Ryan Whited

I’ve always considered myself an injury-prone runner. I used to half-jokingly say that I had suffered more running-related injuries than any runner my age in the history of running, and it wouldn’t shock me if this turned out to be true. Between the ages of 28 and 48 I picked up no fewer than four major injuries—right knee, left Achilles, right hip flexor, and left hip flexor—that each kept me out of competition for more than a year. And those are just the big ones. I’ve dealt with dozens of smaller breakdowns that have sidelined me for days or weeks.

Early on, some of my injuries were caused, at least in part, by training errors. But while I may be slow to learn, I do learn, and eventually I stopped making stupid decisions in my training. I did not stop getting injured, however. Clearly, then, training errors were not the real reason for my proneness to injury.

In the early 2000s, a structuralist paradigm of nontraumatic sports injury became ascendant. According to this model, so-called overuse injuries are caused by flawed movement patterns which are in turn caused by musculoskeletal imbalances, particularly overly weak and overly tight muscles. The way to prevent such injuries, according to this model, is to iron out such imbalances through strength and mobility training.

It was all very pat, and I bought in completely, doubling down on strength and mobility training in a quest for corporeal balance, but all for naught. The injuries kept right on coming, same as before. So I wasn’t too surprised when the structuralist just-so story began to fall apart, with study after story failing to validate the model’s predictions. Just recently, for example, Medicine & Science in Sports & Exercise published a study by Irish researchers titled “Do Injury-Resistant Runners Have Distinct Differences in Clinical Measures Compared with Recently Injured Runners?

The short answer was no. Two hundred and twenty-three runners, including 116 who were recently injured and 61 whose last injury was at least two years past, were subjected to a battery of tests of musculoskeletal balance. The only difference observed was slightly greater hip abduction strength among recently injured runners, causing the researchers to conclude, “Commonly used clinical measures of strength, joint motion, and functional foot alignment were not superior in injury-resistant runners compared with recently injured runners, questioning their relevance in identifying future injury resistance of runners.”

So it appears that my ongoing susceptibility to injury is caused neither by training errors nor by musculoskeletal imbalances. What, then, is the true culprit? A clue comes from the fact that all of my major injurious have been tendinous. I’ve never experienced a nontraumatic bone injury and I can count on one hand the times I’ve strained a muscle over the past 50 years. Yet this clear pattern escaped my notice until 2015, when I stumbled across an article about the genetic underpinnings of injury in The Atlantic.  From it I learned about a gene called COL1A1 that affects the consistency of collagen in connective tissues, certain variations of which are underrepresented in frequently injured athletes. I’d be willing to bet my life savings I’m one of them.

Mystery solved? I’m not so sure. Lately I’ve been taking a deep dive into pain science as I collaborate with Ryan Whited on a book about self-managing athletic pain and injury. One of the things I’ve learned is that the vast majority of nontraumatic athletic injuries aren’t really injuries. They’re pain experiences. In other words, the pain is real but there is no significant underlying tissue pathology. Upon learning this I felt the hairs on the back of my neck stand up. I’d had imaging done on three of my four multiyear injury sites, exploratory surgery done on the fourth, and in all four cases no significant tissue pathology was found. I was in pain but not injured.

Ryan subscribes to a biopsychosocial model of pain which holds that pain experiences are always multifactorial, with nontraumatic musculoskeletal “injuries” being no exception. There is almost always some kind of tissue insult at play, but psychological and social factors are involved as well. As many readers of this blog know, my wife, Nataki, has bipolar disorder. Throughout the long period when most of my injuries occurred, I was under tremendous stress as Nataki and I struggled together to manage her condition. But in 2013, a few things fell in place, our lives gained a level of stability they’d lacked for more than a decade, and my injury rate subsequently plummeted.

I’m not blaming my injuries on Nataki’s mental illness, mind you. I’m attributing my frequent pain experiences to life stress and to my inability to manage it. Pain and stress are almost the same thing, as psychiatrist Claire Lunde and pain scientist Christine Sieberg of Boston Children’s Hospital explain with great cogency in this review paper. Others have described pain as a cup that’s running over. The cup itself is your physical and mental stress receptacle. Stress of all forms ranging from marathon training to trying to keep yourself and your spouse safe in the midst of a mental health crisis go into the stress receptacle. When it fills up and begins to flow over, you become symptomatic. Anything you can do, therefore, to keep new stressors from entering the cup or to siphon existing stressors out of the cup will reduce the likelihood of symptom manifestation. Thanks to fragile tendons and a high-strung personality, I may have a smaller cup than other athletes, but I have less life stress going into it and therefore my tendons don’t hurt as much.

Do you consider yourself injury prone? You might actually be pain prone. And there might be more you can do about it than you think.

I’ve been learning a lot about pain lately. My sudden interest in the topic was sparked by the collaborative work I’m doing with Ryan Whited on a book about self-managing athletic pain and injury. The new science of pain is utterly fascinating and completely contrary to prevailing beliefs about the deceptively familiar phenomenon.

I credit my ongoing crash course in pain science for the lack of surprise I experienced in reading a new study on knee pain in runners that may surprise many others. Led by Shahabeddin Bagheri of the University of Nahavand in Iran and published in the Journal of Athletic Training, the study investigated the effects of mindfulness training on “pain severity, knee function, fear of movement, and pain catastrophizing” in female runners dealing with patellofemoral pain.

Mindfulness

A few definitions: Mindfulness is an intentional mind state that involves being maximally present in the moment and accepting of one’s thoughts and feelings as they are. Fear of movement (aka kinesiophobia) is just that, but it is also a vastly underappreciated contributor to the pain experience. Fear of movement literally creates pain. Finally, pain catastrophizing is a “tendency to magnify the threat value of a pain stimulus and to feel helpless in the context of pain.” Based on past research demonstrating that the pain experience is every bit as much psychological as it is physical, and that psychological interventions including mindfulness training can be helpful in pain management, this new study sought to determine whether supplementing traditional training modifications with mindfulness training could improve outcomes in athletes dealing with one of the most common running injuries.

The subjects of the experiment were women runners with an average age of 28, all dealing with persistent PFPS. Half of them were assigned to a standard, 18-week exercise treatment program focused on symptom control. The other half completed the same exercise program as well as an eight-week mindfulness intervention that started four weeks earlier and thus overlapped with the exercise program by four weeks. At the beginning, middle, and end of the 18-week exercise program, all 30 subjects rated their pain level at rest, during stepping, and during running, provided information of functional limitations of the knee, and completed questionnaires designed to assess fear of movement, pain catastrophizing, and pain coping strategies.

In a word, the mindfulness intervention worked. At 18 weeks, the subjects who received mindfulness training showed a 15.8 percent greater reduction in pain during running, an 8.2 percent greater improvement in knee function, a 20.8 percent lower fear of movement, and a 40.9 percent lower level of pain catastrophizing compared to the subjects treated with exercise only. Members of the mindfulness-plus-exercise group also demonstrated greater reliance on the coping mechanisms of ignoring pain sensations and distancing from pain.

The funny thing about this “new” way of managing athletic pain is that it isn’t new at all. Rather, it represents how everyone used to deal with pain before it became medicalized in modern society, transformed from a normal part of everyday life, like appetite–mere somatic information that’s useful in choosing appropriate subsequent goal-seeking actions–into a cataclysm to be feared and avoided at all costs. The catastrophizing of pain and the fear of movement that mindfulness helped the subjects of this study overcome are modern creations. When an 18th century rancher developed knee pain, they worked around it and through it quite adeptly without giving it more thought than was strictly necessary and certainly without complaining about it to anyone else. But when a 21st century runner develops knee pain, they freak out and stop cold and run (sorry, walk) to the doctor.

Don’t get me wrong—it’s nice that we have doctors. What studies like Bagheri’s are showing, however, is that we need to start to undo the damage that the medicalization of pain has done to the athlete’s psyche without throwing away the evidence-based diagnostic tools and treatments that help athletes get past the few nontraumatic injuries they aren’t capable of managing outside of the clinical context. Ryan Whited and I are doing our part to push what we both perceive as a coming revolution in the management of athletic pain. While our book is still at least 18 months away from publication, I’m certain I’ll be sharing more of what I learn about the subject here in the interim, so keep an eye out.

Currently I’m reviewing the copyedited manuscript of my forthcoming book The Comeback Quotient: A Get-Real Guide to Building Mental Fitness in Sport and Life, which is available for preorder. (Subtle, eh?) Chapter 6 tells the remarkable story of Jamie Whitmore, a dominant professional off-road triathlete in the 2000’s who later overcame a Jobian cancer ordeal to win a gold medal in cycling at the 2016 Paralympic Games. One of the things that makes Jamie’s story so instructive for other athletes is the can-do attitude she brings to bear in dealing with setbacks. “I’ve always been the type to say, ‘What can I control?’” she said when I interviewed her just over a year ago. “Even with cancer, it was, ‘Well, what can I do?” Because there’s so much you can’t do.”

When something is taken away from you, it’s natural to think about and regret what’s been lost. But beyond a certain point, this natural response is unhelpful, standing in the way of making the best of the situation. Successful athletes like Jamie Whitmore do not waste time and energy brooding on what’s been taken away from them. Instead, after acknowledging what they can no longer do, they identify what they can do and then do it. In this way, if their problem is solvable, they solve it faster than the brooders do, and if it’s not solvable (like the permanent damage done to Jamie’s body by her cancer surgeries), they at least make the best of the situation.

The most common type of bad situation endurance athletes encounter is injury. Most athletes get upset when an injury takes away their ability to train normally and remain in a funk until they’ve fully healed. Indeed, this reflexive emotional response to injury is so normal that a lot of athletes assume it’s ineluctable, but it’s not. Some athletes don’t get upset, or at least don’t remain in a funk, when they get injured. After an initial pout (which is only human), they pivot from a problem focus to a solution focus.

I like to say I’ve suffered more injuries than any runner my age, and over the years I’ve come a long way in terms of my ability to manage injuries emotionally. I’ll never forget the 2002 Boston Marathon, which I watched on television, grief stricken, having suffered a hip injury in training just 10 days before, when I was fitter than I’d ever been and couldn’t wait for Patriots Day to roll around so I could prove it. I remember thinking (naively) that I’d missed a chance I might never have again, little knowing that my lifetime-best marathon still lay 15 years in the future.

From where I sit today, I find it hard to believe that grief-stricken runner was me. I suffered my latest injury—an acute strain of the peroneal tendons in my left foot—three weeks ago, and it really hasn’t bothered me in the slightest on an emotional level, even though this one happened during a marathon PR attempt coinciding with another magical fitness peak. I wouldn’t go so far as to say I’ve been indifferent to the injury. It hurt quite a bit for quite a while, and I’ve missed running, but overall I’ve maintained emotional equanimity by doing what I now always do when I suffer any kind of setback, which is to emulate the can-do attitude of the likes of Jamie Whitmore.

Specifically, in this case, I cross-trained with a mix of bicycling, elliptical biking, stand-up paddling, and deep-water running. I modified my strength workouts to work around my pain and consulted my friend Ryan Whited of Paragon Athletics in Flagstaff, who guide me through some diagnostic tests via FaceTime and showed me some rehab exercises that would not only help me get back to running but also reduce my risk of suffering future injuries resulting from lack of mobility in my left ankle. Additionally, I signed up for a 40K cycling time trial race to give my damned-up competitive drive something to focus on and alleviate the emotional burden of knowing I was losing running fitness.

In the first couple of weeks after the injury occurred, friends and family members asked me frequently how my foot was doing, and when I told them I was still limping, they expressed sympathy. But while I appreciated their concern, their underlying assumption that because I was in pain and limping and couldn’t run I was upset was erroneous. Sure, I heard from that fearful inner voice telling me I should be deeply worried about the lack of improvement in my symptoms, but whereas 15 years ago that voice might have gone unchecked, I was now able to tune it out, knowing the injury would heal in due time, as injuries always do.

And it did. Three weeks to the day after I suffered the injury, I completed a short, slow test run on my treadmill, pain free. Injuries happen to everyone; they’re part of the sport. But not everyone copes with injuries equally well. Next time you get hurt, channel your inner Jamie Whitmore and negotiate your way through it with maximum aplomb by manifesting a can-do attitude.

$ubscribe and $ave!

  • Access to over 600 plans
  • Library of 5,000+ workouts
  • TrainingPeaks Premium
  • An 80/20 Endurance Book

 

30 day money back guarentee

For as little as $2.32 USD per week, 80/20 Endurance Subscribers receive:

  • 30-day Money Back Guarantee