Sports Ethics: Play Through Pain

“Pain is your friend.”  “Pain lets you know you are still alive.” “Pain is good.” So Master Chief yells at the beleaguered SEAL recruits in a great movie G.I. Jane.

This lesson, so central to military life, pervades the moral culture of athletic competition. Every athlete trying to be a warrior, and here athletics draws heavily from millennial old origins as preparation for life combat, must learn to fight through pain and to seek goals despite  hurt and obstacles. Playing through pain is a central moral tenet of sports. It exemplifies three virtues critical to athletic success: self-mastery; courage; sacrifice.

It does not matter the moment we tune into sports, but pain splays through the games and the wounded fall before us with startling regularity. If we were not so inured to the carnage, we would be appalled by our callousness. This last month twenty five and counting baseball starters are out for at least three months. Seven Boston Red Sox outfielders alone are on the disabilities list. The first week of NFL pro to-practice saw at least three players end their seasons before even doning pads.  Derek Rose writhed on the floor with an ACL and the Chicago Bulls saw their playoff hopes collapse. The great Junior Seau committed suicide, too much pain. The NFL continues to try to bring to justice the players who deliberately attempted to end the effective careers of other league players through injuring them, not just pain. And this is only one month! 

All this endless pain in sports and life means we should not forget master chief’s lessons.. Pain is our friend, because pain signals to the athlete that his or her body has stressed beyond the point where it can continue to function at full efficiency and still be healthy. Pain signals deeper injury, inflammation, nerve overload, neurotransmitters warning and adrenalin flooded emergencies. The body floods itself with chemicals to deal with pain; some seek to quiet the pain, others to kick up the level  of awareness or body performance for a short time to get through the pain. Sometimes the body narrows the focus of the mind and eyes to prepare for and overcome the danger that body announces.

The ability of an athlete to be aware of and monitor their pain is important. In every sport every athlete lives with attrition of physical skill and strength over a season. They realize there are times when as an athlete they need to play with the pain because it is bearable and will not detract form their performance level. There are moments when they need to demonstrate courage to their teammates and encourage them to also play with a reasonable level of pain out of loyalty to each other; the contagion of a leader, if he or she can do it, so can I.

Last year Washington State University started a redshirt freshman quarterback Connor Halliday against Utah. It was his first start after a stunningly successful first game the week before. He played on cloud nine full of energy and adrenal protection. During the game he took some hard hits and suffered contusions and injuries, nothing that seemed out of the ordinary for the normal pain and injury that football inflicts upon its players. Yet later that day he ended up int he emergency room with a lacerated liver. The WSU doctors had run all the regular and protocol based tests when he was injured and nothing came up. This type of injury remains internal and not immediately evident; its pain should have alerted the quarterback of the severity. But like so many young athletes in the thrall of competition and loyalty and cortisol induced protection from pain, Halliday did not recognize the signals or refused the listen to them; he was going to play come hell or hi water.  To understand the culture of sport and athletes, it is important to listen to what his coach said after complimenting him for  "unbelievably courageous outing." "He hung in there and took hits and threw the ball under duress and pain. I'm very proud of his toughness and grit."

Yet even bearable pain may be a reason to leave the field. First, as in the case of the young quarterback, it may be the tip of an extensive set of damages not yet fully unfolded. It may be the warning signal that the body is pushing limits and catastrophic failure is shortly to occur. Playing on may intensify injuries or magnify the range of the loss. Secondly, even a bearable injury can detract from performance. It may be that a player hurts her or his team by staying on the field as an act of courage or self-mastery. Yet this important point is often missed and when Jay Cutler left the field of play for this reason the NFL's professional football semi-finals, he was vilified.

Pain serves a survival function and as an early warning system to people about the need to protect and attend to their body. It alerts athletes that worse is on the way if they keep pressing against the signals of the body. The young quarterback could have destroyed his life.

Pain manifests as a real physiological phenomena exhibited by neural and chemical responses. But pain is also experienced subjectively, and many persons have different responses to the same physical impact; they read their body differently. Individuals can be trained to deal with higher levels of pain, physical or mental, over time. Dealing with high levels of pain can be learned, and levels of pain that would paralyze a person at the beginning of training can be tolerated and functioned through later.

People experience pain subjectively, and the classic medical scales ask patients to rate pain 1-10. In real life, people might talk of mild or unbearable. It might be stabbing or throbbing or intermittent. It might explode or linger and thrum. The scaling and different manifestations make diagnosing and living with pain an art, not a science.

Sometimes the pain recedes because the pain initially signaled a level of muscle, vascular or pulmonary performance that the sport required pushing past. Pushing past meant experiencing the braying complaints of lungs, muscles and mind as the athlete learns to develop higher levels of endurance, strength or odd skills that require unique vascular and muscle specializations. The capacity of the body to function without hurting itself grows with practice and strength.

At other times the pain simply reflects bodily disorder and breakdown. The picture of Curt Schilling with blood flowing from a bone sticking through his foot as he pitches the Red Sox to a World Series win exemplifies the play through pain mystique and myth and imperative of sports. Jack Youngblood finishing a football game with a broken leg also ranks in the pantheon.

The key to remember is that  playing through pain has serious short and long term costs. First, pain distracts the athlete. It takes indirect concentration and focus to keep the pain at bay, and this distracts from utter complete presence to the task at hand. Second, the pain diminishes actual physical performance and limits physical actions. When a player is injured, they can often keep playing with adrenalin and team loyalty and support holding them together. But once on the sideline the adrenaline falls, the contagious strength of a huddle falters and the full measure of pain explodes and debilitates the player. The next time they go out, the deterioration of performance becomes obvious.

Finally, pain’s early warning nature signals later cost. Players who keep playing through the pain like a torn meniscus just tear the meniscus apart until they play bone on bone. Players with a ripped muscle continue to fray the muscle or micro-fracture grows into a greater break in the bone. Players compensate on the field and in compensating put excessive stress on other unprepared bones and muscle and end up multiplying injuries. The longer the player plays through the pain, the longer the healing and the greater the possibility of more injury and hence even longer healing. In my world of college athletes, the most common medical reason for waivers after major immediate injuries like ACL or broken bones involves players coming back too early, not giving their injury or body time to fully heal.

It makes perfect sense to play through certain types of pain. The accumulated aches, pains, strains, twists and bruises of a season nag at performance and harass a player’s focus. Good athletes know their own bodies well. They usually know when their body has reached its limits. Good athletes, like good professionals, learn to master these physical pains. They also learn to master and play through the mental pains that arise from daily life that ensnare daily suffering or worries about family or child or finances or breakups or friends. Playing through these pains mirrors a primary moral requirement of life.

The legendary status of playing through pain deserves its moral status. To do this humans manifest honor, strength of will, loyalty to goal and team. These are admirable traits and deserve praise. So modern athletes will “power through.”

But we have learned that more often than not playing through the pain of major injuries or threatening injuries makes no sense for athlete or team either in short run or long run. This is especially true for younger athletes who do not have the fine grained sense of their bodies or a well developed sense of self-preservation. This is why college and high school athletics must have independent and empowered doctors on the field to stop the athletes and stop the coaches when they prefer to risk the Achilles Choice that I have often discussed  to seek glory and victory.

The sacrifice of playing through pain makes little moral sense for young or college athletes. Players and doctors know this, even if coaches regularly forget it.

Achilles' Choice--Athletics and Injury I & II

In the Iliad Achilles, the greatest of all Greek heroes, makes a choice offered by the gods--a long, quiet, productive life as King or a brief and glorious life as a warrior. Achilles chose a brief and glorious life. His song would be sung; his life remembered.

Modern athletes are offered the same choice, but the ethics of the choice is far more problematic. Athletes in most sports run a much higher risk of serious injury than a "normal" life. Worse, they risk long-term debilitation as their knees, ankles, hips, backs and necks give out in their thirties and forties. For many, old age strikes in early middle age.

The dangers of athletic endeavor come from the fundamental physicality of sport. Athletic achievement relies upon the body, upon the trained, disciplined and intent guided bodily action. The marvelous human body can be driven to incredible feats, and this is one of the glories of sports and athletic accomplishment. The human body, however, remains a mortal coil, a magnificent but brittle and fragile entity.

Athletics involves the disciplined application of force and constant practice and focus. The force reverberates back on the body. This occurs in violent sports like football but force reacts upon the body in "noncontact" sports like tennis, volleyball  or rowing. The impact of athletic actions accumulate through trauma and repetition. The trauma involves injury beyond normal force applied to the body. This covers collision and impact in football or soccer or distress inflicted upon an arm and elbow of a volleyball or tennis swing. The trauma can ripple through back, legs and torso in gymnastics or swimming. Endless and relentless repetition in practice and competition steel the body against the pain of the trauma but also compound the impact over years of action.

Injury signals the body to stop and heal itself. Pain is the body speaking to itself to warn of danger to the body's integrity. All humans learn to read and in some ways master pain. We could not survive without that capacity. But a trained athlete learns early, very early, that succeeding in athletics incurs levels hurt and pain entwined with the achievement and joy of playing and succeeding.

Immediate severe trauma to the body in some ways is the safest. It stops the body from performing and forces the athlete to stop. It even forces the coach to take the player out because the pain and injury limit the player's effectiveness. Leaving aside team doctors or trainers who will sometimes "shoot up" a player to dull the pain and enable them to play when the body tells them no, the true injury forces stopping and healing. Sometimes it ends a career, sometimes it demands months of rehabilitation to recover and return to the sport. Many athletes--amateur, elite, professional--have lived through multiple damage and injuries that accumulate. They learn to play with pain, not through pain. Often they come back from the injury to play more.

Athletics is a young person's domain. A few pros may make it to late thirties, but most end their careers long before that. The danger of injury seems far away to a twenty year old. It does not even exist for 6 year olds and seems irrelevant to 13 year olds.  Given the ages athletics starts for children, we rely upon parents and coaches to protect players from this trauma and make decisions to protect their health.

Young athletes know they are immortal. They play for the joy the game and of competing, satisfaction at experience of body and achievement, and pleasing their parents, coaches or teammates. They take risks, few sane adults would take, and consider them normal. They come back from injuries and broken bones and ACLs and hernias and hamstrings and concussions and keep playing.

Young athletes are resilient physically and emotionally. They can heal and come back; they often choose to. The immediate and large injuries are clear to them, but none of them sees or understands the long term and nagging injuries that will accompany them for the rest of their lives.  Parents understand but humans are not well designed cognitively to act upon such long term low probability outcomes. These probabilities do not play well with adults when facing the joy and longing of kids to play as well as parents own complicated relation to their children's athletic achievement.

We shouldn't ban children from playing sports. We shouldn't will ban all sports; the logic of trauma and repetition dog all athletic accomplishment. Athletes sort themselves over time as many drop out of competitive athletics or find play at levels appropriate to them. As they stay in the competitive track, the risks of long term impacts arise, but most of them seem manageable and the pay offs for the young athlete feel real and immediate.

We all live with choices with hidden long term costs we cannot envision even if we "know" they exist. Adults often make choices to pursue dangerous activities a person excels at or loves or both. But the defense fails when athletes are young; we rely upon adults--parents, guardians, coaches, doctors to protect and defend the athlete's future. The dilemma arises when the young athlete wants to play, even if the wanting is infused with parental pressure or desire to please authority figures or be with teammates.

The glory and joy of athletics lures young athletes; only parents and coaches stand between them and the accumulating costs of trauma and repetition.

In the Odyssey, Odysseus travels to Hades and meets the shades of great Greek heroes. In his encounter with Achilles, we hear Achilles' verdict on his own decision to choose a brief life of glory over a long life on earth. "I'd rather slave on earth for another man....than rule down here over all the breathless dead (Fitzgerald translation)." At what point does overcoming pain and injury become a journey to Hades for athletes?

People forget that Achilles died ignominiously shot by the coward Paris from behind. Pain and injury accompanies the physical demands and risks of success at sports. Overcoming them and competing and achieving reflects human spirit and courage. We praise an celebrate overcoming adversity in all aspects of life.

At one level playing sports involves a risk tradeoff  similar to other areas of life. People make decisions to devote energy to an activity because of satisfaction, achievement and goals. They give up other activities; they may fail and their efforts bear no fruit. They may succeed up to a point, and then give it up or pursue other activities. In many other areas of life the probabilities of succeeding at least at a professional level are much higher and the opportunities much greater. This accounts for the huge fall off in athletic participation as people grow older. But in America, college educations can be won with sports achievement and for a very few elect, they might have brief careers as professional players, but most of even the best will be finished by the age of 27.

The numbers of people actually affected by sports trauma narrows to a very very small band of people by the time most of them are 18 and to a miniscule by the time they are 23. Fewer than 400 play professional basketball; in the entire history of baseball there have been fewer than 17,000 players. But the way to get there is littered with injuries and cumulative traumas from repetition. An epidemic of knee injuries plagues youth soccer and basketball especially for young women. The body of a twenty-five year-old gymnist evinces the wear and tear of a 40 year old. Many high school and club players have struggled with pain, injury and damage. Most elite college athletes deal with some significant damage. We just don't know the long-term cumulative impact for most of these sports; linear clarity of impact upon their later health is not always clear. Doctors, however,  know enough to be able to warn athletes of the long-term impact of arthritis or debilitating injuries or repeated attempts to come back from injuries. At this point the role of doctors and parents becomes critical to ensure decisions to continue on are informed and made rather than simply taken for granted.

Unfortunately what modern sport gives athletes is glory, if they are good enough, and a long life full of debilitating injury. A recent NFL study suggests that football players who have suffered number of concussions potentially have a much higher chance of suffering early dementia. This data  meshes with compelling studies by the U. S. military of the cumulative impact of IED explosions on soldiers in Iraq. Proposed rules of engagement limit exposures to three and prohibit soldiers from returning to combat. Football and other sports have not reached such conclusions.

The cumulative impact on cognitive functioning differs in a profound way from the cumulative impact upon bodies. Individuals can adapt to physical injury and limits. Most people maintain their own character intact as they grapple with physical injury. But brain trauma from cumulative impacts erode the core personality and cognitive functions. The way the brain works changes, personality changes, people become shadows of themselves, they arrive at Achilles fate.

But athletes, especially young athletes, did not make a bargain with gods. They play for love, joy and accomplishment. They play for the experience of being with other  athletes. They play for their parents and coaches. A few play for dreams of being a professional. At some point, they grow into adults and make their own bargain with the game and their fate. But as youth, they depend upon others to protect them from the shades and shadow world that could await them. The more we learn, the more we need to be alert to protect the young athletes from the permanent injury to their soul that can await them.

What does it mean for people like me who enjoy and admire athletes and athletic competition? What does it mean to pay money and enjoy athletic contests that can be slowly sapping not just the body but the mind of the players? I have not been able to watch boxing for years. Over 28 percent of boxers suffer serious cognitive disability. I can remember the beauty and glory of Mohammed Ali. I recoil with physical and spiritual dismay when I see what his sport has done to his body and mind. We will not outlaw football; we will not find technical solutions to the mounting hidden epidemic. I honestly do not know how to react to this knowledge. How can I revel in the next explosive hit or block, knowing that each hit, each smash contributes to the loss of a mind?

Modern athletic glory is fleeting. Modern athletes are fungible marketing commodities. Even the greatest gain their momentary glory and their treasure, but they gain not eternal glory but a long life after the glory, a life of slow loss and suffering. This may be a deal for adults, but not for children.