Running with Pain: When to Push and When to Rest

Many runners delay seeking help from a professional when it comes to their running pain. The reason is usually because they fear having to stop doing the very thing they are most passionate about.

So, they push through the pain and tell themselves “It will get better”. 

I completely understand not wanting to stop running because as runners, it’s part of our identity. For some of us, it’s our chosen way to stay healthy mentally and physically. It’s a way to blow off some steam, have some time for ourselves, or join a community of other runners to socialize. Who would want to give that up if they had a choice?

But when is it acceptable to keep pushing through the pain and when is it not? 

This blog post aims to shed light on this topic which can be quite controversial as there is still a great lack of scientific research in this area. 

What is pain?

So much to say, so little time.

There are a lot of definitions for pain out there and it sometimes can get confusing.

The Internation Association for the Study of Pain (IASP) defines it as follows in their most recent revision:

“An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage” (Raja et al., 2020).

In other words, pain is a very complex concept.

Not only is it physical, but also emotional. This means that our pain can be affected by our emotions. Think about how much more your little toe that you just banged on the base of your bed would hurt if it happened when you were already having a stressful day.

Pain can sometimes be associated with actual damage to the tissues. For example, if you cut yourself with a knife while you are cooking, there is actual damage to the skin. (Ouch!) In other instances, it can also occur without any actual tissue damage. A couple of examples are having a tension headache or a bad stomach ache related to anxiety. Both of those things hurt so badly, but there is no actual damage to tissues.

Is Pain always bad?

That being said, pain isn’t always a bad thing. It’s a very necessary part of life and crucial for our survival. We can view pain as an alarm. It’s telling our body something is happening and we then need to decide if there is actual danger or not. 

For example, if you put your hand on a burning stove, the pain signal will quickly tell you to pull away to limit the damage. Very useful!

But when it comes to running with pain, when do we have to listen to this pain alarm to stop and when can we let it ring in the background?

6 Factors that Could Mean You Need to Stop Running

Let’s start by talking about the instances where pushing through the pain while running is not a good idea.

1) Red flags

Red flags are signs and symptoms that healthcare professionals need to look out for because they can point toward a more serious condition. 

If you’re a runner in pain, here  are some examples of red flags that would warrant stopping running:

• Pins and needles in one or both legs

• Weakness in one or both legs

• Unexplained weight loss in the last 6 months

• Pain that awakes at night

• Recurring night sweats

• Having had a history of previous cancer

• A recent trauma

• Fever, chills, or sweating (ongoing)

• Loss of bladder control

• Loss of bowel control

If a red flag is found, it can require a referral to a doctor for further investigation. 

Now, let’s not panic though. Having just one red flag on the list doesn’t mean it’s necessarily something serious. Current literature tells us that a single red flag on its own is not enough to give a definite diagnosis. We need to look at the bigger picture and consider the combination of red flags as well as the person’s history (Finucane et al., 2020).

That’s why it’s important to consult a healthcare professional if something feels off. These red flags can be checked with a thorough examination for serious conditions to be ruled out and for peace of mind.

2) Persistent pain

The second reason to stop running would be if the pain doesn’t seem to be getting better over time. 

Pain can come and go, and it’s normal to have some discomfort at times when we are running. However, if you have tried a few things to manage the pain on your own and you find the pain is still present week after week and getting worse, it might be time to get it checked out.

This doesn’t mean that you will need to stop running, but it probably is a sign that you need a more tailored and specific intervention.

3) Pain caused by a trauma (acute stage)

The third reason to avoid running with pain would be if the pain you currently have is due to a recent trauma. 

For example, you twisted your ankle after missing a step and now you have swelling, bruising, and trouble walking. Probably not a good idea to run. 

These kinds of acute injuries could warrant a physiotherapy consultation and some rest from running in the initial phase. You can then establish a plan with your therapist on how and when to return to running in the next stages of your recovery.

4) Possible stress fractures (especially high-risk ones)

I plan to do a whole blog post on stress fractures (I also sustained one myself), but I will try to summarise for now.

A stress fracture is an overuse injury that occurs when the load that is applied to the bone is essentially too much for the bone to be able to take it. 

In their clinical commentary, Warden et al. (2014) explain that stress fractures are part of a continuum. The load on the bone starts with stress reactions which can evolve into stress fractures and lead to complete bone fractures. 

Depending on where the affected runner is on this continuum, the pain presentation can be different, but there is usually an aspect of overuse. Another characteristic of stress fractures is that the pain doesn’t tend to get better as you keep running. Unlike a muscle or a tendon, that can be warmed up, bones tend to remain painful.

The reason it’s important to seek help for this kind of pain is that some stress fractures are considered high-risk. These stress fractures are located in bones where it can take longer to heal and have a higher chance of progressing into a bone fracture (Warden et al., 2014). 

As mentioned previously, it’s better to get it checked out so it can be properly managed. The last thing we want is to get get to the bone fracture stage.

5) The pain can’t be modified

Depending on where the pain is that you present as a runner, there are some temporary cues or modifications we can use to potentially reduce the pain. 

Here are a few examples:

• Increasing step rate (running cadence)

• Reducing speed

• Changing footwear

• Taking out hills
  

A study by Bramah et al. (2019) showed that they were able to reduce pain in runners with Patellofemoral Pain (PFP) after only one session by getting them to increase their step rate by 10%. These runners were able to increase the time where they ran without pain and also to increase their weekly mileage. Score!

If even after you have tried some sort of modifications the pain is still quite bothersome and not improving, it might be time to stop running and have it checked out.

6) The pain is severe

Lastly, if the pain is so severe, that it’s preventing you from enjoying your run or even impacting your running pattern negatively, it might be time to take a break.

But what is too severe? Can we put a number on it? 

That’s when it becomes kind of a grey area because quantifying pain is not easy at all. 

An interesting cohort study by Sancho et al. (2019) found that male runners with Achilles Tendinopathy were able to get a significant reduction in pain with education and a guided exercise program even if they kept running with pain. 

They were instructed that a maximum of 3/10 of pain intensity was acceptable. An increase in pain the following day was alright if the pain levels went back to baseline within the next 24 hours. They were also instructed not to engage in explosive activities and not to increase their training volume by more than 10% per week.

If the pain is 6/10, for example, and the next day it’s increased to 8/10 and it’s not going back to baseline, this might be a sign that we need to press pause on running and seek some help.

To sum up, STOP running with pain if:

• There are red flags

• The pain is persistent

• The pain can’t be modified

• The pain is caused by a trauma

• The pain can’t be modified

• The pain is severe

When Can We Keep Running with Some Level of Pain?

1) The pain can be modified

As mentioned earlier, if we try modifying an aspect of our run and it decreases our pain, that is a very good sign. 

This means changing our training parameters like the volume (how much), the frequency (how many times), or intensity (how hard).

It could also be trying to modify speed and increase step rate, including running/waking intervals or changing shoes, just to name a few examples.

This will be different for everyone and will depend on what the affected part of the body is. A physiotherapist that specializes in helping runners would be able to help with this. 

However, it’s usually best if these modifications are temporary, in my experience, just to give the chance for the pain to settle. 

2) The pain stays at a low intensity

Referring once more to the study by Sancho et al. (2019), runners with Achilles Tendinopathy (AT) were instructed that pain levels were acceptable if they were kept at a maximum of 3/10. They still had an improvement in pain following these guidelines when they kept training. If you want to find out more about AT be sure to read this blog post.

I think pain levels of 3/10 or lower are a good point of reference for runners when wondering if they should keep pushing through the pain. This number is by no means the end all be all but it gives us an idea of what’s acceptable. For someone else, it might be 2/10 or 4/10.

3) The way the pain is the next day 

Another factor we need to consider is how the pain reacts the next day and within the next 24 hours. I think having a slight increase in pain or stiffness the next morning after a run can be considered normal.

Sancho et al. (2019) also discuss this being acceptable as long as the symptoms have gone back to baseline within 24 hours. 

Summary of Running Through the Pain

Now that we have established when it’s best to completely stop and when we can keep pushing through the pain, let’s attempt to summarise.

Here are the main takeaways on running with pain:

• Pain intensity should be about 3/10 maximum.

• Some increase in pain or stiffness is acceptable the next day, as long as it goes back to baseline within 24 hours.

• Trying to modify temporarily certain training parameters can help (volume, intensity, frequency, fewer hills, changing footwear, etc.).

• Scaling back from explosive exercises for a bit.

• Not increasing the volume by more than 10% per week.

• Staying alert to the warning signs that could be pointing toward a more severe condition
  

Closing Words on Running With Pain

As we can see, pain is complex and there is very rarely just a simple answer to “Can I Keep Running Through Pain?’’. 

We need to answer this question on a case-by-case basis and always stay alert to the warning signs that our body is giving us.

Pain and discomfort are part of life and the body is very resilient. However, if something doesn’t quite feel right or we are unsure how to manage it, getting it checked out by a professional is the way to go.

The last thing I would add is to double down on the basic recovery strategies when our body is feeling a bit cranky and in pain. Focusing on sleep, hydration, and proper fueling can go a long way!

Happy Running,

April

References:

1. Bramah, C., Preece, S. J., Gill, N., & Herrington, L. (2019). A 10% Increase in Step Rate Improves Running Kinematics and Clinical Outcomes in Runners With Patellofemoral Pain at 4 Weeks and 3 Months. The American journal of sports medicine, 47(14), 3406–3413. https://doi.org/10.1177/0363546519879693

2. Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350–372. https://doi.org/10.2519/jospt.2020.9971

3. Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X. J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939

4. Sancho, I., Morrissey, D., Willy, R. W., Barton, C., & Malliaras, P. (2019). Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 40, 107–116. https://doi.org/10.1016/j.ptsp.2019.08.007

5. Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners. The Journal of orthopaedic and sports physical therapy, 44(10), 749–765. https://doi.org/10.2519/jospt.2014.5334