Understanding pain is critical to taking control of your life again

Physical pain is common.  Everyone will experience it at some point in his or her life.  Often, pain will result from an injury and will resolve when the injury heals.  This is normal.  This is good news for the 84% of us who will likely experience something like low back pain in our lives.  It will come and go and we will go on our marry way.  But for many, this pain lingers and has become the most common cause of disability and time off work in people over the age of 45 (Balagué et al. 2012). Long term, or chronic pain, that results in disability is a much bigger issue.  What’s worse is that many of these people end up relying on opioid drugs (prescription and not) in attempts to manage their pain.

Opioids and the crisis

Opioid use has sky-rocketed in recent years, and drug overdose deaths are on the rise. So much so that the Center for Disease Control (CDC) has declared that we are in the middle of an “opioid crisis” and it is an epidemic.  This epidemic is not just affecting the heroin addict living in the back alley.  It’s everyday people who rely on opioids to cope with pain (i.e., low back pain, knee pain).  The statistics are staggering:

  • From 1999 to 2017, more than 700,000 people have died from drug overdose.
  • Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid.
  • In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999.

State by State Look at Opioid Statistics

Despite this, it is important to note that THERE IS a time and place for taking opioids—for instance, following significant surgery or injury when managing pain is difficult without them.  However, prolonged use of opioids long after recovery from surgery or traumatic injury can result in addiction and can cause people to rely on opioids long term.  The reason that people become addicted to opioids is that they only mask the sensation of pain—they do not alter the source of the pain.  This is not to mention that the withdrawal symptoms are severe.  It’s hard to get off of opioids.  This is the vicious cycle of addiction.  Taking opioids long term also has side effects of depression, for which many people take more drugs.  This is why there are important Questions to ask your doctor about pain medication  when they are writing you a prescription.  Even the most well-meaning doctors can send you down the road of addiction without meaning to.

Long story short, opioids are a “bandaid” for pain and getting to the root of the problem requires understanding why someone enters a state of chronic pain.  If an injury is healed and there is no more tissue damage or new injury, then why can one still hurt?  This is what is important to get a handle on.  Many factors play a role in creating each person’s unique “pain experience” which includes emotions, thoughts and beliefs—it’s not just physical.  Read on…

Understanding Pain

Research has shown that when people understand pain, they can better manage their pain. And when one can manage his or her own pain, he or she can take life by the horns again. Simply put:

“Know pain, know gain”—David Butler

This is especially true for people dealing with chronic pain.  Many people have an overly simplistic view of how pain is experienced.  And I say “experienced” very deliberately.  As children, we learn that doing something such as touching a hot stove or stepping on a sharp object with bare feet creates pain.  These two events are generally associated with tissue damage—the skin is compromised and you get a blister or a stab wound.  But the shocking thing to most people is that this pain  does not originate in the injured part of the body.  Pain is an experience that is created in the brain once it interprets the signals that the rest of the body send to it.  So when you step on a nail, the sensory cells send signals all the way up the spinal cord to your brain where you brain interprets this event as being painful.  Obviously, this occurs in fractions of second and you generally pull your foot away from the nail.  In this experience, the interpretation of pain is a good thing—it signifies that there is a threat in your environment (the nail) that you harm you.

The fact that pain is an experience that is created by the brain explains why two soccer players can experience the same injury on the field and one gets up and keeps playing while the other lays on the ground crying out for help.  It also explains why people can experience pain in a body part without actual threat to it.  Say you had a traumatic experience as a child when you stepped on a rusty nail with bare feet and you ended up in the hospital with pain and a raging infection in your foot.  Now, when you so much as look at a rusty nail you experience pain in your foot.  You foot is healed and the nail is no where near your foot.  Danger is absent, injury is absent……but pain is ever present.  This experience is created purely in the brain.

Below are a few videos from some of the World’s leading pain experts. Watch them to learn more about how your pain experience is created ….. and how you can take control.

Below, Professor Lorimer Mosely explains how pain works.  Pain evolved as a protective mechanism to indicate when the body was in danger.  However, when our experiences change the way that pain is experienced and skews what the pain is indicating, it can result in a maladaptive response—or extreme fear from harmless sensation (i.e., a tree branch brushing one’s leg on a hike).

Each part of your body is represented on a specific area of the brain.  There is a part of your brain dedicated to being able to detect sensation of your left pinky finger—and every other part of your body.  If you experience prolonged pain in your left pinky finger, the “sharpness” of left pinky’s representation on the brain is lost and you brain can no longer create a pain experience in just your left pinky.  Maybe then your neighboring fingers begin to hurt and the pain becomes more widespread.  This is phenomena is known as brian smudging as explained below by expert David Butler.

If you have recurring or ruminating thoughts of your pain, that is a sure recipe for making your pain worse. Yes—pain has a significant emotional component.  These recurring thoughts have been termed “thought viruses”.

Myth: getting high tech imaging of your painful area will explain the source of your pain. 

 Professor Peter O’Sullivan explains the discrepancy between medical imaging and pain and how thoughts, and beliefs and movement habits actually matter more.

It’s only 1% of back pain that is really serious stuff….99% has no diagnosis based on scan”.  Peter O’Sullivan.


Physical Therapy is a safe alternative to opioids for pain management

If you watched the video above with Professor Peter O’Sullivan, you will have learned that many people with low back pain get medical imaging (i.e., MRI, X-rays, CT scans) that lead them to believe that their backs were really “messed up” structurally.  As a result, they developed fear of further injury and starting moving (or not moving) in ways that actually exacerbated their pain—-it wasn’t the “bulging disc” that might have been found on imaging.

“Pain does not equal structural injury” –Prof. Peter O’Sullivan

Restoring healthy movement patterns in conjunction with understanding pain is essential to managing back pain.  Physical therapists can help you do both.  Even better, physical therapy can not only get you moving better again, they can get you back to an more active lifestyle that includes activities that you love doing.   This is why the CDC has recommended physical therapy as a safe alternative to opioids for pain management.




Resources for helping managing chronic pain have been compiled by the ChoosePT movement organized by the American Physical Therapy Association (APTA). 

7 tips from the ChoosePT movement for managing chronic pain

 If you would like to delve deeper into these topics, here are two books that I would highly recommend. Click on the images to see details.

Weber Physical Therapy and Wellness supports the ChoosePT movement.  If you are experiencing chronic pain and would like a free consult to see how physical therapy can help you, please get in touch or schedule a free consultation:
Schedule Appointment



References and helpful websites:

Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. The Lancet. 2012;4(379): 482-91.

Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report. J Orthop Sports Phys Ther. 2010:40:494–501.

Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis [erratum in: N Engl J Med. 2013;369:683]. N Engl J Med. 2013;368:1675-1684.

Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression. Med Sport Sci. 2012;57:90–99.






Determining Readiness to Return to Running Post Child-Birth

You’ve had your baby.  Other than the sleepless nights, you’re absolutely smitten.  But just when it seems that you couldn’t possibly have any more love to divvy out, you’d really like to give some love to your running shoes and favorite trails.

But are you physically and mentally ready for running?

This is the million-dollar question.

Truth be told, medical guidelines for determining readiness for you to return to running are in their infancy—pun intended.  Relatively speaking, there have not been a lot of extensive research studies to determine hard and fast guidelines for medical practioners to help guide you through this exciting and challenging transition in your life.  However, physical therapists Tom Goom, Grainne Donnelly and Emma Brockwell, have compiled the evidence that does exist as well as their extensive clinical experience to help safely guide women back to running.  What they have published is a beautiful foundation for providing advice to women at present and for building on as new research in post partum running reveals new information.  I will summarize some key points from this publication below.

“Return to running is not advisable prior to 3 months postnatal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to, or after attempting, return to running” (Goom et al. 2019).

postNatalRun1Running is stressful on the body and so is child-birth.  Doing these two things too closely back to back can have adverse consequences.  This is evidenced by the prevalence of urinary incontinence, pelvic organ prolapse (POP), abdominal muscle separation and pain that are experienced by female runners after having a baby.  Urinary incontinence and POP can result from the stress that is place on the pelvic floor muscles.  For a review of the anatomy of the pelvic floor muscles click here.  Post vaginal delivery, the levator ani muscles, which are part of the pelvic floor, take 4-6 months to reach maximum recovery.  When you consider that the impact of running increases the risk 4.59 times of pelvic floor muscle dysfuntion (vs. low impact sports like cycling), you can start to see why it is recommended to wait at least a few months post child-birth prior to running.  If you have had your baby via C-section, additional time for healing is needed.  At 6 weeks post C –section, the uterine scarring is still very much healing and abdominal tissue, known as fascia, is only 51-59% as strong as it originally was.  Even 6-7 month after a C-section, abdominal fascia is only 73-93% of its original strength.

What are some indicators of pelvic floor or abdominal wall dysfunction?

  • Urinary and/or fecal incontinence
  • Urgency that is difficult to defer
  • Heaviness/pressure/bulging/dragging in the pelvic area
  • Obstructive defecation: characterized by feeling that stool remains in your rectum even after trying to pass it, excessive straining, need to use laxative or enemas to pass stool
  • separated abdominal muscles and/or decreased abdominal strength and function
  • low back or pelvic pain
  • Ongoing or increased blood loss beyond 8 weeks post child-birth that is not linked to your menstrual cycle.

If you are experiencing any of these symptoms you are definitely not ready for running and should seek medical care.

 If you are 3 months post child-birth and do not have any of the above symptoms, it is recommended that you have a complete health screening and risk assessment done to ensure readiness for graded return to running.

postnatalRun2The screening process is recommended to cover the following:

Load and impact management assessment: Your physical therapist can assess you ability to walk, squat, hop, jog with good mechanics and without pain, incontinence or feelings of heaviness in the pelvic floor.  Your pelvic floor, abdominal and leg strength should also be assessed.

Gait analysis:  It recommended that your running form be reviewed to look for significant injury risk factors.  This is something that an experienced physical therapist can provide for you.

Preexisting pelvic or lumbar spine dysfunction or hypermobility conditions (e.g., Ehlers Danlos):  If you were having pelvic or low back issues or joint laxity prior to or during pregnancy, you should exercise caution in returning to running and this may exacerbate  problems associated with joint laxity.

Fitness level: Generally speaking, women who maintained high levels of fitness before and during pregnancy, usually bounce back faster.  If you were fairly sedentary and are now looking to increase your physical fitness post-baby—that’s awesome, but you’ll need to take that into consideration when trying to take up exercise and/or running.

Breathing: Proper breathing, which is important for running, may need to be restored post-baby to recreate proper synergy between pelvic floor, abdominal muscles and diaphragm.

Psychology: Postnatal depression is experienced by 20% of mothers and it needs to be considered in the context of return to running.  Obsessive focus on returning to pre-pregnancy fitness and taking running to a level that is too intense for the stage of post partum recovery can result in injury.

Diastasis rectus abdominis: Core strength is important for efficient and injury free running.  If you have separated abdominal muscles, you will need to rehab these to minimize injury risk with running.

Scar mobility: Adhesions in C-section scars can create tension, pain and alter the function of muscles in this region, resulting in subpar running mechanics.

Breastfeeding: maintains lower levels of estrogen and continued elevated levels of relaxin, which may or may not contribute to increased laxity of joints.  Running should be timed carefully around breast-feeding so that you are not running with your breasts overly full, which can create discomfort.  It should be noted here that vigorous exercise does not compromise the quantity or composition of breast milk.

Sleep: Seven to nine hours of sleep are recommended for anyone, but it is rare that new mothers get this many hours.  Sleep deprivation impairs muscle strength, reduces protein synthesis and increases injury risk in any athlete.

Obesity: is a general risk factor for running injury and should be taken into account (BMI>30 increases injury risk).

Relative Energy Deficiency in Sport (RED-S): RED-S is formerly known as the “female athlete triad”.  Energy deficiency occurs when one expends excess energy that is not replenished with adequate nutrition and rest.  The post-partum world is full of energy expenditure via breast feeding, sleepless nights and social pressures to return to pre-pregnancy fitness.  Adding running into this mix further depletes energy.  Without adequate nutrition and rest, the risk of stress fractures, pelvic floor dysfunction and infertility is greatly increased.

Graded return to running

If you pass the above screening, you are ready to return to running!  But this doesn’t mean that you lace up and blast out the front door like you used to.  What is recommended is a graded return to running.  This means slow…literally.  The first time you run, it is recommended that you only run for 1-2 minutes at a slow pace.  Slow pace means that you can carry on a conversation with a running partner if you needed to.  In ramping up your running, you should focus initially on increasing your volume (distance or time spent running), rather than your intensity (how fast you are running). A general guideline is to not increase running volume more than 10% per week.   An example of a good program to begin when you are returning to running is a “couch to 5K” program.  Such a program gets you up to the 5K distance in about 9 weeks time.  An example of a week one starter workout might be 20 minutes total, beginning with a 5 minute brisk walk, and then alternating brisk walking with 90 second bouts of slow running.

Your physical therapist can help

You physical therapist can help you through the above screening process, rehabilitative exercise and a safe, graded return to running.  If you need pelvic floor rehab, it is advised that you see a physical therapist who is a pelvic health or women’s health specialist.  However, most orthopedic physical therapists can assist you with the first line screening, strength testing and gait analysis.  For gait analysis, it is recommended that you see a physical therapist who is experienced in this and understands running biomechanics.  Your physical therapist(s) should work in conjunction with your OB/GYN to optimize your rehabilitation program, especially if you have symptoms listed above for pelvic floor and/or abdominal dysfunction.


Goom, Donnelly, and Brockwell. 2019.  Returning to running postnatal–guidelines for medical, health and fitness professionals managing this population.

 DOI: 10.13140/RG.2.2.35256.90880/2 


Mastering the downhill run is KEY in improving your race performance and in preventing injury

 “Fast and flat course” is a phrase that is utilized to draw some runners into signing up for particular marathons.  Hills are stigmatized even in a runner’s masochistic existence in which pushing through pain is the norm.  One of the most famous hills is “Heartbreak Hill” beginning around mile 20 of the Boston Marathon that rises 91 feet at a 3.3 % grade. Having run it, I know first hand that it’s a taxing little climb, especially at that time of the race. However, it seems to always be the hill climbing in a race that gets noted more so than any hill descent.  The Boston Marathon has a downhill trajectory from the start to about mile 8-9 when the course flattens out a bit.  Research supports that this part of the course may actually be more taxing on the body than the climb later.  In fact, mastering the downhill run may separate the men from the boys and the women from the girls in terms of performance, especially in trail and mountain running where hills are the norm.


Downhill training session at Active at Altitude Running Camp.

Downhill “pounding” = increased impact force= increased injury risk

When running downhill, the force of gravity is with you.  Anyone who runs knows that it feels like your feet are pounding the pavement more when you run downhill than when you are running on flat surfaces or going uphill.  This is of concern from an injury prevention standpoint because as the magnitude of the “pounding” or impact forces go up, so does your risk of injury.  As the steepness or the grade of the downhill increases, you may have felt as though the pounding increases as well as your muscle soreness in the days following.  What you are feeling is backed by research. In a recent study, the impact that women experienced when running at 4 meters per second (8.8 mph, ~6:30 per mile) on an instrumented treadmill at grades of -5, -10, -15 and -20%; researchers found that the impact forces were significantly increased compared to running on level surfaces (Wells et al. 2020).  These findings corroborate data generated by Gottshall and Kram (2005) that indicate running down a -2.5% grade increased impact force by 54%.  Björklund et al. (2019) specifically studied impact forces that trail runners experience when running downhill, uphill and on level surfaces and found that impact forces were greatest on the downhill segments. The stress of downhill running is evident in the days following your run too.  Chen et al (2007) found that running for 30 minutes down a -15% grade decreases running economy 4-7% for several days.  Running economy is a measure of how efficient you are or how much energy your body demands to run at a particular speed and corresponds to the amount of oxygen you need to consume in a given unit of time.  Chen et al. (2007) found that following a downhill run, runners experienced increased oxygen consumption, decreased maximum strength of muscles around the knee (extensors, specifically), decreased range of motion in the knee and ankle, increased muscle damage, increased rating of perceived exertion (how hard it feels to run), and increased lactic acid levels in the blood.  In short, downhill running substantially stresses your body.


Why you should master downhill running to improve your performance

Perhaps you didn’t need the data summary above to prove it to you, but downhill running, without a doubt, is more stressful on your body, than level surface or uphill running.  This is exactly why you need to master it.  If you are better at running downhill, you will not only reduce the negative physiological effects on your body, but you may also have a significant advantage over your competitors in your next race.

Björklund et al. (2019) identified that speed varied the most among runners during the downhill portions of a trail run, and the more technical the section of the course, the more variable the speeds became.  So if you are looking for a window of opportunity to take down your competition on your next trail race, you will probably want to consider working on your downhill running, particularly over technical terrain.  Furthermore, Kerherve et al. (2016) found that runners tend to continue losing speed over time when downhill running, whereas speed tends to reduce and then plateau on the flats or uphill segments.  Learning how to maintain speed on the downs is key to increasing your competitive edge.


Tips for mastering the downhill run

So if downhill running is stressful on the body, how do we train for it without destroying ourselves?  Small doses that allow you to practice mechanics that will reduce impact and prevent injury.

One of the main reasons that people experience greater impact forces when running down hill is that they tend to lean back and run with their feet out in front of them.  This is like driving your car downhill with your foot on the brake.  This will wear out the brakes on your car quite quickly; in running, it wears out your body and puts you at increased injury risk.  At the same time, people tend to run with lower step rate or cadence when running down hill.  This means that the foot is spending greater time in contact with the ground, which translates to greater stress on the legs and rest of the body.

Given this, you need to do the opposite of what you likely tend to do.  You need to keep your steps short, quick and light with your body over your feet.  This can be very uncomfortable for some, because adding a forward lean accentuates gravity’s force to carry you down the hill even faster.  You may even feel like you are about to fall.  But becoming comfortable with this level of discomfort will not only translate to speed on the downhills, there will be less impact on your body.

As with any new skill, it is better to train it in small doses ….CORRECTLY.  And doing downhill running correctly will likely be very uncomfortable at first.  But in time, correct practice will make this skill automatic and you’ll be whipping down the hills (and maybe even having fun while doing it) without thinking much about it.

Here is an example of how you can begin to train down hill running after warming up:

  1. Find a hill that has a grade that is challenging but not utterly daunting for you (only you can define what this is).
  2. Start at the top of the hill and run down for 10 seconds with good form (high cadence, body over feet).
  3. Walk back to the top for recovery.
  4. Run downhill for 20 seconds with correct form and walk back to the top for recovery.
  5. Continue these repeats, increasing the duration of the downhill run (i.e., 30, 40, 50 and 60 seconds).
  6. cool down

As this becomes more comfortable, you can work into using hills that you would like to conquer or maybe those that are part of or mimic your upcoming race.  Strategically place this in your training schedule so that your intense workouts come earlier in the week before your downhill training session.  Remember what the data show— your running economy will be decreased in the days following your downhill workout.  When you start training downhill running, shoot for doing this only once per week.

Tip summary:

*Increase your cadence (step rate).

*Run quietly, softly.

*Lean forward, from the ankles to keep your body over your feet.

*Practice correct downhill running form in small doses (see example workout above).

*If you feel like you are going to fall forward while running downhill, you are probably doing it right!

Want to learn more or get an in-person training session?  Get in touch with me at: cfweberpt@gmail.com


Slate Mountain Trail, Caribou National Forest just outside Pocatello, ID provides great hill workouts.


Björklund, G, Swarén, M, Born, DP, Stöggl, TL. 2019.  Biomechanical adaptations and performance indicators in short trail running.  Frontiers in Physiology. 10: p 506.


Chen, TC, Nosaka, K, Tu, JH. 2007.  Changes in running economy following downhill running.  Journal of Sports Sciences. 25(1): 55-63.


Gottshall, JS, Kram R.  2005.  Ground forces during downhill and uphill running.  J of Biomechanics. 30(3): 445-452.


Wells, MD, Dickin, DC, Popp J, Wang H.  2020. Effect of downhill running grade on lower extremity loading in female distance runners. Sports Biomech. 19(3): 333-341.