My colleague Ben is an avid runner. Last year he embarked on a plan with a goal of running the Chicago Marathon to gain qualification for the 2016 Boston Marathon. His training went really well and by October he was in great shape. He cruised through Chicago and easily made the BQ time.
However, by late fall, I noticed that Ben’s posts on Strava were diminishing. I assumed he was just recovering from the marathon, but when I checked in with him he explained that his foot had been giving him trouble. It seemed that the high volume had exacted a price. I asked if he had seen anyone about this and, like a typical doctor, he replied, “No, I’m sure it’s nothing.”
I was not so sure.
Running is a particularly injurious activity, mostly afflicting our musculoskeletal system in varying degrees of frequency and severity. The medical literature is inconsistent but review articles have suggested that anywhere from 15 to 20 percent of runners experience a running injury of some sort each year and that the number of running injuries can be as many as 12 per 1,000 hours of running. 
However, as anyone who runs on a regular basis knows, it is not at all unusual to experience some discomfort during or at the end of a run. The question then, is how do we respond to that? Is it safe to run through the pain? Can I simply wait this out or does this require medical attention now? The answer to this question is not always so straightforward, but let’s put together some general guidelines to help make the decision a little easier.
First, why do we feel pain and how it is transmitted? Pain is generated by one of two mechanisms:
- Specialized nerves responsible for detecting pain innervate many tissues. When directly stimulated, pain is perceived. An example of this is the skin. When cut, local pain fibers indicate pain in the specific area.
- Many tissues have no pain fibers. Local injury is still perceived as pain but in this case it is through a more indirect mechanism. When tissues of this type become injured, they release chemicals that produce an inflammatory response. Inflammation results in an increase in local blood flow that causes warmth and swelling. The swelling itself often stimulates local pain fibers but even in the absence of this, the inflammatory mediators are sufficient to induce a response that is perceived as pain. Examples of this kind of pain include injuries to the cartilage that lines our joints.
Pain can be treated in two ways:
- A drug may block the transmission of pain fiber signals. Examples include narcotics and acetaminophen.
- You can interfere with the inflammatory process. Examples include the application of ice, compression or anti-inflammatory medication.
It is of the utmost importance to recognize that treating pain does NOT remedy the underlying running injury! By misinterpreting a decrease in pain after taking an ibuprofen as a sign that an injury is healed, a runner can return to activity too soon and exacerbate the problem.
Should I Seek Medical Attention?
When then is pain just a minor nuisance and when should it be taken as a sign to seek a medical evaluation?
The short answer is that all pain that results from running should be taken seriously and evaluated, but of course this is neither practical nor realistic. Unless you are a professional or high-level college athlete with a dedicated medical staff, you have neither the time nor the resources to respond to every minor twinge that arises.
A number of fairly obvious injuries however do warrant urgent evaluation:
- Any associated deformity to a bone or joint
- Associated uncontrolled bleeding
- An inability to bear weight
- Associated symptoms e.g.; head injury, chest pain, etc.
In the absence of these, a more measured approach is often safe.
While it is impossible to give specific advice for every type of injury, here are some common sense guidelines for a few common scenarios:
- Pain that begins suddenly while running. Examples include taking an awkward step or overstretching briefly. If the pain recedes rapidly never to appear again, it can likely be ignored. If it persists but in a diminished form, it is best to interrupt the planned run and head for home to reassess. If the pain persists or worsens, stop running, walk home or call for a ride and then reassess.
- Pain that builds slowly while running. Pain in this form tends to be more worrisome and usually indicates something is amiss. While many runners will choose to simply tolerate the discomfort and ‘run through’ the pain, this is often a short-sighted and ultimately poor choice. Pain while running, especially pain that increases while running must be taken as a sign of injury. Head home at an easy jog or walk and reassess.
- Pain that comes on after running. This is the most common type of pain and the hardest to sort out. It is not uncommon to have pain after running, especially long or high-intensity runs and so careful self-evaluation is needed in order to determine if this is within the norm or not. If the pain is different than your usual in terms of character or intensity, it may mean something is wrong. If it does not improve or gets worse with passing time then it is definitely a sign that something is wrong.
What, then, is one to do about any of these types of pain? The most common response, as we saw with my friend Ben, is simply to ignore it and hope for the best. In many cases this is actually a reasonable first approach. With rest, ice and liberal dosing of anti-inflammatory medications, most minor running pain will abate in time and not reappear. However, you need to be careful about ignoring pain for too long, for you do so at your own peril. Putting off a medical evaluation can delay the diagnosis and treatment of an injury and result in making things worse or at least further delay a return to normal activity.
Here is my advice:
- Give yourself three days for pain to improve and five days for pain to disappear completely at rest. If after these cutoffs the pain persists, make an appointment to see a physician. If the pain is gone before the appointment date, cancel (DO NOT NO-SHOW!)
- Wait two full days after pain has completely resolved without the need to take any medication whatsoever before returning to running.
- Return to running at a low intensity and low volume. If pain returns, stop; make an appointment to see a physician.
- If you can return to previous levels of volume and intensity pain free, move on but try to figure out what led to the original problem and remedy that.
Eventually, Ben did go see someone and had a stress fracture diagnosed. Although his delay did not make things worse, it could have and it did set his training back.
Still, as you have seen, it is true that not all pain requires evaluation and your pain may not exactly fit what I have described in this article. If you have any doubts, see a physician and make sure.
Train hard, train healthy.
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About the Author: Jeffrey Sankoff, MD is a three time Ironman and 70.3 World Championship qualifier. He is an Emergency Physician at Denver Health Medical Center in Denver.
 van Mechelen W, Running injuries. A review of the epidemiological literature, Sports Med. 1992 Nov;14(5):320-35
 van Poppel D, Scholten-Peeters GG, van Middelkoop M, Verhagen AP, Prevalence, incidence and course of lower extremity injuries in runners during a 12-month follow-up period, Scand J Med Sci Sports. 2014 Dec;24(6):943-9