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Sports Injury and the Pain Pri...

Adages that evoke the pain principle in sport include “No pain, no gain,” “Push yourself to the limit,”“Sacrifice your body,” “Suck it up,” “Perform in spite of pain,” or “Work through the pain.”  Toughness is considered a prerequisite for success in sport and young athletes are often encouraged to “pay the price for victory.”  Major league baseball manager Sparky Anderson reportedly explained to a player, “Pain don’t hurt.”  In western culture sport has long been equated to masculinity (McKay, Messner & Sabo, 2000).  The denial of pain in sport was seen as a masculine attribute, an earmark of toughness and masculine adequacy. (Katz, 2006).  The denial of pain has been gendered “masculine” and, concomitantly, the admission of pain has been gendered “feminine.”  In recent decades, however, women have entered sports in increasing numbers and the gendered meanings associated with ascetic postures in sport show signs of changing.

Most athletes do not discuss their pain and, if they do make reference to it, it typically takes the form of a mocking or flippant comment.  (For example, “Don’t worry, it only hurts when I breathe.”)  Athletes do not ruminate or reflect that much about pain, even though they may experience it frequently.  Unsurprisingly, they do not lean toward enlightened stoicism since athletic competition stresses functions and outcomes more so than philosophical reflection.  Traditionally masculine locker room subcultures have also glorified if not sanctified pain.  Real men endure pain and weak or presumably “feminine” men express or give into pain.  Fans and sports commentators glorify injured athletes who play “with” pain or “through” pain, and their collective chorus becomes a cloaking device that hides their emotional turmoil and despair of the athletes who actually suffer injury and pain. (An example would be the media’s mawkish admiration of Tiger Woods’s protracted suppression of pain as he winced his way to victory in the 2008 U.S. Open.)

Until recent decades, researchers typically ignored sports injury and the study of chronic pain among athletes.  Few epidemiological studies have calculated the health risks associated with contact sports.     Where are the longitudinal research findings that can inform parents, coaches, and athletes about the long-term risks incurred by contact sports for arthritis, chronic back problems, knee pain, or hip replacement surgery?  These questions have not been answered because medical, epidemiological, and sport researchers have yet to do the work.  I suggest that the lack of analytical research is itself, in part, an expression of a wider cultural denial of athletic pain.  

In the late 1990’s,  I interviewed a purposive sample of 30 former college athletes, professionals, and Olympians (15 women and 15 men) who self-identified as living in chronic pain that resulted from a catastrophic sports injury or overtraining.  For each of these interviewees to keep playing and get to the “next level,” symptom denial and an acceptance of risk and suffering were seen as “paying the price” for upward mobility.   Both the men and women reported becoming adept at denying their pain and keeping it to themselves.  Denial was an inner badge of courage and an outer symbol of accomplishment and dedication.  Regardless of gender, they all played in spite of injury, and complied with the mandates of coaches or competition.   In short, there were more gender similarities than differences.

While there are many coaches, administrators and medical professionals that counsel athletes to “listen to your body” rather than to sacrifice health and physical well-being, getting athletes to pay attention to pain and symptoms rather than to deny them, to be conscious of feeling well instead of blindly pushing their bodies to harmful extremes, is going to require a long term effort to confront the powerful forces of a sport culture in which acknowledgement of pain is still taboo.   We must start by breaking the cultural silences about pain and injury that have in the past been obscured by the pain principle and begin listening to the critics of pain and injury in men’s and women’s sports whose calls for reform have often fallen on deaf ears. 
In 1994 George D. Lundberg, former editor of the Journal of the American Medical Association, for example, called for a ban on boxing in the Olympics and in the United States military.  His editorial entreaty, while based on clinical evidence for neurological harm from boxing, was also couched in a wider critique of the exploitative economics of the sport.  Today, boxing still flourishes and sadly, ultimate fighters and women have joined the ranks of boxers who risk trading their healthy brains for wealth and fame.  Similarly, as early as 1999, medical researchers documented a significant relationship between concussion history and reduced neuropsychological performance among college football players (Collins, Grindel, Lovell, Dede, Moser et al., 1999).  So too, a case-control study of amateur soccer players confirmed elevated risk for chronic traumatic brain injury and neuropsychological impairment.  And most recently, Sokolove (2008) confronted the need to address increased incidences of ACL injuries in girls sports in Warrior girls: Protecting our daughters against the injury epidemic in women’s sports. 

We must all increase efforts to develop what Mariah Burton Nelson calls “physical intelligence” among athletes and fitness enthusiasts, reforming sport and individual engagement with physical activity to foster health rather than debilitation.  We must transform sport into a more body-enhancing and health-affirmative culture.  
This blog was derived from an article published in the Journal of Intercollegiate Sport, volume 2, issue 1 (June, 2009).  I delivered the essay as an invited commentary for the 2009 NCAA Convention, Scholarly Colloquium entitled, Paying the Price: Is Excellence in Sport Compatible with Good Health?, January 13-14, 2009, Washington, DC.

Collins, M. W., Grindel, S. H., Lovell, M. R., Dede, D. E., et al. (1999).  Relationship between concussion and neuropsychological performance in college football players.  Journal of the 
Katz, J. (2006). The Macho Paradox: Why Some Men Hurt Women and Some Men Can Help. Naperville, IL: Sourcebooks.
Lundberg, G. D. (1994) "Let's stop boxing in the Olympics and the United States Military" Journal of the American Medical Association, 271(22), 1790.
McKay, J., Messner, M. A. & Sabo, D. (Eds.). (2000). Masculinities, Gender Relations, and Sport.  Thousand Oaks, CA: Sage.
Nelson, M. B. (2009).  The damage I have done to myself: Physical intelligence and lack of same among college athletes.  The 2009 NCAA Convention, Scholarly Colloquium, January 14, Washington, DC.