August 9, 2021

The Hurt Locker: Why Athletes Feel Pain

What is pain? What is happening in our body that causes us to feel it? Can you tangibly improve your pain tolerance? Should you? On this episode, Dr. B.J. Leeper, physical therapist and TriDot coach, answers these questions, and more! Listen in as host Andrew Harley, coach Matt Bach, and Dr. Leeper discuss the painful parts of training for, and competing in, triathlon events. Know when (and how) to push past the discomfort, and when to pull back before injury strikes.

TriDot Podcast .098 The Hurt Locker: Why Athletes Feel Pain Intro: This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together. Andrew Harley: Welcome to the TriDot podcast!  Fascinating topic today as we get into the science of pain, so go fire up the hit single, "Sucker for Pain" from the Suicide Squad movie soundtrack, hit repeat on that track, and then settle in for today's conversation.  I promise you, having that song on repeat in the background will round out the experience.Our guide to the science of the body and motion is Dr. BJ Leeper.  BJ graduated from The University of Iowa Carver College of Medicine with a Doctorate in Physical Therapy and Rehabilitation Science. He is a Board Certified Orthopaedic Specialist, a Certified Strength and Conditioning Specialist, and a USA Triathlon Level 1 Coach. He specializes in comprehensive movement testing, and is an avid triathlete himself with over 50 tris under his belt.BJ, thanks for bringing me pain knowledge today! BJ Leeper:  Yeah, it's good to be with you guys, this will be a fun topic! Andrew: I'm also joined by TriDot's very own Matt Bach.  Matt is an accomplished athlete with an Ironman Maryland victory, and a 77nd overall finish in Kona on his résumé. He worked on Wall Street as a trader and portfolio manager for nine years, earned his MBA from Temple University, worked in marketing at UCAN for two and a half years, before coming on board to lead TriDot's marketing efforts.  Hey, welcome back Matt! Matt Bach:  Thanks! I'm excited, I think this is my first time on the interviewer side with BJ here as our guest. Andrew:Yes!  Yep, that's exactly right, I looped Matt in to help me ask BJ, our subject area expert, some questions today.  Just knowing Matt has pushed himself to an Ironman Maryland victory, and far more accomplished than I am in the triathlon world, I wanted somebody from the more elite spectrum asking some questions.  So Matt, thanks for jumping on board to do that today. I'm Andrew the Average Triathlete, Voice of the People and Captain of the Middle of the Pack. As always we'll roll through our warmup question, settle in for our main set topic, and then wind things down with our cooldown. Lots of good stuff, let's get to it! Warm up theme: Time to warm up! Let’s get moving. Andrew: With all the sports the three of us have played over the years, and all the triathlons we've raced, we've no doubt had our fair share of bruises, scrapes, and injuries.  Some a little major, and some a little minor, but all memorable in their own way.  For today's warmup question: what, from all of your sports ball and swimming and biking and running, is maybe the most random injury that you have had?  BJ Leeper, what do you got? BJ: Well, that's a good question, and I don't know if it's as much of a random injury, as it was that, at the time I didn't really know what had happened to me as far as a diagnosis standpoint.  So not to make it too long of a story, but growing up in an Iowa small town, Friday Night Lights were a big thing, so I played high school football.  So the story goes, I'm a receiver, and I'm crossing the middle, the proverbial get hung out to dry.  I go out for a pass, and the linebacker's helmet goes right into my back.  I go down on the field, and I immediately feel discomfort, but I'm not injured, right?  So I pop back up, run to the huddle, and my back feels numb at the time, and it was cold. Andrew:That's not a good sign. BJ:Yeah.  So it was a cold-weather game, I'm bent over in the huddle, we turn to break huddle, and this sharp, shooting pain just goes burning from my back all the way down my leg.  I barely walked to the line for the next play.  The play goes off, luckily it wasn't to me, and then I just drop and crumple onto the field.  Long story short, they basically had to take me off the field by ambulance.  So at that point I'm injured, right? Andrew:  Yeah, I'd say! BJ:And at the time it eventually resolved.I figured out ways.  Nobody really told me what to do, but I figured out ways to kind of mitigate the pain. If I twist this way or lie this way on my stomach it helps, and eventually it just kind of went away.  Again, just a really random injury I guess you might say, but it's the most significant injury I've ever had in my career.  But it was odd in that I never was given an explanation as to why I was feeling what I was feeling, it was just, "Well, we've checked the boxes on these things that's it's not.  Good luck."  So as I've gotten into my PT career, it's been interesting because I can really relate to people on that level that are experiencing severe debilitating pain but maybe aren't quite sure why.  I've been there.  It was a really interesting time. Andrew:Yeah, and I'm sure as you're sharing that story, I'm sure people in our audience are thinking of things that they've dealt with, where they went, saw a doctor, described what they were feeling, described what they were going through, described what happened, and the doctor checked out what he or she knew to check out, and just couldn’t find anything.  So they're hurt, and their body is compromised in some way, and they can't identity what it is but they know something's wrong.  Matt, for you, I trust yours did not come from a blind hit over the middle of the football field.  I trust your story's a little bit different.  What was it for you? Matt:It's pretty random.  I was about 13 years old, we were playing some pickup games in the yard, like throwing a football around, playing tag, and sometime during that I found a little foam disc with a hole in the middle in the yard.It kinda looked like a donut, it was from one of our toys that was what we had been playing with maybe a couple days before.  So I was being a good boy and picking it up, and I was going to bring it inside and clean up after myself, to take care of my things.  So I put my pinky finger through the hole in the middle of that foam disk, and I wanted to keep it with me so that I could bring it inside later and put it back.  So by wearing it like that, it had positioned my pinky finger so that it was pointed away from the rest of my hand, and I continued running around playing games with it on my finger like that.  Then I just jumped off of a small little rock – it was like a measly six inches above the ground – and I put my hands down to stop myself from falling forward.  My pinky finger was pushed even further from the rest of my hand, and ended up dislocating my pinky and breaking it, though we didn't know that initially because my dad ended up actually putting my finger back in place.  He thought that it was just dislocated, and he ended up putting it back into place.But then it was still hurting pretty badly several hours later, so my parents took me over to the ER or to the doctor, and I had a finger splint on my finger for several weeks from a dumb little injury like that. Andrew:Okay!  Alright!  I think at the point in the story where you were putting your pinky finger through a hole in a toy, we could all see what type of injury this was about to become.We didn't know how we were going to get there, but we knew relatively where we were going.  And ironically, Matt, mine is super similar to yours.  So all three of us have kind of football-related stories today.  I was playing in college.  I went to a small Christian college; there wasn't a formal football team, but there was football intramurals, so I played in the flag football intramural league.So we're playing a game, and a player on the other team had the ball and was running, and I'm running this guy down, and I literally just go, with my left hand, to pull this guy's flag.Very, very common flag football move, a very innocuous situation.  I pull the flag, and as I pull his flag – there's no contact, his hand didn't hit mine, his body didn't hit mine, just a routine flag football flag pull – I felt a pop in one of my fingers.  So I go get it checked out by a doctor, and I'm like, "Hey, I think I broke my finger playing flag football," and he's like, "I don't think you broke your finger playing flag football, that sounds ridiculous, there's no contact there."  So they did an X‑ray, and he comes back in, and he's like, "Well, you broke your finger playing flag football."  Then after that, I had to go through rehab.  So I'm literally going through rehab with a physical therapist for weeks and weeks, I had to go multiple times a week to this rehab center.There literally was this girl who was in a car accident, learning how to walk again next to me every day, and I'm sitting there doing finger exercises to get my finger bending again.  And it was painful, it was hard.  It wasn't easy getting that joint loosened back up.  And still to this day – it's actually my marriage finger, it's my ring finger on my left hand – I can't bend that finger as far as I can bend the other fingers.  Just from pulling a guy's flag on the flag football field. BJ:Yeah, that's good. Andrew:Hey guys, we're going to throw this question out like we always do to the I AM TriDot Facebook group.  Excited to hear what you have to say, excited to hear your stories.  As you think on your own athletic endeavors, what is an injury, whether it was major like BJ's or minor like mine, you look back and you're like, "Yep, that was a really weird, random injury that I had."  Can't wait to hear your stories.  Head to the I AM TriDot Facebook group, find the post asking you this question, and let us know what problems you've had. Main set theme: On to the main set. Going in 3…2…1… Andrew:  We recently had sports scientist Andy Blow from Precision Hydration on the show and learned that there isn't a one-size-fits-all approach to hydration, because everyone loses a different amount of salt in their sweat.  As someone who sweats a lot, I wanted to get a better understanding of how much salt I lose in my sweat, so I took their online sweat test.  And after taking the test, I received a personalized hydration plan, and was recommended their strongest electrolyte drink, PH 1500, which is three times stronger than most sports drinks out there.  It's been a game changer for me, particularly in hot conditions.  If you've ever struggled with hydration issues like dehydration or cramping during long and hot sessions, it's worth checking out precisionhydration.com. You can take their free online sweat test and find out which PH strength matches how you sweat, and then get 10 percent off your order with the code TRIDOT10.  To learn more, you can even book a free 20‑minute video consultation with them to ask any questions you have about hydration and fueling, or even to discuss your own strategy for an upcoming race.  Again, that's precisionhydration.com, and use the coupon code TRIDOT10 to get 10 percent off your electrolytes and fuel. The sensation of pain isn't just an athlete thing.It's a life thing.  We all know what it's like to feel pain.  And just to be clear, I'm not talking about emotional pain that leaves you reaching for that newest Olivia Rodrigo album for a good cry.  I'm talking about physical pain.  Whether it's day‑to-day training aches, or the result of an injury, pain is something we feel that largely seems to be out of our control, right?  Sometimes the source of pain is obvious.  But other times, like in our warmup questions, something can just seem to start hurting at random.  So what is pain?  What is happening in our body that causes us to feel it?  All of this and more with Matt and Dr. BJ Leeper today.  Now BJ, this is a topic that you told me you are pumped to cover on the podcast, and Matt you as well when I told you the topic for today's conversation.  You were very excited to get into this.  So BJ, why is this a topic that really interests you?  Why does pain just fascinate you so much? BJ:Well, this is such a deep topic, and there's so many layers to it, and I've heard it said before that this is one of those "cab/sav" conversations: it's best discussed over some red wine, in an intellectual setting.  I've got some coffee, so I guess that'll have to do.  The way I roll, it's like Red Bull and beef jerky in the mornings. Andrew:Okay, alright, quality start to the day! BJ:Right.  So there's so much depth to it, which makes it a complicated topic to talk about, but I believe that pain is the biggest limiter of human performance, period.  And in studying human performance for as long as I have, you just can't get around pain.There's various sides of pain we'll get into, but there's the, "are you hurt or are you injured" type of discussion.  But the reality is, with pain, it's such a fascinating area because it's such a remarkable thing that our bodies are designed to have, where it's the most amazing, protective system that we have, so it's such a great thing.  Although pain gets such a negative connotation because it's also, unfortunately, one of the things that plagues us.  All of us have experienced pain on a certain level, and unfortunately some of us are plagued by pain.  And oddly enough, or not so surprisingly, the word "pain", the root of it comes from the Greek word "revenge", so it comes from this Greek goddess.  I can't remember the exact name, but the interpretation of it means "revenge", which I think it kind of fitting, because all of us, when we feel pain, it's like our bodies' revenge on us in some way.  But if we didn't have pain, none of us would live to be older than a toddler, because it's our protection mechanism.  But at some point, it can get hyper-exaggerated, and there's various levels.  When we talk about performance, again, I think it defines the elite, as far as their ability to suffer more than others, and it kind of asks the question, we'll get into it a little bit more, but is it nature versus nurture?  Are we born with this great capacity for pain tolerance, or is it simply something we learn along the way, or we can train?  Is it a trainable trait, or is it just something in our DNA?  So it's very fascinating.  When I first got into the world of physical therapy, I started my career doing research in anatomy and cell biology at the University of Iowa, and then I decided I wanted to pursue physical therapy.  So when I switched career tracks and decided I wanted to go into PT, I started working for one of the professors in the PT school who had a pain lab.So her whole focus of her lab was research on pain, both peripheral and central pain, and focused on musculoskeletal causes of that pain.  And the first person I met in her lab was this post-doc who was studying pain science.She had started as a clinical PT, but had become so frustrated by the fact that she couldn't get around chronic pain with her patients.  It was so frustrating for her in the clinic that she decided to make it her career to study and figure out how can we solve this issue of pain.  How can we know more about it to improve the body's ability to cope with this?  So I thought that was really interesting, because I was going into the career that she had just left because she was confounded by pain.  And in my time in the lab, and since then working with patients, I've learned a lot about pain.  But the more I learn, like a lot of things, the more I realize that we don't truly know.So again, it's just really an interesting topic. Matt:You know, it seems like pain would be something intangible and difficult to study, but what you're talking about right now is a perfect segue into this question, which is, how has science been able to quantify, measure, and study pain over the years? BJ:Right, and I think to answer that type of question, we have to define pain.  There's a lot of ways to define it, and the definition I've heard said that I keep coming back to is that pain is a conscious feeling produced by the brain 100 percent of the time.  I'm going to say that again, because if we can wrap our minds around that, that will help our discussion, and I think it's pivotal.  Pain is a conscious feeling produced by our brain 100 percent of the time.  Which simply means that you don't feel pain unless your brain tells you such.  We actually don't have pain nerves in our body, or pain receptors in our body.  There's other types of receptors that then stimulate our brain, and our brain has a decision to make.  Our brain is what produces pain.  So when we say, we'll sometimes joke, "We're not saying that pain is in your head, but it's in your head."  That's where pain is generated.  That's what makes it so fascinating, so layered, because in our brains there's so many factors that go into how we perceive pain.  So when you define pain as a feeling, how do you study a feeling?And that's what's really interesting, especially in human study.  When I was in a pain lab, we had an animal model we studied in rats, so we looked at mechanical withdrawal threshold, all these things.  But in human studies, where the rubber meets the road, you have to get a subjective rating of pain.  So we'll use visual analog scales, zero-to-ten rating, all these things.  Pain is obviously very subjective, but there is a way to start to quantify that.  I listened to this book on audio a little while ago – if you guys haven't read it, it's a great read – it's called Endure, by Alex Hutchinson. Andrew:Yeah, I read that one. BJ:  So just basically going back to that, what makes great endurance athletes great?  What are some of the limits of human performance in that arena, and pain is obviously a big one.  In that audio, I remember hearing a couple different studies of pain, studying elite athletes.  Actually, we did one with the pro team a few years back, probably eight or nine years ago, that was kind of interesting.  One of the studies I remember talked about cryo-immersion studies in a group of elite ultra runners.  These were ultra runners that were running the trans-Europe race that was over 60+ days and over 2,500 miles, so this crazy distance.These ultra runners are just fantastic.They took these runners, and the goal of the study was to submerge your hands in ice water for up to three minutes, and then rate your pain at the end of that three-minute cap.  Then they compared that group to a non‑athlete group in the same study.  So not only did the ultra-runners make the three-minute time cutoff, but their average rating at the end of that was like a six out of ten pain on average.  The non‑athlete group was actually, not only did they not make the three-minute cutoff, on average they were about half of that, at a ten out of ten rating when they tapped out.  So again, boding the question, is that what makes these great endurance athletes great, their ability to withstand pain at a greater level?The stimulus was the same for both groups. Andrew:Yeah. BJ:  In another study, very similar, they took elite swimmers, and they did what's called a blood flow restriction type of study, where they in essence put a blood pressure cuff on the upper arm of these elite swimmers, and created a tourniquet, and asked each athlete to do one fist pump per second until they achieved what they would describe as discomfort or pain.  Then they compared to club-level swimmers, the elite to club-level then to non‑athletes.And what they found with that study was that on average, each group started to feel discomfort they would describe as pain at about 50 contractions.  But when they went to max tolerance, the elite group could get to something like 130, 140 contractions, whereas the club swimmers were maybe 80 or 90, and then the non‑athletes were 60 to 70. Andrew:Wow. BJ:  So what's interesting about that type of study is that it shows that these athletes, or even the non‑athletes, were feeling discomfort described as pain at the same level, or at the same point.But the ability to suffer to max tolerance was much greater in the elite group.  So again, we notice very similar things when we tested our triathlete group in the professional ranks, where the main difference between them and amateurs, when we looked at movement screenings, all these different tests, we're trying to figure out physiologically, is there anything that makes these pros better within the sport of triathlon, and the only variable we could find when we were doing the testing we were doing is a side plank cutoff, where the movement capacity of these athletes was roughly the same, pros to amateurs.  But their side plank hold time – we had a cutoff of two minutes – was like twice as much as the amateur.  Now were they just twice as strong through their core?  I don't think so.  I think it was actually their ability to withstand and suffer longer was the thing that made the difference.  So then when we try to quantify and study these things in a human model, again, it's very subjective because pain is a feeling.  However, there's some really interesting data as we get into it about the ability for especially elite athletes to endure and suffer more pain. Andrew:  So you start sharing the story of them putting their hand in the ice water and trying to hold there for two minutes.  So I am 100 percent sure that somebody in our audience is going to try this, because just with our personalities as endurance athletes, as triathletes, you hear that story and you're like, "Can I hold my hand in ice water for two minutes?"  So folks, if you try that, please, my only request is that you take a picture and post it to the I AM TriDot Facebook group, because I just want to see who actually does this, because I know somebody's going to! So BJ, when we feel pain, you mentioned that regardless of where in our body the hurt is, we're feeling the pain in our head.When we feel pain, biologically, what is happening in our body to cause us to, in our brain, get those signals that there's pain? BJ:Yeah, so the interesting fact is we don't have pain receptors or pain fibers in our body on the periphery.  We actually have what's called nociceptors, which you can define those as harm receptors, and the things that stimulate the nociceptors in the body are three basic different things: it's thermal stimulus, chemical stimulus, and mechanical stimulus.  So if there's a stimulus like one of those three things that's significant enough, it's then relayed from those nociceptors in the body as this "harm signal" that travels via nerves to the spinal cord all the way up to the brain, and the brain gets this "harm signal" then to interpret it.  And it has a decision to make at that point, which again there's a lot of factors that can go into that decision with the brain, but in essence the decision the brain has to make is, "Is this harm enough that I need to protect against this threat?  And if so, I'm giving off the signal of pain."  If it interprets that harm signal as, "That's not enough that I'm going to lock things down and create that sense of threat in the body," you don't feel pain.  So again, it's very interesting, because typically in a "normal" situation, you would have the brain operate in a fundamental way where that typically would be a harmful thing.  That signal is sent off as pain, we protect, and we go from there.  But oddly enough, the body can easily override that if your brain doesn't feel that there's a threat. Andrew: Interesting. BJ: And so there's a lot of interesting situations where that can go, at that point, one way or the other.  And a lot of times, the situation that we're in dictates that, the stress of the situation we're in.  The example we always think of is the deer with the broken leg, running away from the wolf.  Does that deer in that moment feel the pain of its broken leg?  Maybe not, probably not.  It's trying to get out of harm's way.  There's bigger fish to fry, it's life and death on the line.  And you hear other stories like this.  You've got a broken ankle, you're in front of a bus, you walk to get out of the way easily because the pain isn't enough to threaten the situation, there's life on the line.  Those type of things. Andrew: Yeah, so to kind of take that and bring it tangibly into the triathlete experience: throughout our training weeks, we're all going to have days where we feel that muscle or joint soreness just from day‑to-day training.  Is there a difference between being sore from a workout, which is normal, and truly being in pain?  Or is general day-to-day soreness a type of pain? BJ: Yeah, I would say this gets the answer, "It depends." Andrew: Nice. BJ: Because we know that if we define pain as a feeling produced by the brain, it's going to be different for different situations.  So the analogy I think of often is, you've got two people on the peak of a rooftop way up in the air, and you've got one individual who's a hypochondriac with heights.They're just in fear of heights, and they're freaked out of their mind, and they're lying in the fetal position or clenching to the roof peak.  And then you've got another individual that has no cares in the world, they could fall asleep up there.  Their heart rate is 40 beats per minute.  So the stimulus in that situation is exactly the same for each individual, but the reaction of each individual is completely different.  They perceive that situation completely different.  So you could have, from a workout, delayed onset muscle soreness or DOMS.  That general muscle ache that would be a natural feeling, a natural response.  And one individual might feel that as debilitating pain where they can hardly walk out of bed that morning, and the other individual might have a threshold where they feel something, but they can move past that, and their body wouldn't represent it as pain.  So it's really interesting, because it's in the eyes of the beholder in a way.  There are mechanical things going on, obviously, to create that stimulus.  But the perception of that stimulus is what really makes the conversation interesting, and when we talked about recovery we kind of addressed some of this, because recovery science is very much tailored to that same concept.  Because each individual is going to feel things differently in recovery.  You have to use your technique or your device to soothe the brain, if the brain thinks there's a threat.  And that's so individualized, person to person.  What somebody feels as soothing, the other person might not.  And that's why there's no one standard approach to recovery, it's what feels good to you. Matt: And speaking of that approach to recovery, when you're working with your clients or patients, your athletes, when you're diagnosing an issue with them, what is that process like in your mind?What are you thinking?  Are you thinking through sort of categorizing the type of pain that they have, are you trying to understand maybe how severely they feel or they're perceiving that this pain is?  Is it in the muscle, is it tendon, is it ligament, bone, maybe it's nerve-related, and then maybe deciphering between is this chronic or is this an acute injury?  So I imagine these factors play a strong role in how you treat the injury, so I'd love to hear your thought process as you're meeting with your athletes for the first time. BJ: Yeah, absolutely, everything you said is a factor.  So one of the things, when I screen an athlete, or the biggest thing is just getting the history from that athlete.  Hearing in their mind and in their own words what they think is happening.That can lead you down a lot of different rabbit holes.  You might hear this history of something that's been going on and off for years, and the first time it ever happened it was very traumatic.  Or you might hear a history like this is the very first time this has ever happened, we're in the first week following injury, it's very acute.The history tells a lot.  Then obviously you'll get into the mechanics of your evaluation, where you're looking at those three big factors: thermal, chemical, mechanical.  Is there acute swelling present?  So there's the typical things you might think of on evaluation of a musculoskeletal injury.But going back to what you're saying, I think the key is getting an idea of where that potential pain source might be coming from.  Is it acute, is it chronic?  If there's chronicity to it, the patient might be feeling something that's not even truly there, as far as a mechanical stimulus, but it might be simply this pain song that their brain is stuck on that they can't get out of their head and you have to help them through that. Andrew: Wow. BJ: That requires a lot of education.Again, if somebody doesn’t know, it's like the amputee that's having phantom limb pain.  Obviously there's no mechanical, rational reason why they should be feeling what they're feeling, yet what they feel in their brain is very true.It's very real.  But somebody that's not in that category, but still it's maybe the same thing going on in their brain, how do you lead them through that?How do you allow them to understand that pain is something truly produced in the brain, and knowledge is power.That can be very freeing to work through, and thinking that what I'm feeling is maybe not mechanically actually happening, but my brain is stuck on this song.  How do I change that?  How do I work through that?  So it can be very complex.  But again, the biggest thing I think is learning from the athlete and the history, and a lot of us, if we're self-diagnosing at home, like I've been having this pain, how should I deal with this, how do I approach it?  A lot of times you have to look into what's our past medical history?  Our previous injury is probably our biggest predictor of future injury.  So what's our previous injury history?  Is this something that just happened?  Is this something that we've been dealing with on and off for years?  Because those two different things paint a completely different clinical picture. Andrew:  So BJ, you said something just a little bit ago that really struck me.  The kind of play on words of beauty is in the eye of the beholder, but it was pain is in the mind of the beholder. BJ:Exactly. Andrew:  So can we feel pain and not really have anything wrong with our body?  Or is pain always a signal that something's wrong? BJ:Yeah, absolutely, you can feel pain without anything wrong in your body, and that's what's wild about pain.Again, going back to that amputee type of patient with phantom limb pain, there's nothing physically there to create that pain, but what they feel is very real in their mind.  And I think there's a sense that we have to figure out what it is important to listen to, what's important to follow down that road.I think this is a bad analogy, but it's a way I think about it in a way where it's the car with that "check engine" light that comes on, that you're wondering should I simply ignore that?Is that real, or is that something that just pops on and off?  I actually drive this old 2004 Acura MDX that's got over 220,000 miles on it, and it's a car I'm kind of trying to limp along to save for my son, who's not driving age yet, but that's the goal.  And a while back the check engine light was coming on.  Then it would last for about a week, and then it would turn off, and then it would come back on again.  I took it in to get looked at, and I took it in to this old-school mechanic.He's great, he's all about being practical.  He took a look at it, he's like, "Eh, I don't think it's a big deal."  He's like, "I'm not seeing anything that's significant," and actually the light turned off again.  So I remember thinking, "Should I worry about this, should I not?"  And it came on again, and somebody had this great idea.  They're like, "Well, if you take a black piece of electrical tape and just place it over your dash board…" Andrew:You'll never even know! BJ:You'll never even know, you don't have to look at it.  And I was like, that seems like a really good idea.  So I actually ignored it for quite a while, and then eventually it came on and lasted longer, and so I eventually took it back in, and said, "Hey, this is the deal, it's lasting longer."  And he finally diagnosed it a little bit deeper and figured out the problem and was able to fix it.  But I feel like that's us with our human bodies a lot.  We'll get the occasional check engine light, and sometimes it's not a big deal, and sometimes it'll go away.  But other times, if it's persistent, and it's consistent enough, I don't think we can just put the black electrical tape over it and ignore it. We really have to have it fully evaluated.  Not that we have to perpetuate on it, because that can lead to other issues, but I think we have to be smart with it at the same time.  So there's that dichotomy of when do we pursue something versus when do we just need to suffer better?  That's the dichotomy in endurance sports, is sometimes we have to simply suffer and train our bodies to push through.  But that goes back to that whole, "are you hurt or are you injured?"  Those are two different types of things. Matt:Those are really interesting perspectives. Especially because throughout my entire athletic career that's something that I've battled, and I think many, many people battle, is this, "Am I actually hurt, do I actually need to put a pause on my training or back off my training?" or whatever it is.  If every single time you have a tiny little niggle or something you thought might be an injury, you stopped training or you backed off, then you'd basically never be training.  Because there's a lot of little things that happen that you really have to just kind of work through, and it's one of the things that takes a long time to really learn, that through the help of experts like yourself, to be able to learn when is it that I should actually be backing off, and when it is that I should actually be just pushing through and just dealing with it, because it'll probably just go away on its own.  I feel like if you want to be the best that you can be, you do have to fight that battle.You have to figure out and gain that experience so that you know when it is that you can keep just moving through.And on countless occasions I've been able to run right through something that seemed like it might have been an injury, and been perfectly fine with it.  But at the same time, that's of course a little bit of a playing with fire kind of thing, is if you do that to the wrong injury, or the wrong niggle, then you might actually end up being injured, and then needing some real downtime.So I like your approach of the three-day check: if it's still bothering you after three days, you get it checked out, you get it screened, you make sure that you're getting it addressed. BJ:Right. Matt:BJ, you mentioned earlier and we were kind of alluding to it, and this is one of the most fascinating areas for me, is on the mental anguish side of things.  How does this all play into it?  When athletes are racing or doing a really hard workout, we often say, "It's so painful," or "I was in so much pain," or "I was in a world of hurt."  But we don't mean that we're injured, we just mean that our brain is screaming at us to stop or slow down.  So would you define that as pain, or is there something entirely different going on in the body with that type of agony? BJ:Yeah, that's one of the most interesting questions, I think, with this whole conversation.  Are top athletes that much faster than everyone else, or can they simply suffer that much more?  You know what I mean?  So when they feel discomfort, pain, however you want to label it, it's a mechanical feeling.  And there's obviously muscular limitations.  However, I think that pain is still the thing that centrally governs our ability to fully fatigue a muscle to end.  And there's obviously other capacities that you can discuss when you're talking about bonking in endurance sports.  You know you've got to factor in nutrition, hydration, all these different factors, but obviously top athletes are all fit.  You guys are all at the peak of your game fitness-wise, but that's the question I think is fascinating, what makes the guys at the top the best?Are they that much fitter or faster, or can they just simply endure and suffer better than anyone else?  I don't know if you guys have ever seen the movie "Without Limits".  It's a movie about Prefontaine.  It's kind of this cheesy early-90s movie.  It kind of takes some liberties with the Pre story, but a lot of it's based on a lot of factual things about Prefontaine.  I used to watch it before every 5k road race I'd run, and then after I'd watch it I'd feel like I could run through a brick wall.  But there's a quote in that movie that Prefontaine says, something like, "I can tolerate pain better than anyone I've ever met, that's why I think I can beat anyone I've ever met."  And there's athletes – we all kind of know these guys, that are like that – where you look at them and you're like, "There's no way they should be faster than me."  But they can just suffer better.  Jens Voigt, he's another guy that comes to mind.  He's the old Tour de France cyclist, that he was always – Andrew:He's the "shut up legs" guy, right? BJ:Yeah, he was the "shut up legs" guy, and he was known for these daring breakaways, he would just go out so hard.  And you hear these quotes from him, and literally he says that he literally felt in his mind that he could suffer 10 to 20 percent more than anybody else he was cycling and racing against.  He believed that, and I think as a result he was able to be as successful as he was because of that.  So again, going back to your question, I think what do you truly feel when you're suffering?  Is it pain, is it muscular fatigue, is it the lactate buildup, all these different things you could question?  But some people have a different pain tolerance.  That's the question.  Are you born with a higher pain tolerance, or do you learn to suffer better than everyone else?  I don't think we can fully understand that concept, or know what everybody feels, but we try to study it the best we can.  Again, I think it comes back to, I think it's very trainable.  We look at even our high-intensity training.Especially working with TriDot, we all know how often those threshold tests come up, and how much we dread them.I hear from athletes I've coached, "I just did this test four weeks ago, why am I doing this again?"You dread it because, "I don't want to test again, I don't feel like I'm that much more fit than I was before."  And I usually tell my athlete it's not about how fit you are right now.  You're actually getting more out of this session by learning to suffer through that threshold test than maybe the physiological gain from building more muscle, resistance to fatigue, all these things.I think our high-intensity threshold training has more to do with our capacity to train our brains than sometimes it does for our muscle physiology. Andrew: Wow, yeah. Matt: I'm definitely on board with that claim.And the ability to suffer definitely can be improved.  I would stake my life on that statement.  It's not something you're just born with, it's definitely something that can be improved.I know that from my own experiences for sure, but then in many of the athletes that I've worked with, their ability to cope with a certain type of suffering for a longer period of time can be improved dramatically.  There's a reason why I think the phrase, "gone soft" or "grown soft" is out there.  Because I feel like right now, I'm not competitively training in a way like I did in the past, in particular 2014, 2015, and I've "grown soft" compared to those days.  Like right now, I know I can't cope with the same type of suffering, even at lower wattage levels or paces on the bike or run to my fitness level currently.  There is just no way that my mind could cope with a lot of the suffering that I used to deal with.  So it's definitely something that you can grow and improve, which to me is very exciting, because it means that you can get better from a fitness standpoint, and you can get better from a mental anguish standpoint, and being able to deal with that discomfort and suffering.  So you could actually have the same exact fitness and still be getting better as an athlete.  And sort of the same thing, you can be improving your fitness but actually be only getting better because your fitness is improving, but you're not really getting better from a mental standpoint if you're not really working on that area.And those FTP tests, like you said, they do help in that area, to kind of get you new perspective.  I love the word "perspective", because after you've done an FTP test, and you've pushed it to the limit, and you went somewhere you never thought you could go, then for at least a while going forward you know that there's this new uncharted territory that was beyond what you ever thought was possible from yourself.  And I found that, in my own experiences and the experiences of my athletes, that happens often multiple times.  Many, many times throughout any athlete's career.  Like you thought you gave it 100 percent, but if somebody asks you at the end of a certain race, "What did you do out of 100, one to a hundred, what percentage did you give it your all?" And they're like, "Oh, I gave it 100 percent."  But then, say, two months later they do another race, and they actually gave it a much harder effort there.  They might say, "Oh, wow, I didn't give it 100 percent that last time."  Like it's this epiphany moment, this new perspective moment, where you realize, "I didn't give it 100 percent last time, and I know that because I just gave it an even higher effort level now."  Then if you're not naïve, and you don't have an ego about you, then you'll realize that if you just did that once, and you just thought maybe in this race that you gave it 100 percent, you're probably still wrong, you probably still didn't give it 100 percent.  There's still room to grow.  Maybe you only gave it 92 percent, and there's still just so much more room to grow above where you currently are. BJ: Right, and this is a fascinating question or conversation, because we've got so much more capacity in our brains, in our minds, in our muscle even, than what we even know.  And this is a question I propose sometimes.  You always hear the mantra, "You'll pass out before you die."  So we can push ourselves so hard, but our body would protect us before death, we would simply pass out.  When you think about that, and you think, okay, our brain is our central governor.It's protecting us from even these extreme endurance events, and I think this has happened, I've heard these stories before.  Like the Olympic marathon, where it's the pinnacle of the sport, and you've got at the very end of that marathon, you've got guys that are neck-and-neck, and you see a guy get passed at the finish line, even in a marathon where it's a longer distance.  But yet it was that close, and the guys passes the other guy at the very end, beats him by two or three seconds.  Was the motivation for that guy that got passed just simply not as much as the winner?I doubt it.  They're in the Olympics, they're both going for gold.  I don't think the guy getting passed was like, "I'm settled for top two right now."  There's no way.  He's at the peak of the Olympics, he wants gold.  But yet, when he gets passed, why is he not dead at the end?  Why is he not passed out at the end?  Did he not give it his all?  Why would he hold back?  But I think the reality is, our brains will limit us.  Our brains will protect us to a certain degree, and some of us have a capacity to get more out of that.  And like you said, Matt, I think it's very much trainable.  But at the same time I think there is some predisposition in our DNA.I think some of us are born with maybe a little bit less of a filter on our central governor than others, so to speak.So if you're listening to this podcast, riding your bike like crazy on your FTP test, just suck it up. Andrew: Shut up legs! BJ:Y ou can push more.  This is a funny story: when I was first listening to that book "Endure", it was on audio.  I was driving cross-country on a 16, 17‑hour road trip across Montana to South Dakota.  And I remember listening to this book and just being inspired, and thinking, "I'm not going to take a break, I'm going to push on.  If these guys can push on, I can drive.  I'm not going to go to the bathroom, I'm not going to listen to that pain signal that I need to go," all this stuff. Andrew:I'm going to endure, right here in the driver's seat! BJ: Exactly.  It was actually a great book to be having on audio as I'm driving that distance, because it just inspired me, it pushed me.  It's that mental thing.  But again, it's a big deal. Matt:It's funny you brought up that whole idea of you might pass out or faint, because I actually asked that exact question to my team, back when I was heavily competing.  I asked them, to several members of my expert team, I said, "Is it possible to run myself so hard that I'll actually kill myself?"And they said that exact answer, they said, "No, you might pass out or faint before that happens.  Your brain's going to stop you, it'll shut you down."  That was actually a crucial piece of information, because I knew pain is there to stop you from permanently damaging your body.  But you can override those pain signals.  And in this case when they told me, "You'll pass out before you'll actually kill yourself," I was like, "Alright, then there's no permanent damage that's going to be done here.  I might as well just run as hard as I possibly can without the fear of causing any permanent damage."  It allowed me to ignore that powerful pain and discomfort signal that my brain was sending me.  Just run through it. And it led to better performances.  Another great book, by the way, I want to mention:  "Endure" is a great one, and I have read that one.  Another one though, is Matt Fitzgerald's "How Bad Do You Want It?".  That book is up into my top five ever books, and I've read it several times and listened to it on Audible.  It's an amazing, amazing book with some great anecdotes, some great science, talking about how mental anguish can be overcome.  It definitely has helped me have new perspective and chart new territory in my own performances. BJ:Yeah, in full disclaimer, and this might sound bad coming from a physical therapist on this episode here, but we're not saying throw caution to the wind, run through every injury you have.At the same time, suffering is part of our sport, and there's a capacity to suffer greater.  But there's two different things.  Again, I think our intuition serves a lot of us well.  I think we know the difference.  But at the same time, if you're struggling with that, pursue expert help.  Because there are times where we really need to listen to that central governor, and it's a true thing that we need to respect and evaluate.  But like you're saying, Matt, I think there's so much capacity to train the suffering side of pain and those types of things.  There is a time for that, and there's a time to push through, and we need to be strong, and we can do more than what we think we can do. Andrew:  So BJ, along those lines: if somebody's hurt, if you're feeling some sort of hurt that you think might be an injury, get it checked out.  Talk to somebody.  But if we're in a healthy place, you're doing your day-to-day training, you mentioned a couple different times that, to a certain extent, your pain tolerance can be learned.  It can be improved through our training, and you shared the example of on an FTP test.That FTP test, month-to-month, every four to six weeks, can help you learn how to push yourself to the limit for 20 minutes on the bike, a 5k on the run. Is just doing the workouts day to day, is that the best way to improve our pain tolerance?  Are there other things we can do as athletes to improve and raise our ceiling on what our pain tolerance actually is? BJ:Yeah, I think there are.  I think there's a lot of different ways, and sometimes it's the mentality you take into your approach.  There's the whole idea of, "Well, when I start to feel discomfort or pain, I'm just going to try to block that out."  But then there's another approach that I find very interesting, in that some athletes will simply try to embrace it.  They almost crave that level of pain as they're racing or training, and it's almost comforting to them.  It helps them pace.  Even to the level, I remember Jesse Thomas once saying, every time he would foam roll he would use that as an opportunity to embrace the pain and discomfort he was getting.  He wouldn't try to block it out while he was rolling his legs out, he would embrace it as an opportunity to train his brain to love the suffering, love the discomfort. Matt:That's when you know you're truly deranged. BJ:Yeah, that's when you know you're psycho.  Well, we already know all triathletes are psychos.  But yeah, I think it's different, it's individual, but I think you use it in your training.  You use those opportunities.  I think that's, in my opinion, the physiological benefits of high-intensity training or our threshold testing, and just really our general training that has those high-interval efforts, I think the benefits we're getting from those are more tied to our brain than the actual muscle physiology, the VO2 max changes that we're actually getting.  You know, we're obviously getting different systems trained, but I think the training of the brain system to suffer through that is arguably more valuable. Andrew:Lots of great stuff here today, BJ.Thanks as always for your expertise.Let's end our main set today talking just a little about race day.  Whether it's the pain of pushing your muscles racing short course, or the pain of enduring the long course race, managing pain on the way to the finish line is often just a part of race day.  What can athletes do to minimize the effects of pain, or the perception of pain even, in their brains so that we can get the most out of our race day performance? BJ:Yeah, that's a great question.I'd love to hear Matt's thoughts on these too. Andrew:  Me as well, yeah! BJ:  I think preparing our mind, because the brain is what's creating that feeling of discomfort or pain.  I think the context or the setting we're in can really help that or hurt that, for that matter.  But in a race situation, we're ramped up, we're ready.  I think the race in and of itself helps take us to a better place to embrace that suffering.  But I think the key in training our brain is having something you can always go to in the middle of that.  If you've done that in your training, it's very, very easy.  But you hear people talk about a different mantra they place in their mind.  I remember Elizabeth James talking about her mantra would always be, "I'm stronger," and just going to that mental cue.  So I think there's a lot of things that can factor into that mentally, and in how you prepare yourself.  But I think the setting in and of itself, when you're racing, is already going to get you closer to bettering that. Matt:And I can add, what you're saying about training and what we've talked about training to be better with your pain tolerance, is absolutely one of the biggest factors there for minimizing the effects of pain and suffering on your race performance on race day.  But another one is just knowing that it will be painful, that there will be suffering.  Going in with this mindset, this expectation that I'm okay with the suffering, "getting comfortable with being uncomfortable," that quote that you may have heard before.  Just going into a race, being at peace with the idea that it's going to be uncomfortable, and just being okay with that.  Saying that's part of the process, that's part of having an amazing performance, and if I am uncomfortable like that, it's probably because I'm pushing myself.And that's what we want to do, right?We want to see how much we can get out of ourselves, and try to push that limit.  And then the other piece is caffeine.  Drugs. Andrew:  Hey, yeah, you got my attention! Matt:Caffeine is actually just a clear way to minimize or just reduce the effects or perception of pain, and it's been shown in numerous studies, and many many, probably thousands or millions of anecdotes at this point, that caffeine, for most people, is something that reduces the perception of pain and suffering.  So using caffeine: try it in your training first, and then use it on race day.  For me, I've definitely found that to be the case.  Some of my biggest breakout performances were when I first started using caffeine, and since I've started using caffeine in my races.  In particular I'm thinking of, it was a half-marathon where I looked at the heart rate at the end of the half-marathon, and noticed that it was the highest average heart rate that I'd ever had.  I knew that from my perception of that pain was very high, but I was able to actually push that much deeper into those dark, dark places that you get into during that race, and I think it was very much correlated with the fact that I had taken caffeine in that race, and it was the first time that I had taken it.  I dug deeper than I ever thought I could.  I think I had an average heart rate of 181 for a half-marathon, and ended up PR'ing with a 1:13.  I had a max heart rate of 197 at the very end of the race.  So for me, I'd never reached heart rates like that before, and was just amazing how deep I was able to push into it, and I know that the caffeine had something to do with it. BJ:Yeah, that's interesting you said that.I'm glad you mentioned that, because it's one of those substances I think we take for granted.  It used to be a banned substance on USATA, now it's not because everyone uses it, it's a legal thing.  You can take advantage. Matt: It's a legal performance-enhancing drug. Andrew: I'm hearing just permission to drink more coffee every single morning.  I'm just getting my body used to the caffeine that I'm going to need on race day, right? Matt:Actually, I do the opposite.  I try to deprive myself of the caffeine, so that way on race day it hits me good.  Hits me hard. Cool down theme: Great set everyone! Let’s cool down. Andrew:  I always love hearing from you, the TriDot podcast family, and I got a really great note from Craig from the UK.  Craig started training for his first Ironman, and was looking for a way to stay entertained during all the long hours training for a 140.6-mile race.  He discovered the TriDot podcast, and has been listening ever since.  Craig raced his Ironman and had a HUGE day.  He didn't share his time in his voice message to us, but he did tell it to me over email.  I'm not going to be the one to air out his stats, but know this: Craig is real fast, especially on the bike.  He had a great race.  He went hours faster than I hope to go in my own Ironman debut, and he had the pleasure of crossing the finish line with his daughter, which is just a special treat at a race that distance.  So here's Craig telling us all about his first Ironman. Craig:Hi.  I just wanted to get in touch to tell you how useful I find your podcasts.I'm not really a triathlete, having only done one sprint, one Olympic, and one middle-distance event ever between 2008 and 2017, really.  I'd say I'm a cyclist that occasionally strays into the world of triathlon.  So in a mini-midlife crisis I thought I'd enter a full-distance triathlon before I turned 40, so it was originally scheduled for June 2020.  But because of the pandemic, it was postponed until June this year.  In all honesty, I would have enjoyed the extra training time, but this just gave me more time to actually doubt that you could do it, that it was actually possible, because the distances just seemed so, well, long.I'm not part of a tri club, so I just followed a training plan from a magazine.  But that also means I trained on my own all the time.  Every stroke, every pedal, every step, always on my own.So I found the mental part leading up to this event really, really tough.  The distances seemed unachievable in themselves, and then trying to motivate myself to train in the winter and spring English weather, which is typically rain, hail, ice, and swimming in 6° water, was just awful.  Then I stumbled across your podcasts, and in all honesty they were exactly what I needed.  Firstly and foremost, a friendly voice just so you have something else in your head, so those long sessions went a little bit quicker.  But of course, the considerable added benefit that was having training tips and advice from qualified coaches.  And what I found really useful were the anecdotes that came with that from experienced athletes.  They certainly helped my confidence, in that I knew more of what I was going to expect on race day, what I should be doing in the run up to race day, preparing throughout my training, but also in your taper, which was really important, and what to do if things didn't quite go to plan during the race, and how I might adapt for that. So come race day, I was definitely, definitely still apprehensive, but certainly had a plan, and knew what I was meant to do.I got to the end, so I count that as a significant success, and I just wanted to drop you a message to say a big thank you to Andrew and your team, and good luck in your first full-distance race! Andrew:That's it for today folks!  I want to thank Dr. BJ Leeper and TriDot's VP of marketing Matt Bach for talking about pain with us today.  Shout out to Precision Hydration for partnering with us on today's episode.  Head to precisionhydration.com to learn how you sweat, and to check out their hydration and fueling options.  Use code TRIDOT10 for 10 percent off your purchase.  Enjoying the podcast?  Have any triathlon questions or topics you want to hear us talk about?  Head to TriDot.com/podcast and click on "Submit Feedback" to let us know what you're thinking.  We'll have a new show coming your way soon.  Until then, happy training! Outro: Thanks for joining us. Make sure to subscribe and share the TriDot podcast with your triathlon crew. For more great tri content and community, connect with us on Facebook, YouTube, and Instagram. Ready to optimize your training? Head to TriDot.com and start your free trial today! TriDot – the obvious and automatic choice for triathlon training.
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