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physchology of sports injury, dissociation, association, pain, overtraining, injury risk

The physchology of sports injury: is 'no-pain no-gain' the path to sports injury?

Should distance runners concentrate on their bodily sensations, or try to think of something else? Distance runners and their coaches recognise the importance of developing an aerobic base and then implementing progressive overload training in 'safe doses' in order to allow the necessary adaptations to occur. Those working in sports medicine, however, acknowledge that problems can arise when the overload principle is applied too rapidly and the loads exceed the athletes' capabilities. This might include overtraining and running too many miles per week, or too much work conducted on hard surfaces. These precursors to injury are quite obvious, although when athletes become so focused on their goals the path towards injury may only be retrospectively recognised.

Previously in SIB, I have tried to emphasise that mental processes can also become injury antecedents. In this article I will concentrate on runners and the 'attentional strategies' that are used by the recreational and the elite during training and competition. Research using running samples has identified two important attentional strategies that are commonly used, and, interestingly, the use of certain attentional strategies has been linked to injury rates. This finding could once again be shown in the so-called 'no pain, no gain' philosophy of some athletes and coaches.

Which is better, association or dissociation?
A groundbreaking American study of elite and college distance runners (1) that was mainly concerned with the psychological profiles of athletes triggered a great deal of research by sport and exercise psychologists. This happened because of the different types of attentional strategy used by the two groups. The elite runners tended to use a strategy called association, which involves monitoring sensory inputs and focusing attention internally on bodily sensations such as muscular strain, breathing, etc. in order to set an appropriate pace and potentially avoid pain.

In contrast, the non-elite runners were more likely to try to direct attention away from bodily physiological signals by distracting themselves. Although many different dissociation strategies exist, the idea is essentially to shift attentional focus from an internal to an external perspective, although internal dissociation can occur. For example, an athlete may complete a training run while listening to music on a personal stereo system. The music can capture attention and help distract it from inner feelings, such as pain and discomfort.

Following the initial research findings, psychologists have spent many hours attempting to discover if association is indeed related to higher levels of performance, and as such is a better strategy for distance runners to use. Although research results have been mixed, the current general consensus is that:

1. Association is related to faster running times than dissociation;

2. Regardless of level of performance, it appears that runners use more association in competition and dissociation in training (usually conducted at a slower pace) and

3. Elite runners seem to have flexible attentional strategies that allow them to change focus during races as required(2). For a more detailed examination of the performance consequences of cognitive strategy, and the accompanying research findings I refer readers to one of my previous articles in Peak Performance(3).

Dissociation, pain and injury
Considerable evidence exists to link dissociation strategies with increased pain tolerance during endurance tasks. Essentially, theorists suggest that by attending to an external stimulus, our limited attentional channels become flooded with this information and consequently physiological sensations can be blocked-out temporarily (4). In support of this, many experimental studies that have asked participants for their ratings of perceived exertion (how hard the exercise feels) during sub-maximal exercise trials have shown that, at given intensities, lower ratings are found when participants dissociate. However, since dissociation apparently involves blocking-out potentially important warning signals (physical pain) some researchers have suggested it is a risky strategy that could increase the chances of sustaining an injury. In one study(1) the authors reported a runner who had sustained fractures to both fibulas and subsequently suggested that this could have been avoided if the athlete had not tried to dissociate from the pain. Unfortunately, such speculation does little to advance our scientific understanding of any relationship between dissociation and injury. Clearly further research is warranted.

Although relatively few research studies have been conducted, there is little support for the notion that dissociation is related to injury. One study (5) found that dissociation scores in both marathon runs and in training did not correlate with history of running-related injuries. In contrast to expectations, four marathon runners who stopped running during the race due to injury were actually using association in the miles immediately prior to getting hurt. In two follow-up investigations(6, 7) no relationship was found between injury rate and dissociation strategies, although injury prevalence was greater in those who ran more races and were more competitive.

Motivation rather than pain relief
Some elite runners do appear to use dissociation some of the time, but current research involving marathon runners suggests this is safe and unrelated to injury(2). It has been argued that the type of cognitive strategy used has little to do with pain relief and is more closely linked to motivation. Take the example of elite marathon runners who apparently use more association in competitive runs rather than in training. In competition, runners will be pushing themselves towards the upper limits of endurance and are more likely to experience pain. If dissociation is used for pain relief and blocking-out aversive stimuli, one might have expected greater use of this strategy in competitions, but the opposite appears to be true. In fact, evidence suggests that dissociation is a limited pain reliever that is most effective in mild and moderately painful situations. It seems that when physiological (pain-related) inputs begin to increase towards higher intensities, they demand attention and cause a shift from an external to an internal perspective. Simply stated, although you may temporarily 'switch-off' from pain, as soon as it exceeds a specific threshold (high intensity work) dissociation strategies are no use.

Association, pain and injury
Careful examination of early research suggests that elite marathon runners were well aware of the pain (in fact they associated to it) but chose to continue running(2). This may well be competitiveness but, interestingly, it has been implicated in relation to injury. Perhaps of greatest significance is one study that assessed attentional strategy and then evaluated its relation to injury after a four-month period (7). Importantly, after controlling for running addiction, competitive and goal-oriented motivation, history of injury, miles and days of running per week, and number of races and marathons, association still predicted injury while dissociation was unrelated. Runners may use associative strategies by redefining incoming physiological inputs as a coping strategy, expecting the sensations and focusing on the actual sensations (stripping away emotional content) which can render the state less aversive. This tough-minded approach can allow the runner to continue through pain but the drawback would appear to be increased risk of injury. This finding bolsters previous research that has also linked association with injury rates (8).

Summary and conclusions
The attentional strategies employed by long-distance runners have not only important implications for performance but also for injury risk. Although runners may shift attention during races and training between body monitoring (association) and external / distracting focus (dissociation), the type of focus used does seem to be related to injury even when other important variables are controlled. Results suggest that, despite past concerns, dissociation is unrelated to injury while associative strategies have been shown to predict injury. The reasons for this are at present unclear, although some theories suggest it is due to redefining painful stimuli in non-emotional ways and choosing to associate with it, expect it, and thereby reduce negative emotional arousal. Ultimately, the runner decides to continue when slowing or stopping appear more sensible behaviours.

Further research is needed to confirm these initial findings and allow greater understanding of the responsible mechanisms. Such strategies may well conform to the 'no pain, no gain' philosophy. The process of changing the focus and behaviours of some runners to reduce injury risks is likely to be challenging, given the importance placed on goal attainment, winning and the links between association and faster running times. The use of dissociation in training has been recommended to avoid compromising safety(2), but if correctly implemented association can allow runners to ride the thin line between pushing hard and over-doing it, providing they listen to their bodies and correctly interpret warning signals. Associating with pain might reduce the responsiveness to warning signals and increase the likelihood of injury.

Lee Crust

(1) Morgan, W.P., & Pollock, M.L. (1977). Psychological characteristics of the elite female distance runner. Annals of the New York Academy of Sciences, 301, pp.382-403.
(2) Masters, K.S., & Ogles, B.M. (1998). Associative and Dissociative cognitive strategies in exercise and running: 20 years later, what do we know? The Sport Psychologist, 12, pp.253-270.
(3) Crust, L. (2002). When it comes to doing your best, it's the thoughts that count. Peak Performance, 172, pp.6-8.
(4) Rejeski, W.J. (1985). Perceived Exertion: An active or passive process? Journal of Sport Psychology, 7, pp.371-378.
(5) Masters, K.S., & Lambert, M.J. (1989). The relations between cognitive coping strategies, reasons for running, injury, and performance of marathon runners. Journal of Sport and Exercise Psychology, 11, pp.161-170.
(6) Masters, K.S., & Ogles, B.M. (1992). Dissociation and injury revisited: There is still no relation. Paper presented at 100th Annual Convention of the American Psychological Association, Washington D.C.
(7). Masters, K.S., & Ogles, B.M. (1992). Retrospective and prospective studies of cognitive strategies among marathon runners: Relations with injury, motivation and performance. Paper presented at 104th Annual Convention of the American Psychological Association, Washington D.C.
(8) Ungerleider, S., Golding, J.M., Porter, K., & Foster, J. (1989). An exploratory examination of cognitive strategies used by masters track and field athletes. The Sport Psychologist, 3, pp.245-253.

physchology of sports injury, dissociation, association, pain, overtraining, injury risk