Pain in Elite Athletes: IOC Recommendations on Contributing Factors and Treatment Approach

Although sports-related injury and associated pain are common among elite athletes, there is limited evidence and there are no guidelines on effective pain management in this population. In September 2017, the International Olympic Committee (IOC) published the first consensus statement on pain management in elite athletes in the British Journal of Sports Medicine.¹

In a related narrative review, some of the researchers who authored the consensus statement noted that a “rational approach to pain management in elite athletes involves identification of the cause(s) and type of pain and development of a treatment strategy that addresses the contributing factors across physiological, biomechanical, and psychosocial domains.”² To that end, they provided an overview of such factors and of their potential impact on sports-related pain.

The researchers made a distinction among the different types of pain, noting that athletes may present with more than one type of pain concurrently:

Nociceptive pain: This includes inflammatory pain (resulting from active inflammation) and subacute nociceptive pain, defined as pain lasting approximately 6 to 12 weeks. The latter may develop from overuse injury, for example, and may be influenced by factors such as training load and sleep. 

Neuropathic pain: This pain is commonly observed in wheelchair athletes with spinal cord injury. Neuropathic pain may also “develop following surgery for a sport injury or from repetitive mechanical and inflammatory irritation of peripheral nerves in endurance sport athletes,” wrote the authors. “It is important that treatment for neuropathic pain occur with the understanding that the primary contribution is a nervous system lesion rather than tissue injury.”

Nociplastic/algopathic/nocipathic pain: This refers to pain that is not a consequence of nerve or tissue damage despite signs of altered nociceptive function. These types of pain are observed in fibromyalgia, irritable bowel syndrome, and complex regional pain syndrome. Nociceptive pain refers to a change in function of nociceptive pathways, algopathic pain is pathologic pain not generated by injury, and nocipathic pain refers to a pathologic state of nociception. Nocipathic pain was recently proposed as a descriptor for chronic pain syndromes and is distinct from pain of unknown origin or from pain that results from central sensitization.³

The narrative review includes considerations for pain assessment in elite athletes, including general components such as pain intensity, location, duration, and impact on performance, as well as precipitating and aggravating factors. “The general rule relating to duration of pain is that the longer pain persists, the less likely it is to reflect tissue damage and the more benefit there is likely to be in taking a multidisciplinary approach to the problem,” wrote the researchers.

The physical examination should include a biomechanical assessment, which takes the kinetic chain, training load, and periodization into consideration. Although a sensory assessment is essential and may require referral to a neurologist, a basic sensory examination may yield valuable insights. “When no known lesion or disease is identified, regional, generalized, or widespread sensitivity to pain may reflect nociplastic/algopathic/nocipathic contributions to pain.”

For subacute or chronic pain, the assessment should also include an evaluation of psychological, social, environmental, and lifestyle factors. For example, sleep deprivation was shown to affect the release of growth hormone and overall recovery and has been linked to anxiety and depression, which can lead to worsened pain and performance.^4,5 “Pain can disrupt sleep, and sleep problems can worsen pain. A sleep-deprived athlete is not in an optimal state of recovery, and sleep deprivation can alter tissue sensitivity and load capacity, thereby increasing risk of injury and pain,” the authors explained. A 2014 study found that the risk for injury was nearly doubled in adolescent athletes who slept an average of <8 hours per night vs ≥8 hours.⁶

The importance of nutrition is also emphasized, particularly the need to address eating disorders — defined as insufficient caloric intake relative to caloric needs — that may result in osteopenia, diminished performance, illness, and injury.^7,8

In addition, athletes may face social pressures that can influence their response to pain and recovery. For example, there may be real or perceived pressure from family, coaches, fans, and others to dismiss pain and return to play quickly.

Although these complex issues may warrant referral to a mental health specialist, sports clinicians should “consider this complexity and manage patients from a patient-centric biopsychosocial conceptual framework,” emphasize the review authors. “Critically, this approach must be endorsed by the entire clinical team and, ideally, the wider team, including teammates, coaches, and management.”

To further explore the topic of pain management in athletes, Clinical Pain Advisor interviewed lead review author, Brian Hainline, MD, chief medical officer of the National Collegiate Athletic Association (NCAA), and clinical professor of neurology at New York University School of Medicine and Indiana University School of Medicine. 

Clinical Pain Advisor: You and your co-authors emphasize the distinction between pain management and injury management. Could you elaborate on that notion?

Dr Hainline: Injury management usually focuses on returning an athlete to play or competition following a musculoskeletal injury. The focus is tissue healing and assessing biomechanical forces that may have led to the injury. Pain management focuses on improving pain and function. One can be injured without pain, and one can have ongoing pain despite a healed injury, or even no injury. For pain management, the most important issue is to understand what is driving the pain, and if there is an appropriate relationship between pain and injury.

Clinical Pain Advisor: You also mentioned the need for greater communication between experts in pain medicine and sports medicine. What are some ways to encourage such interactions?

Dr Hainline: We hope this first-ever IOC consensus statement will be the start of a more meaningful dialogue. The IOC hosted this meeting because there has never been a meaningful collaboration between pain medicine and sports medicine clinicians. The NCAA plans to host an interassociation task force on pain management in college athletes, using the IOC paper as a springboard, and we hope this will help increase awareness of this important dialogue in our country.

Clinical Pain Advisor: What are the key points from your reviews for our audience of pain clinicians?

Dr Hainline:

• Injury does not mean pain, and pain does not mean ongoing injury.
• Sports medicine clinicians who treat athletes in pain must first identify the nature of the pain: Is it pain consistent with an injury, or is it pain that is more consistent with some other biomechanical, psychological, social, or addiction factors?
• Medication is only one facet of managing pain in athletes. There must be an immediate focus on nonpharmacologic strategies, ranging from proper exercise to proper emotional support.
• Opiate medication has an extremely limited role in managing musculoskeletal injuries and should rarely be used for more than 3 to 5 days. Cannabinoids have no role in managing musculoskeletal injury.
• Medications should never be used for pain or injury prevention.

Clinical Pain Advisor:  What should be the focus of future research in this area?

Dr Hainline: We need more comprehensive data to help us make data-driven decisions. We will also track the impact of this paper for future consensus statements.

Clinical Pain Advisor: Are there any additional points that our audience should be aware of on this topic?

Dr Hainline: Pain is a great teacher, and we should always listen. In most cases, pain in athletes means that there is a fundamental imbalance between overreaching and recovery, plus an imbalance in the biomechanical forces of the activity vs the state of readiness of the body and mind of the athlete to adapt to such forces. Given that pain teaches us, we should listen. This means we should not simply [advise athletes to] “rest, take nonsteroidal anti-inflammatory drugs and then begin basic physical therapy.” Rather, we should reassess where we are and where we would like to be, with pain pointing us to the sources of dysfunction at potentially many levels of our being — physical, mental, emotional, social, and spiritual. Each of these influences pain perception.

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References

1. Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51(17):1245-1258.
2. Hainline B, Turner JA, Caneiro JP, Stewart M, Lorimer Moseley G. Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Md. 2017;51(17):1259-1264.
3. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016;157(7):1382-1386.
4. Neckelmann D, Mykletun A, Dahl AA. Chronic Insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873-880.
5. Bonvanie IJ, Oldehinkel AJ, Rosmalen JG, Janssens KAM. Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain. 2016;157(4):957-963.
6. Milewski MD, Skaggs DL, Bishop GA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014;34(2):129-133.
7. Martinsen M, Bratland-Sanda S, Eriksson AK, Sundgot-Borgen J. Dieting to win or to be thin? A study of dieting and disordered eating among adolescent elite athletes and nonathlete controls. Br J Sports Med. 2010;44(1):70-76.
8. Sundgot-Borgen J, Torstveit MK. The female football player, disordered eating, menstrual function and bone health. Br J Sports Med. 2007;41(Suppl 1):i68-i72.