Pain vs Injury During an Ultramarathon: When to Pull the Plug

You're listening to the Restoring Human Movement podcast, and now your host. Hey everyone, it's Dr. Mandy for the Restoring Human Movement podcast. Thank you for joining the Movement Movement. As many of you know already, I am your handy-dandy running injury expert, and today we're going to be going over what to do during an ultra if you have a pain that you're not sure if it's pain as in sensitivity or pain as in, oh, I'm going to get injured if I continue. So ultra athletes, and especially coaches and support staff, your crew, this one's really for you guys, and for crew and coaches, this can really help determine if your runner should keep going or not, and y'all are going to have a much more level head about it versus the person who might be, you know, 89 miles into a race.

Coaches specifically, please reach out to me. This is a general overview of these rules of thumb, but they get so detailed, and there's a few assessments that go into more detail that you can do with your runners. So I have a handout, actually, that by the time this releases should be about out, that really is aimed at coaches and what to do when an athlete is experiencing pain during a race. So reach out to me. I am so happy to discuss this stuff. I will talk your ear off. All right, into the good stuff. And quick disclaimer, always, always, always get checked out by a medical professional. And if you're really not sure, go to the med tent at an aid station.

They're here specifically for this stuff, really for like the big scary stuff. But musculoskeletal-wise, if you're concerned, go to the med tent and ask them what's up. But rules of thumb you can use. We're going to separate this into categories of it's likely sensitive and not necessarily an injury or true pain. If we're going to use use your best judgment, if so that's not really sure I'm going to leave it up to you and your gut feeling. And it may be an injury, if and within that last section, we're going to have a few absolutely stop sort of things to look out for. So for likely sensitive, but not necessarily an injury, part of what you need to keep in mind is the injury history.

So if you've had like a nagging hamstring thing, or maybe it's even like sciatica or plantar fasciitis sort of thing, and it's flaring up, you may be able to determine if it's pain, like true injury pain, or if it's sensitive, just based on your history with that. If it's really chronic, like it's been there for months and months and months, and it's about the same level or a little worse than you usually feel for it, I'm not that worried that you've injured it unless it gets drastically worse. My rule of thumb for anything, even if you haven't had the injury before, is if you start feeling something and it doesn't get significantly worse in the following, you know, two-ish miles, then it's probably sensitive and not an injury.

And again, all of this has nuance in it, but rule of thumb, if it hasn't gotten significantly worse in the last two-ish miles, it's probably sensitive. Similarly, if nothing happened to make it hurt, like you didn't trip on a rock and fall, or you didn't run into something with your leg, like you didn't, you know, kick a log or something like that, if nothing actually happened to make it hurt, and it just sort of started coming on on its own, we're likely talking about sensitivity there, too. So main categories there, if there's no trauma to the area, you didn't fall, you didn't twist your ankle, you didn't hit it with something, and it hasn't gotten significantly worse in the last two-ish miles, probably in a solid spot.

But other things to look out for, and crew and coaches, this is really where you guys are going to come in, because again, judgment at, you know, halfway through an ultra could be a little funky. I've been there. If there's no deformity, so obvious, oh my god, your ankle looks mega screwed up. That's the sort of stuff you see on, you know, YouTube, where the basketball player shoots a hoop and he lands, and like all of a sudden his ankle doesn't look like an ankle anymore, and it's all bent weird. If it doesn't look like that, okay, yeah, that's a fairly obvious, not broken, injured sort of thing.

But also if there's no bruising outside of normal ultra bruising, that can happen for some people. Normal ultra bruising is usually towards the bottom of the feet. As blood pools down, they like to say gravity sucks. So gravity sucks bruising down if there's broken, you know, blood cells, blood vessels. This is really mostly relevant for the 100 plus mile races, but it can heavily depend on what you're doing. So if it's a long, long race and it's not 100 miles, you may be in that category too. So if there's no bruising apart from maybe that, especially if you are somebody who usually gets that sort of bruising during an ultra, I'm not too worried.

The only exception with bruising towards the bottom of the feet not being big deal is if you had an ankle thing happen. So if you twisted your ankle, say really bad on a rock, and there's some bruising down there, and it's only on one side, and it's fairly obvious that it's only on one side, that's where maybe go to the med tent, check it out, do some ankle assessments. There's plenty of assessments you can find on our YouTube for if your ankle is injured or not, and if it is, what's up. But apart from that, if it's the same on both sides and there's some bruising, not too worried. Also, this is the big one.

If there's no visible, easy to see swelling outside of normal ultra swelling. This is important for unilateral or one-sided injuries, and you can tell by comparing the sides. So my feet swell when I do ultras and my ankles kind of swell too, particularly if it's hot or if I'm doing poorly on hydration, which I admittedly often am. But the obvious, visible, easy to see swelling should be compared side to side. And again, this is mostly for ankles, sometimes knees. For the ankles, you should be looking at the outside or the inside ankle bone and if you can see it or not. So this is not something you stare at for 10 minutes and you're like, eh, I think there's a little swelling, but I'm not really sure.

This is like, oh, I can't see my ankle bones. That's a problem. But it's really only a problem, again, if it's side to side. So if you twisted one ankle and it looks swollen, but the other side looks just as swollen and you didn't twist that one, it's probably okay. Obviously, use your judgment at all times. But crew, this is where you guys come in, again, because you're going to have a better visual on it. You can get down there and look at their ankle. But always take off shoes and socks to assess. You can't really tell through the sock. And if you can tell through the sock, it is probably an injury.

So quick recap of likely sensitive and not pain injury. Again, use your judgment, use your judgment, use your judgment. Quick overview here. If it hasn't gotten significantly worse in the last two-ish miles, if nothing happened to it, you didn't hit it, you didn't trip. If there's no deformity, obvious, gross-looking thing that happened to the area. If there's no bruising that is different side to side, and if there's no swelling that is different side to side, both of those should be quite visible, then you're probably sensitive and not in an injury sphere. We're going to move on to use your best judgment if, again, crew, you guys are so important.

You are the backbone of ultra running and likely the backbone of why your runner is out there and able to complete this race. This is for you guys largely, but runners, there will be a gut feeling. And when you're creating that gut feeling, when you're feeling pain, it's not going to be very logical. Crew, this is where you come in. But also, runners, if you're feeling something and you're starting to freak out, which, again, I've been there, it happens, you need to sit on a log at the aid station, wherever you can, doesn't matter. Take a few deep breaths, maybe wait a few minutes, maybe wait several minutes, maybe eat something that really can help, and then make a judgment call.

If you do it in the moment, it's just going to spiral. So make sure you give yourself some time and maybe some calories to make that call. So judgment category here. If there is mild to moderate limping, like you're favoring one side to the point where something on the other side starts hurting, that's a yellow light. And this is in part because I don't want you to injure the other side. So even if it's sensitive on the side that started hurting, it may become that you are compensating so much that you're injuring something else. And, again, you can use the following category of maybe an injury to determine if the other side is actually getting injured or not.

But mild to moderate limping, especially if you're early in the race, say you're 30 miles in to 100, you know, use your judgment, check in with your body. And this is also the point where it depends on what your goal for the race is. If this is, say, your first 100, you have nothing else on the calendar, you have great access to medical care, again, reach out, shameless plug, and your life goal is to complete this 100, it may be okay. And you may just be able to accept that it might hurt like heck for significant weeks afterwards. But if you're somebody who's doing, say, a training race, you're doing a 50K before 100K to get in shape, this might not be the best time to push through.

So limping to the point where you're really compensating on the other side. And similarly, if the pain is preventing you from doing the technical parts of the race, so if you're able to stay on your feet when you're going over rocks or when you're making a sharp turn on a trail, you may have not encountered that yet. Say if the pain just showed up in the last couple miles, but think about the course ahead. Again, wait to make the judgment, sit down, deep breaths, get some calories, but make the judgment call on if you can complete to the actual technical aspects of the race coming up. This is also where poles can come in handy.

Poles are the great compensator in a good way. I use poles, I actually, I've only started using poles in the last year because like many of us, I am a young ultra runner. I, you know, had an ego about like, oh, I don't need poles. My legs are plenty strong. And then I started using poles. I'm like, oh my God, these are great. Why wasn't I using them before? Highly, highly recommend. But if you're experiencing something that is limiting you from performing the technical aspects of the race, but it's maybe borderline and you feel pretty good about it, but not 100% confident, poles can come in handy.

Let them be the great compensator. Let them do the work as much as possible. There's great resources out there on how to use poles. The technique actually does matter in part because you're going to use a lot more energy than you need to if you're not using your technique right. And a lot of that comes down to pole height and what type of system you have for keeping your hands on the poles. So usually that's loop or clipping gloves. So look up some stuff there. It does make a difference, but make sure you prepare for that ahead of the race in case you end up in this situation. And now for everybody's favorite category, it may be an injury if.

And this sucks. And again, I'm going to reiterate it a million times. Make the judgment when you breathe, when you eat. Crew and coaches, this is absolutely where you guys come in. Coaches, it may be tempting to be like, oh, you can do it. You can push through. Obviously, your athlete's safety is paramount. And for other coaches, it's going to be like, oh, my God, I don't know. I just pulled the plug. You can use these rules to help out. Always talk to the medical staff, too. If you really think it might be an injury and you're thinking about pulling the plug, they are there to help you. Please use them as a resource.

So it may be an injury if the pain has gotten obviously worse over the last two-ish miles. Now, this is a tricky one because it may still just be sensitive. But if the pain has gotten so bad that you're really, really limping, this is more like a severe limping. Oh, God, I can't really put much weight on it. And it's not responding to significant time at an aid station or some rest. It's worth it to probably pull the plug there if also there is obvious swelling or bruising. Those don't need to go together. It can just be the pain is so severe that you really can't move well or it got so bad that you're really, really not comfortable continuing.

But the swelling is big. And, again, there is normal amount of swelling in an ultra. But for foot and ankle stuff in particular and sometimes knee stuff, too, if the swelling is to the point where you get in the chair and your crew comes over and without saying anything, they go, oh, my God, what happened? That's probably pull the plug time. And I have had a couple folks who have pushed through swelling, like obvious injury swelling, and they landed with me several weeks after there are races where this happened. And it took much, much longer to recover, frankly. There have been other patients of mine who pulled the plug early and they were mostly OK, just needing some treatment, some rehab.

But the folks who pushed through, the two that I have in mind, actually, both of them had damage rather than just, like, pain or sensitivity. Now, thankfully, both of them are back to running. They're both back to racing 100K plus. But still, it took much longer than it would have otherwise. So pain has gotten obviously worse over the last two-ish miles. And there's obvious, visible, oh, my God, swelling. For the Achilles tendon, this is tricky because it is in the area where swelling sucks down. Same with ankle, but Achilles tendon, it can be tricky. You need to take off both your shoes and socks and compare standing side to side.

Now, for Achilles tendon runners, this is going to be difficult because you're just going to kind of be looking down at your feet and not really seeing much. You need somebody else to assess yourself standing up and looking at your ankles from behind. If you were the person assessing, the swelling will not necessarily be at the heel, like where the Achilles tendon attaches to the heel bone. It might be, but keep in mind that shoes rub on that area all the time. And it's possible that it just rubbed more on one side and not the other. That happens all the time. I only get blisters on my left foot.

I don't know why. I think maybe it's a little bit bigger than my right, but that stuff can happen. But we're really looking for tendon swelling in the mid-length of the tendon. So that's like where it should be skinniest, where those kind of depressions are on the side of the ankle. If there is swelling, like it looks like there's a marble or like a diffuse marble in the Achilles tendon over there, that's where we're not happy. And then last thing for it's probably an injury, injury. Actually, last two things. I'm going to throw one extra one in there. If something happened and the pain has gotten worse and or the swelling has appeared suddenly.

All right. Yeah, we're probably talking about an injury. The last thing I want to add here is, and for those of you who have listened to my podcast, you know I am on my soapbox all the time about this. Bone injuries are tricky. If you have a history of relative energy deficiency in sport, you guys are probably way sick of hearing about that. Go check out my other podcasts if you haven't heard of REDS. If you have a history of that or you are breastfeeding or anything else that can happen with bone density, older female runners, this is for you. Post-menopausal runners, this is for you. And you have sharp, limping pain, pull the plug.

It is not worth the bone injury that can develop into a full fracture. I've told the horror story before about the woman who had a stress fracture, ran on it, and on a downstep, broke her leg, cleaned through. That is an important one to look out for. Now, crew and coaches who are there, usually this is differentiatable by pushing on the bone specifically in the area. And if there is something like a bone injury, it's not going to be that diffuse. So, like, shin splints that are just general, you know, like periostitis or just general shin splints. Check out my other podcast for that again. That's pretty diffuse.

Like, it covers an area of several inches. But if we're talking about, like, man, my shin really hurts and it's only in this one spot that's, like, the size of a quarter or less and it really hurts to touch it, probably pull the plug. Again, postmenopausal women, people with low bone density, breads, breastfeeding, all y'all, be a little bit more sensitive to this. If you're a 30-year-old male and it's, like, questionable, maybe try and get to the next aid station, depending on how far it is. But you're going to know it's going to get significantly worse fairly quickly if we're really talking about a bone thing.

Many of you guys know, but I am not just a podcast person. I am a doctor of chiropractic and certified medical exercise specialist who specializes in ultra and trail runners specifically and distance runners, too. If you need help, reach out. My information is in the description. Until next time.