When It’s O.K. to Run Hurt

by Gina Kolata
Copyright 2007 New York Times

JUST before the end of last year, a prominent orthopedic surgeon was stretching to lift a heavy box and twisted his back. The pain was agonizing. He could not sit, and when he lay down he could barely get up.

So the surgeon, Dr. James Weinstein of Dartmouth College, decided to go out for a run.

“I took an anti-inflammatory, iced up, and off I went,” Dr. Weinstein recalled. When he returned, he said, he felt “pretty good.”

It sounds almost like heresy. The usual advice in treating injuries is to rest until the pain goes away. But Dr. Weinstein and a number of leading sports medicine specialists say that is outdated and counterproductive. In fact, Dr. Weinstein says, when active people consult him, he usually tells them to keep exercising.

The idea, these orthopedists and exercise specialists say, is to use common sense. If you’ve got tendinitis or sprained a muscle or tendon by doing too much, don’t go right back to exercising at the same level.

The specific advice can differ from specialist to specialist. Some, like Dr. Weinstein, say most people can continue with the sport they love although they may need to cut back a bit, running shorter distances or going more slowly. Others say to cross-train at least some of the time and others say the safest thing to do is to cross-train all the time until the pain is gone. You might end up cycling instead of running, or swimming instead of playing tennis. But unless it’s something as serious as a broken bone or a ripped ligament or muscle, stopping altogether may be the worst thing to do.

“We want to keep you moving,” said Dr. William Roberts, a sports medicine specialist at the University of Minnesota and a past president of the American College of Sports Medicine. “Injured tissue heals better if it’s under some sort of stress.”

He and others acknowledge that the advice to keep moving may come as a surprise and that some doctors feel uncomfortable giving it, worried that their patients will do too much, make things worse and then blame their doctor.

“I’m not convinced this is part of every doctor’s training or that everyone is ready to make it part of mainstream medicine,” Dr. Roberts said. “You have to work with athletes a while to figure out how to do it and how to do it well.”

“The easy way out is to say, ‘Don’t exercise,’ ” said Dr. Richard Steadman, an orthopedic surgeon in Vail, Colo., and founder of the Steadman Hawkins Research Foundation, which studies the origins and treatment of sports injuries. That advice, he added, “is safe and you probably will have healing over time.” But, he said, “if the injury is not severe, resting it will probably prolong recovery.”

Medical researchers say that they only gradually realized the importance of exercising when injured. A few decades ago, Dr. Mininder Kocher, a sports medicine specialist and orthopedic surgeon at Children’s Hospital Boston, said doctors were so intent on forcing hurt athletes to rest that they would put injured knees or elbows or limbs in a cast for two to three months.

When the cast finally came off, the patient’s limb would be stiff, the muscles atrophied. “It would take six months of therapy to get strength and motion back,” Dr. Kocher said.

At the same time, in a parallel path, researchers were learning that painful conditions that are essentially inflammation — arthritis and chronic lower back pain — actually improve when patients keep moving.

Now some researchers, like Dr. Freddie Fu, a sports medicine expert and chairman of the orthopedic surgery department at the University of Pittsburgh Medical Center, and a colleague, James H-C. Wang, are studying minor injuries at the molecular level.

Their focus is on tendinitis — the inflamed tendons that are the bane of many exercisers and that affect 15 to 20 percent of all Americans at any given time. The symptoms are all too familiar — pain, swelling and soreness. To study the injury process, Dr. Wang grows human tendons in the laboratory, stretching them repeatedly. In separate experiments, he has mice run on treadmills until their tendons begin to show the tiny microscopic tears that occur in the early stages of tendinitis.

So far, Dr. Wang reports, he and Dr. Fu learned some important lessons: First, forceful stretching of tendons elicits the production of molecules that are involved in inflammation. But small repeated stretching of tendons that are already inflamed leads to the production of molecules that heal inflammation. That suggests moderate exercise can actually speed healing.

And now, their preliminary results suggest that the usual treatment for tendinitis — taking drugs like aspirin or ibuprofen — can help reduce inflammation when the injury begins. But after inflammation is under way, they can make matters worse.

But medical experts caution that people have to be careful if they try to exercise when they are injured.

Some, like Dr. Fu, who is himself a cyclist, Dr. Roberts, and Dr. Steadman say the first priority is to see a doctor and get an accurate diagnosis in order to rule out a serious injury.

Others, like Dr. Weinstein, say that such an injury, a broken bone or a torn Achilles tendon, for example, has symptoms so severe that it is obvious something is really wrong.

“If you had inflammation and swelling that was very tender to the touch, you would know,” Dr. Weinstein said. And if you tried to exercise, it would hurt so much that you just could not do it.

Dr. Weinstein’s advice for injured patients is among the boldest — he said it’s based on his basic research and his own experience with sports injuries, like knee pain and tendinitis of the Achilles and hamstring. Before exercise, he said, take one anti-inflammatory pill, like an aspirin. Ice the area for 20 minutes. Then start your usual exercise, the one that resulted in your injury, possibly reducing the intensity or time you would have spent. When you finish, ice the injured area again.

The advice involving an anti-inflammatory pill, Dr. Weinstein said, is based on something surgeons know — in most cases, a single anti-inflammatory pill before surgery results in less pain and swelling afterward. It also is consistent with Dr. Wang’s research because, at least in theory, it should forestall new inflammation from the exercise that is about to occur.

The icing is to constrict blood vessels before and after exercise, thereby preventing some of the inflammatory white blood cells from reaching the injured tissue.

Dr. Steadman, who works with injured athletes in his clinic, does not advise trying to go back to your old exercise on your own until the pain is completely gone. Play it safe, he said, and cross-train.

But others, like Dr. Fu and Dr. Kocher, are more inclined to suggest trying your old sport. Both also tell injured patients to ice before and after exercising. Dr. Kocher said he sometimes advises taking an anti-inflammatory pill, but worries about masking pain so much that patients injure themselves even more by overdoing the exercise.

His rule of thumb, Dr. Kocher said, is that if the pain is no worse after exercising than it is when the person simply walks, then the exercise “makes a lot of sense.”

It also helps patients psychologically, he added. “If you take athletes or active people out, they get depressed, they get wacky,” Dr. Kocher explained.

Noah Hano knows all about that.

Mr. Hano, 34, a commercial real estate broker in Boston, was competing in marathons and triathlons. Then he developed severe sciatica, whose pain is a direct result of inflammation. He tried physical therapy, he tried acupuncture, he tried massage therapy, but nothing quelled the “nagging, terrible pain” down his leg, he said.

He stopped exercising, but the pain persisted.

“I started getting desperate,” Mr. Hano said. His father, who lives in the same town as Dr. Weinstein, suggested that Mr. Hano call the Dartmouth orthopedist. Dr. Weinstein told him to continue to exercise. Mr. Hano could not wait to get started. “I drove to the gym and ran on the treadmill,” he said. “When I woke up the next morning, I went for a swim and rode my bike. It hurt, but when the doctor told me I wasn’t going to be paralyzed, it made it a lot easier.”

Dr. Weinstein said that Mr. Hano’s problem was a huge, bulging disk, a herniation so severe that most doctors would say he should stop running immediately. Dr. Weinstein, though, thought exercise would help Mr. Hano heal. His treatment was a single injection of cortisone into the inflamed area around his disk. The sciatica gradually went away. And Mr. Hano continues to run.

“I had faith that I was going to be able to work through it,” Mr. Hano said. “I don’t want to not do what I like just because I’m in pain.”

What You Can Do When You Are Injured

• Evaluate yourself. Is there redness or swelling? Does one side look different from the others? If not, continue exercising.

• Cross-train in a way that exercises around the area, like cycling instead of running for an injured Achilles tendon.

• Ice the injured area for about 20 minutes after exercising.

• See a doctor if you have severe pain and are having trouble with your daily activities. Otherwise, you can give it time — up to a month or two — to get better before rushing to see a doctor.

• Exercise, and if the pain goes away and is not worse after that exercise, it probably is safe to do it.

• Walk on it; if you can’t do that, you should not run on it.

BEGINNING TO RUN: How To Get Started As A Runner

by Hal Higdon, Copyright © Hal Higdon

RUNNING CONTINUES TO GROW IN POPULARITY. More and more people are taking up the sport. More people are running 5-K races. More are running marathons. An even larger number simply run for fitness and never go near a starting line, or win a race T-shirt.

There are many good reasons. Running is simple and inexpensive. It's a good way to lose weight. It makes you feel good. Running is good for your health. You'll look better and have more energy if you learn to run.

Certainly, more people write my "Ask The Experts" column on America Online with questions about beginning running than about any other subject. They want to know how to start running. They want a training program. They want information about shoes and equipment. They worry about sore muscles.

Every runner experiences what might be described as "Start-Up" problems. Many have "Restart" problems. Former runners (who stopped, for one reason or another) want to get back to their old running routines. They too need help.

Here is how to start. Here's how to begin to become a runner. And if you've been a runner before, here's how to get back in stride.

Becoming a Runner

How you begin depends partly on your current level of fitness. A teenager, or someone already in good shape, may have little trouble running two or three miles the first day. Someone unused to exercise might struggle to walk even a mile.

Start slow. You'll have fewer problem with sore muscles, or other injuries, if you don't work too hard the first few days, or even the first few weeks or months. You'll enjoy running more if you try to do less than you're capable of accomplishing. You'll also achieve more, since the most important factor in achieving success is consistency.

The best approach for beginners is to start by walking, then after you feel comfortable with that basic fitness exercise, begin to include jogging (easy running) in your routine. Jog, walk. Jog, walk. Jog, walk. Eventually, you'll be able to jog continuously, both farther and faster. How fast you progress depends on you, but don't be in a hurry to run fast or run far.

The 30/30 Plan

Here's a simple 30/30 plan to get you going, featuring 30 minutes of exercise for the first 30 days. It is a routine similar to one that Chuck Cornett, a coach from Orange Park, Florida, uses with beginning runners.

Walk out the door and go 15 minutes in one direction, turn around, and return 15 minutes to where you started: 30 minutes total.

For the first 10 minutes of your workout, it is obligatory that you walk: No running!

For the last 5 minutes of your workout, it is obligatory that you walk: Again, no running!

During the middle 15 minutes of the workout, you are free to jog or run--as long as you do so easily and do not push yourself.

Here's how to run during those middle 15 minutes: Jog for 30 seconds, walk until you are recovered, jog 30 seconds again. Jog, walk. Jog, walk. Jog, walk.

Once comfortable jogging and walking, adapt a 30/30 pattern: jogging 30 seconds, walking 30 seconds, etc.

Follow this 30/30 pattern for 30 days. If you train continuously (every day), you can complete this stage in a month. If you train only every other day, it will take you two months. Do what your body tells you. Everyone is different in their ability to adapt to exercise. When you're beginning, it is better to do too little than too much.

If you continue this 30/30 routine for 30 days, you will finish the month able to cover between one and two miles walking and jogging. Your next goal is to develop an ability to run continuously for a mile, then two miles, then more if you want. The way to do that is to gradually increase the length of time in the middle of your workout spent jogging and decrease the number of walking breaks. Do 45/30 (45 seconds jogging, 30 seconds walking), then 60/30, then 75/30, or 60/15.

Vary your routine. Work a little harder one day, then make the next an easy day. Program in occasional rest days when you do no walking and jogging, or cross-training days when you do some other exercise. Test yourself to see if you can run a half-mile continuously, then a mile. It won't happen overnight, but you should begin to see a gradual improvement in your physical fitness.

If the above routine seems too difficult for you, do a little less. Nobody is looking over your shoulder when you write how much exercise you did today in your diary. Only you can judge whether you are pushing too fast or too slow, but it's best to err on the conservative side.

You too can become a runner. All you need to do is begin.