When It’s O.K. to Run Hurt

I have been increasingly worried about various triathlon training related pain as I have tried to run more relative to swimming and cycling since last October.  In fact I have  abandoned the high-mileage running training I had planned as preparation for the Tokyo Marathon (and begun to worry that I will need to abandon plans to do the marathon entirely).

But today's NYTimes is emboldening.   For decades I have heard the advice to cross-train, ice, and use anti-inflammatories when faced with injury.  I would always cross-train anyway when injured to maintain cardio-vascular fitness and keep from going crazy.   But I have never heard medical advice nearly this aggressive about continuing to run when facing a running related injury - and new research indicating that rest itself prolongs the injury.    Here is a summarized version of the article:

When It's O.K. to Run Hurt

By GINA KOLATA

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 Weinstein and a number of leading sports medicine specialists say that is outdated and counterproductive.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 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.

"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.

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. Kocher said 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.