Pain management

By David Kuneš
Zvládání bolesti

In the summer of 2017, Kilian Jornet won the Hardrock 100, a challenging 100-mile race with more than 10 kilometers of elevation gain, for the fourth time in a row. This news wouldn’t have been a big surprise if Kilian hadn’t dislocated his shoulder in a fall at mile fourteen. In the following minutes, he could “pop” it back on, but he struggled with a lot of pain for the rest of the course and even had to have his entire arm strapped to his body at mile 57 due to the pain to keep running. However, as he confirmed at the finish line, he took no pain medication.

Anyone who has ever dislocated their shoulder knows it is associated with unpleasant pain. In online advice, you will read that “immediately after the injury, there comes a sharp pain in the affected area and the inability to perform any activity with the injured arm.” The physician says, “It is necessary to rule out movements or shocks – all are very painful.” How was it that Kilian not only managed to run for the next twenty hours or so with such a painful injury but even won the race by half an hour?

I have experienced something similar in a much milder form. A few months ago, when I ran the 100km race Černohorské šlápoty, my ankle hurt intensely from the start. Yet somehow, I managed to push the pain to the edge of my consciousness while running because I was unaware of it unless I focused on it directly. I crossed the finish line in one of my best times for a 100km run.

Release from pain

To understand how this is possible, let’s go back to 2009. In that year, the second edition of the Trans-European Ultramarathon Run took place. The total distance the runners had to cover was an incredible 4885 kilometers. This race was particularly significant because a study investigating the effects of long-term physical exertion on the human body took place within it. The research compared a group of participants in the event with a control group of non-runners with similar characteristics. Based on the results, the experts concluded that ultramarathoners have a higher pain threshold than the general population. Thus, ultra-runners are less sensitive to pain and can tolerate it much better and longer than ordinary people.

But why is that? There are several possible explanations and opinions. In her doctoral thesis, Dolores Christensen argues that ultramarathoners gradually learn to accept pain as a fact that is inherent to running. This acceptance allows them to exist “alongside” the pain – they know about it and perceive it but don’t credit it with as much importance. In short, they are aware of the physical pain throughout the run, but at the same time, it doesn’t affect them.

Kenneth Kamler also encountered a similar ability in the Amazonian Indians and described it in his book Surviving the Extremes. During his Amazon expedition, Dr. Kamler meets an Indian boy who nearly cuts his wrist with a machete. Yet the little boy responds matter-of-factly and shows no sign of pain. Dr. Kamler explains that in the hostile jungle environment where Indians fight daily for survival, succumbing to pain would make no sense. Here, letting go of pain and acting matter-of-factly dramatically increases the chances of survival.

The Gate Control Theory of Pain

The gate control theory of pain explains a biological point of view. According to it, a complex system of neural connections called “gates” regulates the transmission of pain and numbing signals from the periphery (for example, from the skin, muscles, or internal organs) to the brain. This system comprises nerve fibers that transmit pain signals and nerve fibers that send numbness signals.

According to this theory, we perceive pain when the gate opens, and pain signals can enter the brain. Conversely, pain signals cannot flow when the gate is closed, and perceived pain is muted. However, the gate theory of pain emphasizes the importance of psychological and emotional factors in pain perception. For example, stress, anxiety, or emotional state can influence these gates’ opening and closing, thus affecting pain perception.

(The gate control theory has not been proven in previous years and is now considered disproved.)

Narrowed consciousness

A similar explanation from a psychological point of view is that our focus of consciousness narrows during a long exhausting run. We enter a trance state in which we perceive only a few facts closely related to the run. Andrew Mojica, who in 2003 studied participants in the Badwater ultramarathon, one of the toughest ultramarathon races ever, came up with an interesting finding. During the event, runners answered questions about hallucinations. Some runners clearly described the hallucinations they experienced during the race but, immediately after the race, categorically denied all hallucinations and visions. Through interviews with their teams, it gradually became clear that the runners did not remember much of the events of the race.

This narrowed consciousness is more intense at night and is triggered by increasing fatigue, reduced blood sugar, and less blood oxygen during runs at higher altitudes. Our brains begin to adjust their attention as the situation demands. It will focus only on basic bodily processes like breathing or movement. Any other sensations, including prolonged pain, are relegated to the margins of consciousness. At the moment, the brain evaluates pain as less critical.

The runner's high

The last explanation is related to the so-called “opioid theory.” Research from 2008 suggests that prolonged running releases chemicals in our brains that work similarly to drugs or painkillers. These substances then bind to nerve receptors in the brain centers, influencing pain perception. The body produces its anesthetics to help relieve the pain.

There is another research related to the topic of pain. In 2012, Przemyslaw Bąbel interviewed participants of the Krakow Marathon after the race and asked them about the pain they experienced while running. The runners were mainly happy to have finished. However, they still reported quite a lot of physical discomfort and various aches. When Bąbel asked them again three and six months later to describe the pain they experienced during the marathon, participants often reported significantly less pain intensity and discomfort associated with it. They seemed pretty oblivious to the difficulties accompanying their marathon experience.

But one question remains: What if ultramarathon is the sport of choice for people with an innately higher pain threshold? Individuals who can naturally dampen the pain they experience. In that case, practicing our sport would have far less effect on pain than is assumed.

Author’s note: I first published this article on 31 October 2017 on; the current version has been significantly updated.

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