June 28, 2024 – Lying in an ambulance, her nose busted, gums sliced to the bone after hitting a barricade on her bike, Katie Zaferes had one question on her mind: How soon can I get back to training?
The World Triathlon Grand Final was 17 days away, and Zaferes was also competing for a seat at the Summer Olympics in Tokyo. So, a few days later, she was back at it, enduring the sting of the pool’s chlorine on her mouth’s 23 stitches and the dull throb in her face during runs and rides.
“It’s not like I love pain, but I do kind of embrace it,” said Zaferes, 35, who went on to win the world championship that month and take home a silver and bronze at the Tokyo Games in 2021. (She just missed qualifying for this year’s Paris Olympics but is going as an alternate.)
Remarkable as her story is, it is not, in the world of Olympians, uncommon.
The history books are filled with examples of athletes triumphing in the face of seemingly insurmountable injuries. And injuries aside, the burn of pushing the body to its physical limits can, in itself, be a suffer-fest most people are unwilling to bear.
How do they do it?
“You could say elite athletes have a friendlier relationship with pain than the average person,” said Jim Doorley, PhD, a sports psychologist with the U.S. Olympic and Paralympic Committee.
In fact, an overwhelming body of evidence shows that high-level athletes have a higher tolerance for pain: They take longer to “cry uncle.” Some studies suggest they also have a higher pain threshold, meaning it takes more punishment for them to start to feel pain in the first place, and lower pain sensitivity, meaning they rank their pain as, say, a 4 when others subjected to the same hurt call it a 9.
Precisely what’s going on in their brain and body is a matter of great interest to doctors, psychologists, and physical therapists. By taking a cue from people at the pinnacle of sport, experts say, we mere mortals can potentially get fitter, deal with adversity better, and even prevent or manage chronic pain.
“Elite athletes are just normal people who play sports,” said Colleen Louw, a physical therapist and therapeutic pain specialist and spokesperson for the American Physical Therapy Association. “They have the same biology that we do and the same pain-producing mechanisms as anyone else. The difference is that they learn to think about pain in a completely different way.”
What Is Pain?
Any discussion of pain research must begin with a critical caveat: Pain is tough to define and even tougher to study.
“For a long time, people talked about pain simply being a reflection of tissue damage,” said David Sheffield, PhD, a pain researcher and professor of psychology at the University of Derby in the United Kingdom, “but it has become clear that that is an inadequate definition.”
Even people who have lost their limbs can have what’s known as phantom limb pain, and with many chronic pain patients, the tissue has healed but the pain persists. On the flip side, Civil War histories provide anecdotes of soldiers suffering excruciating injuries but feeling no pain at all.
Then there are the Olympics.
Who can forget gymnast Kerri Strug’s gold medal-winning vault on a sprained ankle at the 1996 Olympics, or Canadian rower Silken Laumann’s bronze in 1984, 73 days after shattering her right leg in a freak accident? Just this February, U.S. runner Fiona O’Keeffe, who had recently had ankle surgery, famously crossed the finish line at her Olympic marathon qualifier with her bib visibly bloodied from chafing. She told reporters she hadn’t even felt it.
Of course, the acute pain of a serious injury is different from the pain of banging out laps at the pool or grinding through a grueling physical therapy appointment.
“The best athletes are cavalier in their approach to exercise-induced pain but conservative when it comes to injury,” Doorley said.
Recognizing how subjective pain is, the International Association for the Study of Pain recently revised their definition to “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
For ethical reasons, that’s tough to replicate in the lab.
Sheffield and others have come up with a variety of sinister techniques, like having people being studied dip their hand in icy water, delivering a mild shock or hot wand to their forearm, or injecting capsaicin (the scorching extract that makes chili peppers hot) into their veins.
In study after study, the evidence is clear, said Sheffield, who recently published a review paper examining 36 studies including 2,500 people.
“In a nutshell, athletes are able to tolerate pain better than non-athletes,” he said.
But why?
Brain Chemicals and Facing Fear
Inside each of our brains rests a built-in pharmacy of “endogenous” painkillers, including endorphins (our ready-made morphine) and cannabinoids (much like the feel-good chemicals in cannabis).
Research shows that during and after a rigorous workout, the brain releases these opioids, reducing pain not just during the workout – the legendary “runner’s high” – but also for about 30 minutes after.
More intense exercise strengthens and prolongs this effect, known as exercise-induced hypoalgesia.
While the science is young and research is mixed, some theorize that if the brain is repeatedly subjected to pain via training, it is constantly sending signals down the spinal cord and gets really good at reducing the pain – a phenomenon called conditioned pain modulation.
“If you stub your toe, obviously that really hurts and maybe you are hopping around on one foot,” said Nils Niederstrasser, PhD, a senior lecturer and pain researcher at the University of Portsmouth in the United Kingdom. “But say you then bang your head on the wall. Presumably, that would be less intense because your body has already sent out the inhibitory signals.”
The more an athlete trains, the more of these inhibitory signals their brain sends out, the more dialed-in this system becomes.
In essence, pain kills pain, Niederstrasser said.
The athlete’s brain may also process pain in ways that aren’t fully understood yet.
In one German study, scientists used functional magnetic resonance imaging (fMRI) to scan the brains of 18 male athletes and 19 non-athletes while applying painful heat to their arms. They found that brain regions typically known to light up with painful stimuli were considerably less active in the athletes.
Pain With a Purpose
Elite athletes also adapt psychologically to pain over time.
“The more athletes experience and push through pain in training, the less emotionally triggering the pain becomes,” Doorley said. “A virtuous cycle ensues whereby more training leads to better pain tolerance, which allows for more intense training, which improves pain tolerance further.”
Eddie O’Connor, PhD, a clinical and sports psychologist in Grand Rapids, MI, works with both with elite athletes and chronic pain patients. He said athletes (unlike many with chronic pain) benefit from having a clear purpose to their pain, whether that is a spot at the Olympics or a personal record.
“They know that in order to achieve it, they have to invite more pain than perhaps they have ever felt,” he said. “They choose the pain in service of speed or performance.”
Knowing the difference between pain that is dangerous and pain that is just part of training or rehabilitation is also key in not only staying safe but also boosting tolerance, Louw said.
“The more you understand about why you hurt, the less anxiety you have,” she said. “Your nervous system ramps up when you have fear, and that can actually lower your pain tolerance.”
Science backs this up. In one study, researchers looked at a variety of personality traits in athletes and non-athletes. They found that those with more “grit” (defined as passion or perseverance toward a goal) and less fear of pain could keep their hand in cold water longer.
Karen Cogan, PhD, a sports psychologist with the U.S. Olympic and Paralympic Committee, encourages her athletes to think of training pain – muscles burning, heart pounding, lungs stinging – as a sign of getting stronger.
“You may not be training 8 hours a day like an Olympic athlete, but a toned-down version of this can work for the rest of us too,” she said. “It can help us get the most of ourselves and make it count.”
All these psychological tactics – identifying a purpose to the pain, understanding the difference between dangerous pain and productive pain, and managing fear about pain – can also be applied in helping chronic pain patients, Louw said.
For them, the purpose may be to throw a ball to a grandchild, and a trusted mental health therapist can help them cope with fear.
What the Rest of Us Can Learn
One key takeaway: “In terms of prevention of chronic pain, I think there is a strong argument to be made that physical activity can be beneficial,” Niederstrasser said.
In a study published in the journal PLOS One in 2023, researchers from Norway followed 10,732 adults, assessing them twice, 8 years apart. The more physically active they were, the longer they could keep their hand in cold water, with those considered very active able to tolerate the pain for 16 seconds longer than those who were least active. Even more encouraging: The people in the study who increased their physical activity level over the 8 years also increased their pain tolerance.
Another, smaller study found that cycling three times per week for 30 minutes at a vigorous pace boosted pain tolerance in older adults after just 6 weeks. And Niederstrasser’s own research in nearly 6,000 people age 50 or older has shown that playing tennis, running, swimming, and even gardening can help ward off chronic pain long-term.
For those just starting an exercise program and struggling to stick with it, knowing that your tolerance for pain will increase can be motivating, Sheffield said.
“Through both becoming fitter but also because of changes in your pain perception, you’ll likely find it not so bad after a few months,” he said. “Your anchors change and you sort of recalibrate what pain is.”
Zaferes can relate.
Even after years of training at the highest level, she acknowledged that she, and other athletes like her, are “not above the struggle.” Exercise often does not feel good when she starts. And when she’s working so hard she can feel her heartbeat in her throat, she’s not immune to the temptation to quit.
But she has learned to lean into the pain, a strategy that has helped her outside of competition, too – during the birth of her 2-year-old son, managing the grief of losing her father, and even following through with public speaking engagements (which terrify her).
“I think the pain felt through sport translates to everyday life in a lot of ways,” she said. “Pain has led to me feeling the most proud of myself and achieving things that I never would have thought possible.”
