great. Truth be told, I’ve never treated one runner who’s “hip alignment” made any difference in their injury recovery. The human body is not a car. Our ecosystems are complex and include factors like joint congruency and bone health; muscular strength, resiliency and capacity for work, as well as our functioning nervous systems. All of these complicated tissues are attached to and controlled by the human brain. Telling ourselves that our pain will be resolved by the alignment of our hips or our leg length is too narrow a view to take. We should expand our view to include all relevant factors that make us happy and healthy runners, like training behaviors and beliefs, past injury and your response to it, and your current understanding of what might be happening when an injury occurs. Your ecosystem is maintained by your physical training habits as well as your beliefs about pain, load, and how you handle physical and mental stress.
Movement is medicine. Your approach to movement matters. Pain science literature focuses on building a tolerance to physical stress, rather than putting exercise or activities into “good” and “bad” categories. I have interacted with many people who have been told they should “never run again” for some reason or another. The reasoning is never sound. If you want to run, you can. Starting with the right “dose” of running and gradually building your tolerance to the activity will help you be successful. It can also help avoid the “all or nothing” approach, which usually ends with burnout, injury, and buying into the belief that running is truly bad for you. It’s not. In fact, research shows there is no increased risk of knee osteoarthritis among runners compared with non-runners.1
Your body is resilient, even when experiencing low back pain. Up to 80% of American have experienced low back pain at some point in their lives, and that number includes runners. I have treated runners who experienced low back pain from training or had an acute exacerbation of back pain that was unrelated to running. Just because you may have low back pain does not automatically mean you’re hurting yourself. The spine is the most stable structure in the body and is meant to withstand a lot of force while moving through a relatively large range of motion. The spine likes to be loaded, so stopping all running, exercise, and movement due to back pain often makes the problem worse. I experienced low back pain at the age of 19 when I was competing as a collegiate runner. This pain didn’t happen because of my age (a common myth I hear from people), or because my spine was misaligned (another common myth), or because my glutes were weak (yet another common myth). It happened because I was applying too much running volume, intensity, physical and mental stress to my body in a short time without allowing myself the time to recover and adapt.
There is no ideal way to run. This can be a hard one for runners to believe. We’ve all been told about the “dangers of foot pronation” and that we should all have a cadence of 180 strides per minute just like the pros, and we should all land on our forefoot (opposed to our heels). While these tidbits may have come from a good place, broadly applying these concepts to runners is illogical at best and mentally and physically destructive at worst. Pronation is a normal part of the running gait cycle that helps the foot attenuate energy and force. Increasing cadence may lessen tibial shock and knee pain, but it sends stress down to the calf-ankle complex. Imposing these loads on a body part that isn’t yet ready to handle it can lead to injury. I love performing detailed running gait analysis on runners but I’ll be the first to tell you if you don’t need one. Running gait analysis can help give insight into how your body exerts and absorbs stress. Those movement patterns may correlate to current pain or past injury. But running gait analysis does not exist to turn you into a robot runner. You need to move like you. Gait analysis and retraining isn’t meant to change a runner’s entire movement system but rather to introduce new ways to move into their existing patterns. I like to explain to patients that they have a current “movement library” to choose from. Gait retraining will help expand the options in the library, not replace the current collection.
Working through chronic pain is a process. It takes time to get over pain, even though an injury has healed, but stick with it. It’s a slow but steady process where you’ll gain critical tools to help yourself heal now and in the future. It’s important to remember that pain doesn’t always just go away and never comes back. There are times when we feel more pain and times when we feel less. Pain is a normal part of being a human and the presence of pain doesn’t necessarily have to hold you back. Pain is a signal meant to be interpreted to sometimes change our approach and at other times to be worked through. A skilled physical therapist can help you interpret pain signals and collaborate with you to make a plan to move forward.
The overarching concept of pain science is this: our bodies are strong, resilient and adaptable. Pain should be respected but not feared.
1. Roberts W. Running causes knee osteoarthritis: myth or misunderstanding. Br J Sports Med. 2017;52(3):142-142. doi:10.1136/bjsports-2017-098227
Katie Noble is a Doctor of Physical Therapy, a journalist, and a runner. She enjoys empowering and supporting female runners with evidenced-based education.
Dr. Katie Noble, PT, DPT, SCS 