A friend of mine (and former patient) messaged me yesterday.

It was one of those types of messages that encapsulated a lot of the types of conversations I have with people who are struggling with pain and injury.

So, I thought I’d share it with you and talk through some of my advice and thought process.

“Hello! Sooo I’d like your expert opinion. Turns out my knee issues are arthritis ( xray and mri ). I was training for the 50 miler and had knee pain but just ran thru it then last week at mile 15 I could barely walk. Had to resort to crutches the next day. The ortho PA told me no running until my knees are pain free. She gave me a cortisone shot and anti inflammatory pills a week later I am much better but still hurt. My question is - will running ( especially 20 plus miles) make my knees worse in the long run?”

There’s a lot to unpack in this message so let’s break em down one by one:

1. “Sooo I’d like your expert opinion.”

This is a kind statement but I’m not an expert. However, I like to believe that my 15 years of experience of helping athletes bridge the gap from pain to performance has allowed me to share a helpful opinion or two.

2. “Turns out my knee issues are arthritis ( xray and mri ).”

I’ve written extensively about the limitations of medical scans in the past, which you can read here. Do they have the ability to see things like arthritis in a joint? Most certainly.

Does that mean we can assume all the “issues” of pain, weakness, limited mobility, etc. are all a direct result of the arthritis? Of course not.

In this instance, the arthritis was present before the 50-Miler when she was running, walking, and training and it’ll be there after. Take another x-ray and you’ll see there’s no change in the degree of arthritis in knees.

So why the pain if it’s not just the arthritis? We’ll get to that.

3. “I was training for the 50 miler and had knee pain but just ran thru it then last week at mile 15 I could barely walk. Had to resort to crutches the next day.”

Training for a 50-Mile race is no joke. Lots of stress and a ton of volume.

It’s common to have some aches, tightness, and pain leading up to a race like this because of that amount of workload.

But I think this is where people oftentimes make a mistake by “pushing through it.” We chatted a little bit about what her training looked like the 4-6 weeks leading up to the race and it was clear there were some signs that the programming and plan should have been adjusted. Unfortunately, it wasn’t.

There are so many modifiable variables we can look at here:

Adjusting even one or two of those could’ve decreased the knee pain as a result and would’ve had nothing to do with her arthritis.

Also, at this point in her training she had more than enough fitness to complete a 50-Mile race. The legs were strong and her endurance was great. Therefore, the goal should have been to get to the start line feeling as good as possible. Pushing through pain just to add more miles wasn’t the best decision here and I think is a part of the reason why she hit a wall of pain at Mile 15.

4. “The ortho PA told me no running until my knees are pain free.“

This is some of the worst advice you can give to an athlete. Yet, nearly all doctors (or PAs in this scenario) say it to their patients.

Here’s a list of questions highlighting why I hate it and why it makes zero sense:

“No running? Like at all? I can’t jog? What if jogging feels fine? How will I know if I’m pain free if I don’t run when running is the only thing that hurts? What if my knees hurt but running actually makes things feel better? Is it pain free at rest or pain free with everything that I do? How long is this the recommendation? Forever? Until next visit?”

There is zero clarity here. It’s a blanket statement because clinicians have no idea what’s going on, what to do about it, and want to just cover their asses.

It’s dumb and I hate it. Moving on.

5. “She gave me a cortisone shot and anti inflammatory pills a week later I am much better but still hurt.”

Of course she did.

This is the “usual care” of pain management after all.

Imaging, injections, pharmaceuticals, and surgery. Rinse and repeat with VERY little evidence to support any of these treatments, especially for the active population.

Me - “Hey doc, how is a cortisone shot and pills supposed to do anything to change the arthritis?”

Doctor - “Well, it’s not really. We’re just trying to manage the symptoms.”

Me - “Ok got it. Then why do you base all of your decisions around a picture that shows you how bad the arthritis is? Are we trying to change the x-ray or are we trying to manage the symptoms? Make up your mind.”

Even if she starts to feel better, what’s the next step from there?

These are passive solutions that don’t take into account what someone who’s active training and daily lifestyle looks like. What happens when she starts to run again and the symptoms return? More injections and pills? Is that going to be the long-term plan?

I sure hope not.

Rather than focusing on the medical diagnosis and non-modifiable risk factors, a better approach is to create a functional diagnosis.

The factors in the left hand column are things we can’t change and are less likely to actually be contributing to the pain someone is experiencing.

The right hand column, on the other hand, can change and is MORE likely to be contributing to the pain.

So, which one should we focus on? You got it. The functional diagnosis.

Once we go through an assessment and “needs analysis” phase of testing, we can start to identify the low-hanging fruit and build a plan.

If we really simplify and break it down, running is a combination of two things:

• Absorbing force (which is important for avoiding injury)

• Producing force (which allows to run fast and perform well)

So, we’ll identify the target areas here and priorirtize what’s needed.

6. “My question is - will running ( especially 20 plus miles) make my knees worse in the long run?”

Should we stop running altogether? Most likely not. Rest is rarely ever the solution.

As mentioned above, there are so many variables we can consider to modify the running / training before completely eliminating it.

Everyone’s plan should be different and hers will be no exception.

But these are common examples of how we can tinker with the programming to still run, build some volume, and avoid aggravating the current injury.

My goal is to do everything I can to keep my athletes and clients moving. Staying in the gym, continuing to train, without going to the doctor.

Our bodies don’t wear out. They rust out.

Running helps our joints. It doesn’t hurt them, as shown here and here.

Stay moving, and if you’re not sure how, respond directly to this email or book a call with me. I’m happy to help.

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Ryan