Chronic pain and the female endurance athlete

Lloyd Emeka

PhD researcher, St Mary’s University

“In January and February of 2017, I had surgery on my left and right shoulders. It should have been a quick recovery, but when I was back in the pool in April, I knew based on my pain level that I needed more time to heal. I’m ready to not be in pain every day. I’m ready to continue growing each and every day to be the best person and role model I can be. I’m ready for the rest of my life”.

The above quote from Missy Franklin, a former American elite swimmer and five-time Olympic gold medallist provides a brief insight into her experiences of chronic shoulder pain which ultimately led to her retirement from competitive swimming in 2018. Her story received significant media coverage and helped to bring attention to a health condition that is often overlooked within endurance sport.

Establishing what chronic pain is and isn’t

Chronic pain can come across as a relatively abstract term, so it is important to clarify what it is and what it isn’t. The International Association for the Study of Pain (IASP) defines chronic pain as persistent or recurrent pain for 3 months or longer. In contrast, exercise-induced pain occurs naturally and typically disappears shortly after exercise is ceased or intensity is reduced. Dull-aches, soreness and a burning sensation in the muscles are often associated with exercise-induced pain.

While the IASP definition is useful, it can be constraining to only consider chronic pain within the context of a timeframe. Increasingly, chronic pain is described as low or high impact. That is, persistent or recurrent pain of 3 months or longer might or might not be associated with major social, personal or role restrictions for an individual. For female endurance athletes with chronic pain, they will be affected in different ways and to varying degrees. There isn’t a universal lived experience of chronic pain – two athletes with persistent low back pain as an example could have completely different experiences.

We can consider chronic pain as an umbrella term that includes many conditions such as endometriosis, fibromyalgia, low back pain, osteoarthritis, achilles tendinopathy, and chronic migraine. Chronic musculoskeletal pain is the most common form of chronic pain, which is often associated with injuries or overuse of joints.

Why is chronic pain important and relevant for female endurance athletes?

 An estimated 20% of the total population in Europe live with chronic pain which is approximately 150 million people. Similar trends have been found in non-European countries such as U.S, Canada, Australia, and South Africa which highlights the scale of the issue globally. Although difficult to capture precise numbers, research shows that chronic pain is commonly experienced by endurance athletes.

A deep dive into these statistics indicate that females have the highest prevalence of chronic pain during adulthood, and this pattern is similar in children and adolescents. There are several reasons why many individuals live with chronic pain – a complex stew of social, psychological, biological, and cultural factors which are intertwined, and can also be influenced by childhood experiences. The complexity of chronic pain means that it cannot be reduced to a single explanation.

Language matters

The tonality, phrasing and choice of words that are used in everyday interactions can help to build positive, sustainable relationships or damage them. Actively listening to female endurance athletes with chronic pain, taking their pain experiences seriously and asking them ‘how can I best support you?’ are important aspects of building positive relationships and providing support to the athlete.

Unfortunately, research has consistently shown that health care practitioners can use dismissive language towards women with chronic pain, which can affect their psychological well-being and increase difficulty with obtaining a diagnosis. For example, it currently takes approximately eight years for endometriosis to be diagnosed, a condition that typically occurs in women of reproductive age.   

Within the endurance sport context, the language that is utilised to describe pain can be problematic. Enduring some level of pain in training and/or competition is considered as a fundamental part of endurance sport, but this does not always mean that we should endure pain. Endurance athletes (and athletes in general) are often described in media coverage and sporting environments as ‘brave’, ‘heroic’ or ‘warriors’ for pushing through severe pain but is this language helpful and for whom? It is important that we create spaces where female endurance athletes with chronic pain can share their experiences which might be counter to dominant pain narratives in endurance sport.

Providing optimal support

Members of an athlete’s support network have an important role to play in providing support to female endurance athletes with chronic pain. Adopting a biopsychosocial approach to how we understand chronic pain and develop knowledge of the athlete’s lived experience can help to present a more detailed picture.

This could be perceived as a daunting task but showing a willingness to learn and understand the athlete’s experiences of chronic pain is a good starting point. This in turn can lead to rich discussions about what optimal support looks like and how best to provide support. There is also a role for sporting organisations as they can help widen knowledge through inclusion of chronic pain training modules in coach education programmes.

Chronic pain has often been overlooked in endurance sport despite being commonly experienced by athletes. We need to give wider attention to this important topic and further our understanding of how to provide optimal support to female endurance athletes with chronic pain.

Lloyd is a 4^th year PhD researcher at St Mary’s University, Twickenham. His current study explores the relationship between chronic pain and psychological well-being in endurance athletes. If you have any questions or would like to discuss further, please feel free to send me an email (191831@live.stmarys.ac.uk) or connect with me on LinkedIn.

Blog editor: Dr Tess Flood

Blog administrator: Dr Jacky Forsyth