Pain Sensitivity, Pain Catastrophizing and Fear-Avoidance in Adult Runners: Injured vs. Uninjured Comparisons and Multivariable Associations.

PURPOSE: Personal beliefs about pain, such as pain catastrophizing and fear-avoidance, are believed to influence central pain processing, but their relationship to pain sensitivity in injured runners remains unclear. This study examined whether injured runners exhibit greater pain sensitivity, pain catastrophizing and fear-avoidance beliefs compared to uninjured runners, and explored the extent to which pain catastrophizing and fear-avoidance predict pain sensitivity.

METHODS

A total of 235 adult runners (18-76 years) who had been running consistently (1-3 times/week for ≥ 3 months) were included. Using scores from the update to the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O2), participants were categorized as uninjured (score = 0) or injured (score > 0). All participants completed the Pain Sensitivity Questionnaire (PSQ), Pain Catastrophizing Scale (PCS) and Fear-Avoidance Beliefs Questionnaire (FABQ). Between-group differences were tested with independent-sample t-tests and adjusted linear regression models, while PSQ predictors were examined using stepwise multivariable regression adjusting for demographic and training covariates.

RESULTS

Injured runners (n = 91) reported significantly higher scores across measures of pain sensitivity (PSQ mean difference = 1.1, p < 0.001), pain catastrophizing (PCS mean difference = 7.9, p < 0.001) and fear-avoidance beliefs (FABQ mean difference = 15.3, p < 0.001). Stepwise regression revealed that greater pain catastrophizing rumination, higher fear-avoidance beliefs and select training characteristics were independent predictors of pain sensitivity (adjusted R2 = 0.41, p < 0.001).

CONCLUSION

Injured runners reported higher pain sensitivity, pain catastrophizing and fear-avoidance than uninjured runners. Although catastrophizing rumination and fear-avoidance beliefs were associated with greater pain sensitivity, these cross-sectional findings do not establish causation, and longitudinal studies are needed to determine whether targeting these factors influences running participation limitations.

SIGNIFICANCE STATEMENT: Injured runners reported meaningfully higher pain sensitivity alongside elevated pain catastrophizing and fear-avoidance beliefs despite similar demographics and training exposure to uninjured runners, highlighting that injury-related pain experience is not explained by running load alone. Pain catastrophizing (rumination) and fear-avoidance independently predicted pain sensitivity, supporting a biopsychosocial model in which cognitive-affective factors uniquely shape the pain experience in runners. These findings identify potentially modifiable targets for clinical screening and rehabilitation (e.g., pain education and graded exposure) to better contextualize symptoms and guide training decisions in injured runners.