When you can’t “run it off”: Exploring correlations between musculoskeletal pain, training volume, and elevated mental health screening risks in ultra-endurance athletes

Background: Ultra-endurance athletes (UEA) frequently experience musculoskeletal (MSK) pain. Physical pain and mental illness can co-occur, yet their relationship in UEA remains poorly understood. This study explored the correlations between MSK pain, training volume, and mental health screening scores in a UEA sample. Methods: A cross-sectional online survey comprising the Patient Health Questionnaire PRIME-MD (PHQ PRIME-MD) and Eating Attitudes Test-26 (EAT-26) was administered to self-described UEA. MSK pain was derived from two somatic symptom items within the PHQ PRIME-MD. In total, n = 527 athletes were categorized by training volume (0–9, 10–20, ≥21 h/week) and MSK pain profile (one-item vs. both-item symptoms). Descriptive statistics, correlations, linear and logistic regression models, and odds ratios were calculated. Results: MSK pain was reported by 71.0% of respondents (n = 374) and associated with higher mental health screening scores. Modeling weekly training volume continuously, linear regression showed a significant positive association with composite PHQ PRIME-MD scores ( B = 0.24, 95% CI 0.06–0.41, p = .010), retained after age adjustment and normalizing transformation. Among athletes reporting both-item MSK pain, elevated composite scores increased across training-volume groups (4.7% 0–9 h/week to 45.5% ≥21 h/week). ED screening outcomes similarly rose to 54.5% in the ≥21 h/week group (0–9 vs. ≥21 h/week: OR = 0.02, 95% CI 0.003–0.11). Conclusion: MSK pain was prevalent among this UEA sample and linked to higher mental health screening scores, notably at the highest training volumes. High training capacity is a flawed proxy for individual wellbeing, and pain burdens in UEA warrant greater attention.