Today we’re talking about whether or not you should run when you have pain about 10 days out from a marathon.
This morning I got a call from Amy in Houston, and she’s running a marathon in 10 days. She’s doing the Houston Marathon. Today’s Thursday, so a week from Sunday she’s running the marathon. She has pain, and she’s 10 days out, and wants to know if she can run now. That’s the thing. She says, “I got this new pain, and I wanna run and finish my training.” She admits that she didn’t really train effectively, so she didn’t train as much as usual. She normally is prepared for the marathon, but this year a bunch of stuff happened, just didn’t get to train as much. Her plan was to try to run 10 miles today, on Thursday, and then maybe do a final 18 mile run on Saturday, and then maybe a few runs next week, you know, five, seven miles, or six miles, or whatever a couple of times next week, leading up to the marathon next Sunday.
So, her question is whether or not she should run. You know, she has this weird pain, this weird soreness. She’s not sure what it is. She’s done a bunch of marathons, but she doesn’t know what it is. Is it a good idea to run or not? All right. So, just to back up, let me tell you, the first thing you have to know is that if she goes and sees a doctor, they’re almost certainly gonna tell her to not run. Right? Why? Well, doctors tell you to not run, because they assume you wanna heal. Now, that sounds kind of simple, but that’s the thing. When you’re a runner, we know that that’s not always the only consideration and certainly, in many cases, not even the primary consideration. They’re not assuming your goal of finishing a marathon, an ultra marathon, an Ironman Triathlon, anything. They’re not assuming that that goal of finishing is actually more important than your overall goal of making sure that you don’t make your injury worse.
Now, David Goggins, he came out with a book recently called Can’t Hurt Me. It’s an awesome book. You should get it if you haven’t read it. That guy’s done ultra marathons with stress fractures in his feet. Now, I’m sure his doctor would have told him to quit, but Goggins has a mission. So, he wasn’t gonna quit. He was gonna do what he wanted to do, and he was gonna wanna finish, and then he’s gonna do more races. So, it didn’t kill him. Running stress fractures in his feet is probably not the best idea in most scenarios, but again, you have to figure out what is your actual goal? What is your mission? Is your mission gonna be to finish the race? Is it gonna be to use the marathon as a training event? Is it gonna be a way to increase your fitness and then launch into Ironman training? You have to really think about what your goal is, first and foremost.
Of course, without question, if your goal is just to stay healthy, and you get an injury, no matter what the injury is, you should probably just heal, and let it heal, and not continue to train for and ramp up for the marathon, but understand this. Right? You have to try to figure out what’s wrong with you. So, one of the questions Amy asked me is she said, “Well, should I stretch it?” She wanted to know, “Will stretching show me if I have a bone injury, like a stress fracture, or if it will show me if it’s something different, like a soft tissue injury?” This happens all the time. Let’s say you get a calf muscle strain and you feel like it’s in your calf muscle. It doesn’t really feel like a tibial stress fracture. It feels like clearly a muscle issue. You know, you squeeze the muscle. It hurt. You do calf stretches, and it hurts some more, but then it feels a little but better later.
That’s a really clear cut example, but you have to remember in other areas it’s really not that clear cut. Sometimes you get a weird pain in your hip. Well, that could be bursitis. It could be where the tendon attaches to the bone. It could be a femoral neck stress fracture. It could be lots of things. If you have a stress fracture and it confuses things, you know, you have to be certain of what’s going on. If you think about this, if you have inflammation in the bone, because you have a stress fracture, and you stretch the soft tissue, and it’s pulling on the attachments to the bone where you have a stress fracture, it’s gonna hurt. So, it may fool you into thinking that you actually have a soft tissue injury when in reality you actually have a bone issue, because you’re irritating the covering of the bone where the soft tissue structures attach to that bone. So, just because you can move it and stretch it, and it causes pain, it doesn’t mean that you don’t necessarily have a stress fracture. So, that’s one thing that often confuses people, so you have to be very cautious about that.
If you think you have a soft tissue injury, in general it’s less risky to continue to run and train on it than if it’s a stress fracture. The stress fracture will more predictably get worse if you continue to run on it. This sets up a confusing set of scenarios for people, because they say, “Okay. Well …” In Amy’s case she says, “Oh. Well, what if I rest today and it feels better tomorrow and Friday? If it does, if it feels a lot better on Friday, does that mean it’s okay for me to go run 18 miles on Saturday and then feel better about my marathon?”
So, we had to have a talk about that and say, “Okay. What’s the real goal here? What is it? What’s the problem? What is your concern? Is it that you didn’t really train enough, and so you’re just psychologically trying to tell yourself that it’s okay to continue to do the marathon, because if you can just jam in a few more workouts and kind of cram at the end, when everybody else would be tapering, is that really a good idea, or is that not a good idea? What is it that you’re trying to do? Are you trying to just basically say, ‘Okay. Psychologically I know that if I can fit in a few more workout, if I can run 18 miles before the marathon and get through it without stopping, then I’m confident that I can finish without walking.’? Is it that you just don’t wanna walk, or is it that you’re afraid that some of your friends, your coworkers, whatever, your neighborhoods, somebody is gonna see you walking during the marathon, and it’s gonna be embarrassing to you?”
That sounds kind of silly, but these are real concerns. Right? If you know that you’ve done lots of marathons, you didn’t really train that much for this one, but you’re gonna do it anyway, you’re trying to figure out how to do as well as you can. If that means the difference between not walking versus walking or running a decent time or what you think of as a decent time or a good enough time, whatever, whatever that measure is for you, you have to decide whether or not it’s worth the risk. That’s the whole point here. We did talk about that. Okay. Having said that, let’s go get back to this point of should I run if my soreness goes away? So, if I take a day or two off and I feel better, then should I do those last few workouts, jam them in just to feel better about it, feel like I have more confidence, more prepared, I’ll be better off? Should I do that maybe just in a shorter form, a shorter workout, not maybe 18 miles, but maybe 15 miles, maybe not doing seven or six mile runs all next week, but just doing two or three miles or four miles next week?
All right. For just a second why don’t we just suspend the whole premise and the idea of considering your injury risk in terms of making your injury worse or more severe. Instead, for a second let’s just think about this scenario and how these things, whether you run or don’t run, how it increases your probability of actually finishing the race and achieving your goal? Because if you think about that, it simplifies things a lot. Again, if David Goggins had stress fractures, and he went to the doctor, they’d said, “Well, you can’t do Badwater, or you can’t do this. You can’t do Ultraman. You can’t do any of these races with stress fractures in your feet,” I think Goggins would just Goggins-Up and do it, because that’s what he does.
So, if you say, “I have a new pain, and I have a marathon in 10 days, and I just wanna finish my marathon. I wanna get my t-shirt, say that I did it, and I wanna go back to my normal workout routine of running four or five days a week,” that’s very different than if you say, “Well, I plan on just finishing the marathon, because it’s a training run for me, and then I wanna start ramping up for Ironman Texas in three months.” Right? If you think about these, you have to think about what these individual goals are and what they mean to you.
Obviously if you have a soft tissue injury or a potential stress fracture that’s developing, and you don’t know which, and you take a day or two off, then if you go and you feel better, but then you go run 18 miles a few days later, and it really makes the thing worse, well, are you gonna be more likely or less likely to finish that marathon on time? Are you gonna be more likely or less likely to return to Ironman training immediately after the event or returning to your running four or five days a week immediately after the event? That’s absurd. Right? It’s completely preposterous to think that you are going to be way better and way better off if you just do those runs. If you think about that, it makes it a little simpler.
You have to remember, your brain’s telling you when you shouldn’t run, because it hurts. So, then you think, what is your goal? Why are you trying to do this? Why are you trying to obsess on finishing these few workouts? Is it because you have a fear of not finishing, of walking, that embarrassment that we talked about, or is your goal to just finish and get t-shirt? So, once you know which of those things is actually your case, then it makes it a lot easier to make a decision about what you should really do or should not do in terms of these other runs.
One of the things I tell runners all the time is that if your goal is to actually do a race, and you potentially ave a metatarsal stress fracture, well it’s better to let it calm down and heal, but you have to decide what’s most important to you. It’s not my job as a doctor to ever tell an athlete they should or should not run. My job as an athlete is to say, “If you run, these are the possible scenarios. If you want to run and there’s a risk of a bad thing happening, like making a metatarsal stress fracture worse, you can do these things to reduce that risk, but it doesn’t remove that risk. You have to decide how much risk you can tolerate.”
If your goal is really to finish the marathon in under four hours, even if you’ve never done that before, you’ve never run under four hours, and you want to say that you did run under four hours in your marathon when you actually had decreased fitness, because that’s sort of like this additional feather in your cap, then you think about running versus not running. Right? Again, forget about the injury risk. Think about the probability of actually achieving your goal. If you run and you make a stress fracture worse, it’s definitely going to be more difficult to run under four hours.
So, if you have this weird, new, asymmetric pain, you only have it in one foot, you only have it in one leg, you only have it in one place, you have pinpoint tenderness, you can actually push on it and reproduce the symptoms, and it hurts, and you know that it hurts there, then that is not a good thing. If you’ve never had this pain before, and you’ve been running for many, many years, that is unusual, and it’s ominous. It’s not a good sign. So, you have to assume at that point that it’s something bad, that it either is a significant tendonitis issue, or a stress fracture that’s brewing, or something that you should take really seriously. But all of those things, you know, something that’s unusual that has pinpoint tenderness, all of those things really do help you determine that it’s not a good sign, and you have to protect it. Right?
So, if you’re in the last 10 days, the truth is is you are not going to build up any significant increase in your aerobic fitness in the next 10 days, even if you run every day. You’re gonna do a lot of tissue damage. This is why there is a taper. Right? You’re supposed to taper right before your race, because you’re supposed to recover from all of this tissue damage and let things rebuild and become stronger, so that you can run your race faster. That’s the main point of a taper. So, you do not want to just ignore one of these problems right at the end of your race and keep … for the sort of mental security of having done some final race preparation. You have to figure out whether or not that preparation is good for you or bad for you. That’s the bottom line.
That’s what we do though as athletes is we always think if we can just train more, we’ll be better off. That is not always the case. So, when you’re a few days out, you think, “Will it help my aerobic fitness?” Well, no. That’s a given. If you only have literally four more days of potential workouts before your marathon, you are not gonna increase your aerobic fitness. Are you gonna increase your actual strength? Well, the argument many people would say, “Well, probably. If I haven’t run 18 miles yet, but I can just jam in an 18 mile workout, then I’ll be stronger.” I would argue that you’re gonna get a lot of tissue damage running 18 miles and that it can help you psychologically, but if you’re already injured, it’s not worth the risk of potentially worsening that injury in a way that’s gonna make you more likely that you’ll fail at achieving your goal during the actual event.
So, those are really key consideration when you’re trying to figure out whether or not you should do those last few workouts. You’re not gonna get increased aerobic fitness. You’re not really gonna develop better form. You’re not going to get much stronger physically. Your potentially gonna get a lot weaker. In Amy’s case I would say that you are not gonna be well served by jamming in a 10 mile run today, and then an 18 mile run on Saturday, and then two or three runs the week of the marathon, because you have something brewing. There’s problem. Yes. It would be better if you would just go and see a doctor, get completely diagnosed and all that. Of course there is a real risk that when you go into the doctor, the doctor’s gonna say, “You’re completely nuts, and you should not run the race at all,” but that’s none of the doctor’s business.
It’s your job to go there, listen to the doctor, and then take that advice, and decide whether or not you’re willing to tolerate the risk that the doctor is telling you you’re going to go through if you do the event without being properly diagnosed and then knowing what the real problem is. Because, again, if you don’t know if it’s a soft tissue problem, you don’t know if it’s a bone problem, you don’t know if it’s a stress fracture, if you don’t really know what it is, you can’t really make that call on assessing risk. But on base level, we know that most runners who want to do a marathon, have been training for many, many months, it’s very, very difficult for them to let go and just skip the event right when it’s race time. That is a really hard pill for most runners to swallow. So, you have to really think about it.
Now, we’ve created a quiz and a thing that can actually help you process some of this and help you figure out whether or not you should do those final runs right before your marathon. So, if you want to do that quiz, you can just go to Pre-marathon Pain Quiz at DocOnTheRun.com. You can get it. It’s free. You can go through it, and it’ll help you to determine whether or not it’s a good idea for you to continue to jam in workouts or not. With each of those, depending upon your answers, we’ll give you a couple of different videos that will help you to understand really what the key considerations are. So, you have to be thoughtful about this.
Again, we always talk about risk, because that’s what we as physicians do. We assume you just wanna be healthy, and you wanna be strong, and you wanna be fit, and you don’t wanna make anything worse. But just like in Amy’s case, many times we know that when it’s time the show up for the race, you wanna be there psychologically and physically prepared as much as possible. But that’s the thing. You have to really figure out what’s most important to you and what you really wanna do after the race. If you just wanna finish, then you can probably run, and you have less risk, but if you have another event afterward, like ramping up for another marathon, or an Ironman race, or something like that, then you have to take this very, very seriously.
Even if you’re just thinking of this as a training run, you do not want to go do an 18 mile run as a training run when you’re already having something that’s sore and injured. Your coach would probably tell you to shift gears and do something different that day. But all that seems to go out the window when we’re right in final race preparation. People want to finish a few workouts. They want to add them on. They wanna keep going. They think it’s gonna make them better, but you only wanna do the things that are gonna make you stronger. Don’t ever do the things that you know will make you weaker. That is a recipe for a disaster, not a recipe for success.
Pain is the best tool to help an injured runner decide when run. You don’t have to figure out what to write down. We made a simple Pain Journal PDF for you.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!