Pain and injury are not the same or well-related

Despite piles of research and narratives that have taught us pain and injury are not the same or well-related, this remains the predominant belief in society. It is a belief that informs both self-management and more seriously, professional healthcare management: the search for a structure, injury or pathology to explain pain.

Whilst we must determine the existence of an injury or pathology that may require intervention, this is only ever a part of the story. The lived experience must be the primary focus. The ‘what it is like’ is a unification of thoughts, feelings, perceptions and actions. Bringing these two together is essential, whilst giving the person a clear picture of what is happening. It is complex because we are complex. There’s no need to dumb it down.

It is the person who feels pain, not the body ‘part’

On the London to Brighton ultra a few weeks back, we had criss-crossed the urban areas and reached the countryside. With very little of interest along the Surrey roads, conversation kept you going. There were some very mild slopes but nothing that would be considered ‘technical’. So the foot fall is easy, requiring little or no thought as you trot along establishing a rhythm.

Then you hit the uneven terrain that requires more focus, paying attention to what is coming, adapting to the loose stones, divets, slopes, small mounds hidden by long grass, tree roots and other small obstacles. Duck! That was a low hanging branch, more difficult to clock because it’s a bit darker on the trail in the woods.

Crossing a section of a field that was sun-baked mud with a good covering of grass, my right foot hit the edge of concealed tractor tyre track, woah…! My ankle rolled in and I over the top, but I managed to steady myself and continue. ‘You ok?’, called my running buddy of that section who was just behind. ‘Yep..no problem’, I lobbed back. We carried on. That was about 40k into the 100k day (it ended up around 104k…runner’s were sure the course was longer than it was marked).

We reached the halfway point. Hot food was available and I saw fellow runners tucking into burgers and chips. Food held no appeal, so I forced down some chocolate and fruit together with plenty of fluids. With the second half to go, my feet deserved a check and a change of socks. Inevitably feet sweat and swell, both a risk for blisters. There’s always a little hesitation before removing socks: what will my feet be like?

Remember that what we feel (perceive) and what is going on in the tissues is often different — they are not the same. My state, biological and emotional (that are unified), means that it is entirely possible to experience no unpleasant sensations in my feet, yet I have a reddened area developing or even a formed blister. Checking your feet becomes an essential strategy. A little bit of TLC here and there and all was fine to get going: a couple of preventative Compeeds, a bit of a rub and a stretch.

70-80k was tough. Over half-way, but still 30k to go, including a climb over the Downs. This is a big part of the ‘why?’. At one point I was struggling to get past two other runners who were traveling at barely a walking pace. This is the time to use those mental (embodied) strategies to keep going. You know these moments are going to come; not if but when. I call the my ‘sticky bits’. I also know that they will pass if I keep going.

It was also this time that my right foot started to hurt. The front of my ankle was stinging, accompanied by a sharp pain down the side of the foot. I have a weird little toe on the right that sits up meaning that I use the foot differently to the left. I land and push off more medially. So be it. That’s the way I’m built so there’s no point making a big deal of it, despite what my mind seems to want to say.

There are many things that lift you. People supporting at random places. Some pop up all the way along the route so you get to know them even though they are there to support someone else. Other runners that you come across and then plod along with for a few hours. When else would you meet someone you don’t know and spend hours chatting? The aid stations are GREAT. Usually full of encouragers and definitely packed with treats. Many have said that ultras are eating competitions. I wouldn’t disagree. The normal diet that nourishes goes out of the window as you consume all the naughty stuff that you can get ahold of! Melon has a special place in my heart in these moments. Music and purpose are two further tools that spur me on.

The pain was not abating and if anything was trying to grab more and more of my attention. It didn’t occur to me that maybe I had sprained my ankle until much nearer the end of course. Even then I didn’t give that thought much credence. In essence, it would not be useful to consider this as a possibility. What use would that be? In particular as there was no way I was going to stop anyway.

I love the burst of excitement, energy and emotion that emerges right near the end as the finish line appears. The last few kilometres at dusk, following a looping path towards the Brighton Racecourse, were a push. I wanted to end with a burst so decided to walk a few hundred metres to gather myself. A couple of runners went by and I saw another shadow in the distance behind. There was no way I was going to let him or her pass! I started running again towards the lights in the distance, Brighton below the hills beckoning.

Hitting the longer grass of the racecourse was an unwelcome surprise. Heavy ground and the need to lift my feet meant that I had to bend my knees and flex my hips, neither of which my body was keen to do. But as often happens, there is an easing as you relax into the job in hand, and that is to finish at speed. How often do you see that at the end of a race? The explosion of energy as if some superhuman force has taken over the runner, powering them to glory!

My power burst came, fuel injected with a mantra I can scarcely remembered as I stormed past the two runners who had overtaken me a kilometre or so before. They waved me on, cheering, as is what happens at these events. Everyone supports each other, on a day of sharing an incredibly tough experience, in a way that I have not seen in any other walk of life. It’s a unique camaraderie.

Suddenly it’s over. The last few steps under the inflated finish archway, applauded by the race officials, finishers and other people milling around the end. You know who has run because there’s a style of walking that looks like you’ve…. (you get the picture).

Sleep after a long run for me is an interesting business. Vivid dreams, lots of movement and half waking. The inevitable leg stiffness meant walking to the shower room, all of two meters away, was a challenge. It looked so far away. Ooh, what’s that? I thought as I stepped with my right foot. I looked down and saw the bruising and swelling you can see in the picture at the top of this blog. Indeed I had sprained my ankle. But the pain experience, which is always subjective and uniquely mine, had varied so much since the tractor track incident.

As I looked and wiggled my foot it started to hurt more. Paying more attention to the sensations and what I could see, the discomfort intensified, as it typically does. Of course, when I injure myself it is meant to hurt as a means of helping me protect myself to allow healing to proceed. This is biology in action, and it is going on in the dark. I have no access to this, only what I can feel and see. From there I make assumptions about what has happened and what I must do now for the best. This is all based on my belief that I can get better because I have done before, and there’s no reason to think anything else. Each person will have their own set of beliefs, past experiences and expectations.

Pain and injury are not the same. Pain is subjective — I, the whole person, feel the pain. Injury is objective. They are different and do not relate well. The circumstance, past experience and expectations all play a role, which is why I injured my ankle at 40k and did not really know until the next morning. Pain was and is not a good guide. It just tells me that there is a need to be met as an inference for what maybe happening, yet still compelling action even in the case of no or a minor injury. We are wise to acknowledge and assess, which is why understanding pain is so important. We can then choose the next best action.