CHAPTER 26

THE PAIN GAME AND HOW TO CONTROL IT

The symptom of pain is a subjective yet important part of endurance sports. It’s an emotion our brain relies on for survival, helping us get to the finish line, or telling us there’s a problem somewhere in the body. While pain is felt in the brain, the body parts that produce it may have either physical or chemical causes.

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Pain is how our body tells us to slow down or rest so it can repair itself. While pain is often the symptom associated with muscle imbalance, the gut can produce pain from cramping, a common problem in athletes. Pain medications, which only treat the symptoms, not the cause, are among the best-selling prescription and over-the-counter drugs worldwide.

Pain’s many cellular chemical compounds are even triggered by certain substances that are directly associated with the balance of fats. Too many omega-6 fats, including some saturated ones, can promote the production of more pain-producing chemicals. The same mechanism promotes excess inflammation. With acute pain, these changes are an important, healthy part of the healing process of recovery from easy workouts to hard events. But pain can become chronic, which is not normal or healthy.

There are at least three possible causes of chronic pain:

 

 

 
  • The problem that caused the pain is unresolved. For example, a muscle imbalance causing stress in the knee joint can cause inflammation and pain. Until the cause of the problem is corrected, inflammation and pain will continue.
  • Even when the physical cause of the problem is corrected, the chemical imbalance associated with poor fat balance may still be present. Until this problem is corrected, pain-producing chemicals (including those of inflammation) can continually be produced.
  • Certain types of brain cells, called glia, can become overactive following some injuries that have caused pain. These cells can continue to stimulate the pain in the brain even after the original cause of pain has resolved. And certain pain medications, especially morphine, seem to actually worsen this process. What triggers the glia to become overactive and act in this fashion is not well understood by scientists. Some substances can potentially turn off the overactive glia. These include THC, the active component in marijuana, and stronger prescription drugs (immune suppressant drugs such as etanercept and narcotic receptor blockers such as naloxone).

Pain starts in nerve endings found in the skin, blood vessels, nerve fibers, joints, and coverings of bone. These nerve endings send messages through the nervous system to the emotional center of the brain (called the limbic system), where we interpret the feeling as pain. Call it an emotion, a feeling, or a mental state—it’s simply an interaction between the body and brain. This is why pain is relatively subjective, with no two people feeling it the same. If pain were a true sense, like smell, taste, vision, or hearing, it would be much more difficult, if not impossible, to control it with physical measures (applying cold), chemicals (taking aspirin), or mental measures (through hypnosis).

Once pain messages reach the brain, the brain sends messages back to the source of pain in order to release natural analgesics such as endorphins. The spinal cord, comprised of nerves that go from the brain to the body, is the relay station for pain perception. This is one reason that “spinal blocks” can reduce pain.

The cause of a problem that produces pain is usually located where the injury occurred. But many times pain is associated with problems elsewhere in the body, or with problems that don’t produce symptoms. To those with non-traumatic pain in or around the knee, the physical cause of the pain is likely due to muscle imbalance in the foot or ankle—and is often silent (asymptomatic). This is one reason so many knee problems never get fully corrected and become chronic; the true cause remains undetected and only the symptom is treated.

The gradual development of knee pain is a phenomenon I have seen and heard from countless endurance athletes who limped into my office. The chronology of a typical patient history went as follows: slow onset of knee pain, then, after several weeks, more severe pain. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) improved symptoms by reducing pain and inflammation somewhat, but the pain kept returning and restricted training. Running typically made the pain worse, so biking and other activities such as swimming were used to maintain activerecovery fitness. Racing only worsened the pain, and in time, competition was restricted or eliminated altogether. Several other remedies were tried, including various therapies applied to the knee—the usual ice, creams to dull the pain, rest; therapies for feet, including orthotics; trying different running shoes; and others administered by various healthcare professionals. Some of these approaches appeared to help temporarily, but the pain soon returned. In some cases, the pain disappeared only to show up in another location around the knee or even in the hip joint.

As simple as this may sound, I’ve seen many hundreds of athletes with just this type of injury. Often, it marked my first encounter with them. My comprehensive evaluation of the athlete usually revealed an imbalance of some of the muscles of the foot and ankle, causing mechanical instability of the ankle and stress in the knee. Correction of the foot problem through the use of biofeedback would often quickly resolve the knee pain and the athlete was happily able to return to normal training and competition.

More importantly, a positive outcome often affected the athlete in another positive way—he or she learned to look at the big picture such as diet, stress, training, and other lifestyle factors.

Unfortunately, some athletes I’ve helped overcome a significant injury could not relate well to the big picture. While they relied on me to fix their physical problems, they would not improve their diet or training, and when another injury cropped up, they would visit me again for repair. I would expend significant energy trying to educate them—explaining that injury means they’re not training well, eating well, or have other problems that need correcting. I also told them that by fixing their injury, I was simply treating symptoms and they were basically not allowing me to correct the true cause of the problem. For those few who could still not understand or were unwilling to comply, I would reluctantly decide that I could not see them, since there were many other injured athletes on my waiting list who wanted to see me.

One benefit of pain, however, is that it informs us there’s a problem. By doing so, it can help the body compensate by using other muscles or changing the running gait to avoid further stress on a particular joint that’s inflamed. It can also prevent us from continuing activities that should be avoided. Different types of pain such as throbbing or swelling have particular meaning. For example, physical pain can be associated with increased pressure, such as a swelling, typically from trauma. This type of pain is often described as “stabbing” or “knifelike.” Or if it’s associated with blood vessels, sufferers experience it as “throbbing” or “pounding.”

Chemical pain often comes from inflammation and muscle fatigue. This type of pain is often described as “burning” or “hot.” Thermal pain from extreme cold or hot temperatures can also produce pain. This may be due to an ice pack left too long on the skin or sunburn. In fact, sunburn pain can come from all three types: thermal stress (hot sun), physical damage to skin, and chemical inflammation.

Songwriters and novelists have longed portrayed the extremes of emotional pain, like losing a loved one. Athletes are not immune, of course, to grief and sadness. Studies show that an athlete’s response to a season-ending injury or dropping out of a major race can be emotionally traumatic.

Emotional pain may be experienced in the same brain areas as physical pain. In addition, emotional pain can be stressful enough to adversely affect training and racing. This can occur due to the brain’s relationship with adrenal function. While training usually helps those trying to cope with emotional pain, overtraining may worsen it.