I would like to start by taking the time to personally thank Joseph Brence, DPT for collaborating with me on this very important piece about pain. Joseph is a dynamite clinician, who is based in Pittsburgh, PA and specializes in pain management. He is also an avid researcher and is working tirelessly to enhance our understanding of pain. Joseph also runs the blog, Forward Thinking PT, which serves as a great resource for both patients and clinicians. 

As Physical Therapists, we are in the business of dealing with pain. Considering the fact that triathlon is a triple threat for injury, it’s not surprising that triathletes often come knocking on our door. Despite the bad rap that pain receives, we would like to persuade you that it is not always a bad thing, but rather an elaborate and necessary alarm system to protect the body. An analogy that we often use in educating triathletes suffering from pain is that of a smoke alarm. For example, when a smoke alarm is triggered, it serves as a warning system that prompts us to take action. In some cases, the alarm may sound simply because of excess heat or smoke from cooking on a stove with poor ventilation. On the other hand, it may indicate that the apartment is on fire and danger is imminent prompting us to take immediate action. Sometimes, the alarm may even go off for no apparent reason due to a simple malfunction. Can you imagine, however, if the battery had died and the smoke alarm was not working yet there was carbon monoxide in the air?! This would pose a potentially lethal threat. Similarly, what if the body’s pain system had malfunctioned and we tried completing a run with a shard of glass in our shoe? Based on this information, it is readily apparent that pain plays a vital role in protecting us from any actual or potential danger so we take prompt and appropriate action to ultimately get back to training in a timely manner. Unfortunately, a common motto among triathletes is “NO PAIN, NO GAIN.” While pushing through aches and pain often comes with the territory, triathletes would be better served to adopt the slogan, “KNOW PAIN, NO GAIN.”

According to the International Association for the Study of Pain, pain is defined as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Below are 9 things we would like you to understand about pain

1. PAIN IS 100% AN OUTPUT OF THE BRAIN – this is one of the most important facts about pain. There are several examples illustrating this point. A common example is that of the phantom limb. Many amputees will often complain about pain in a limb, which no longer exists. This freaky sensation occurs because a road map to that limb, which exists within the brain, has not been re-written since the limb was lost. So the person will still feel pain, in a limb, despite that limb being gone. Even crazier, research has been performed on treatment approaches which use mirrors, to make the intact limb reflect a healthy image to appear as the amputated limb.

2. PAIN RELIES ON CONTEXT – have you ever noticed that your aches and pains often magically disappear as you are closing in on the finish line of a triathlon? This most likely occurs secondary to hormonal regulation through what we call the neuromatrix. I can personally attest to this experience during the final year of Ironman St. George, which took place under treacherous conditions. Despite finding myself in a bad way during the second half of the marathon, I somehow managed to find yet another gear during the final two miles of the race.

3. THE AMOUNT OF PAIN DOES NOT NECESSARILY CORRELATE WITH THE AMOUNT OF TISSUE DAMAGE – all we need to do is consider how painful a hangnail is to appreciate this pain fact. As it relates to triathlon, the amount of pain doesn’t necessarily correlate to the amount of tissue damage. We can sometimes run on a fractured foot, and feel no pain, or have a hangnail and experience a lot of pain. Pain is a warning system, but its intensity is not always predictive of injury severity. 

4. NOVICE TRIATHLETES WILL LIKELY EXPERIENCE MORE PAIN THAN A SEASONED TRIATHLETE – after being involved with the sport of triathlon for a few years, one starts to become acquainted with certain aches and pains. To a beginner, however, such aches and pains may very well be perceived as a greater threat because they are most likely foreign sensations. This may wind up triggering a pain response, which could prompt them to briefly halt their training whereas it may not even register as pain to a veteran triathlete. Again, not only do the tissues need to adapt to threats, but the brain does as well. Conditioning should cultivate both mind and body.

5. FINDINGS FROM DIAGNOSTIC TEST RESULTS MAY NOT BE A DIRECT CORRELLATE OF THE AMOUNT OF PAIN A TRIATHLETE EXPERIENCES – given the relatively high incidence of low back pain associated with cycling, it is not uncommon for triathletes to eventually undergo diagnostic tests. In many cases, triathletes have marked structural changes in their spinal structures yet have minimal to no complaints of pain. On the contrary, I have worked with certain triathletes, who have pristine MRIs, yet are complaining of extreme pain. This reminds us that findings from diagnostic tests often do not correlate with subjective complaints of pain. Diagnostic tests rule out major pathology; not pain.

6. WEATHER CONDITIONS ARE NOT TRULY PREDICTIVE OF THE PAIN YOU WILL EXPERIENCE THAT DAY – perhaps one of the most common questions that we receive as physical therapists is, “Do you think the weather has anything to do with my symptoms?” As we all know, it is easy to find so many woes when it is pouring down rain. The truth of the matter, however, is that bad weather does not mean that you are going to have more pain that day. So stop pretending you are a weather forecaster based on how you knees feel when it’s raining.

7. CORE STRENGTHENING IS NO MORE EFFECTIVE THAN GENERAL EXERCISE FOR PAIN AMELIORATION – while core strengthening may afford performance benefits, it has not been shown to be any more effective than “general exercise” when it comes to pain amelioration. Despite this information, medical and fitness professionals continue to tell their patients and clients that they need to “strengthen their core” to improve their low back pain. So be careful of subscribing to such misinformation because this advice has been scientifically invalidated.

8. PAIN IS SIMPLY TELLING YOU THAT SOME BEHAVIOR NEEDS TO CHANGE – there are countless examples that illustrate this point. One example that comes to mind is the development of low back pain from holding an aero position while time trialing. At some point, when the pain becomes too unbearable, we are forced to make a change. This typically takes the form of lifting your bottom off the seat to stretch the legs or simply coming out of the aero position to decrease the static strain on the tissues of the low back.

9. MOTION IS LOTION – as humans we always love hearing sound bites and this is one that I often use with triathletes. The human body is designed to move. Through movement we are able to provide our joints and tissues will valuable nourishment and overall health. This is particularly important when it comes to the joints of our bodies, which are typically lubricated with synovial fluid. Exchange of this fluid plays an integral role in the integrity of our joints. So I always tell triathletes that “motion is lotion,” and that “your next position is your best position.”

In closing, PAIN plays a valuable role in our livelihood as triathletes. It provides us with critical information that fosters good decision-making that ultimately allows us to continue participating in the sport. While pain may sometimes get us down, trust in the body’s inherent ability to repair itself. By taking the time to better understand pain, it will hopefully be perceived as less of a threat and more as an amazing alarm system that works to protect our bodies to engender a long, healthy, active life.

Yours in Health,

Chris Johnson and Joseph Brence