Does Pain Equate to Injury? Yes Or Maybe Not.

You’re running along one day and your left heel becomes sore. It’s not too bad, so you complete the run. When you run again, the pain returns, and it’s a little worse this time. It’s still tolerable, though, so you complete this run as well. But in your next run the heel pain is even worse, so you decide to bail out and take a few days off.

Are you injured? Maybe, maybe not. For decades, doctors and scientists equated pain with injury. The idea was that the sort of “pain experience” I just described was always caused by damage to the tissues in the painful area, and that such damage constituted an injury by definition. But the latest science suggests that the story is far more complicated. Pain and injury are only loosely coupled, in fact, and it is not at all uncommon for runners and others to have significant tissue damage in a particular area yet feel no pain and to feel pain in an area that lacks significant underlying tissue damage.

In a 2006 study by researchers at the Karolinska Institute in Sweden, comprehensive testing was performed on 80 patients diagnosed with patellofemoral pain syndrome (PFPS), among the most common injuries in runners. Twenty-nine of these runners were found to have perfectly healthy knees as judged by standard imaging tests and another 29 had no measurable damage but above-normal levels of “metabolic activity.” Even among the minority of patients who did have observable degrees of tissue disruption, there was no consistent pattern to the damage.

That’s one example of pain existing largely in the absence of injury. There are also many examples of injury existing without pain. A study appearing in Physical Therapy in Sport reported the results of ultrasound imaging of the Achilles tendons of high-mileage runners who had no history of pain in that specific area. Nearly half of these asymptomatic individuals were found to have significant pathology in at least one tendon. If one of these runners had developed Achilles pain and gone to their orthopedist and undergone an ultrasound, it is very likely that the pathology revealed by this test would be fingered as the cause of the runner’s pain. And the doctor who did so might have been dead wrong.

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