A common question patients and athletes alike have is: “How do I know what kind of pain I can push through?”. “How do I know when to push more vs when to back off?”, “How do I know if I’m doing the right amount”, “If I’m exercising with pain, am I causing damage?”.
This is probably one of the most important questions you may have for your Physiotherapist. And it's important for you to leave with a clear answer. So today, we’re going to dive into this so that you can leave with increased confidence with your body and training/rehabbing through pain.
What Is Pain?
Good question. We’ve only recently started asking it. For as long as we know, humans and animals have felt pain, and pain has been one of the leading causes seeking medical care for treatment, but only recently in our history have we actually started questioning what it is.
Pain is best understood through the lens of the Biopsychosocial model, which in short means pain is an experience influenced by biological processes (such as nociception) as well as psychological and social environmental factors. What this means is Pain is your brain combining the biological input your body is telling it—such as “this burned you” or “that bone just broke”—and combines it with psychological factors such as your prior experience with pain and injury, whether or not you are suffering from mental illness or distress, how threatening this injury is to you (is it career ending? Or do you get to take a week off work and hang out at home), as well as social factors like your socioeconomic status, how much familial and friend support you have, etc., and combines all of these factors into an experience. And this experience is you feeling something that is a potential threat to your body. Breaking bones hurts, because evolutionarily speaking, that made you slow, weak, and dinner for a predator—not exactly a great thing, so we evolved to avoid wanting to break out bones. Getting a cut hurts, because your body likes to avoid having open wounds where bacteria can get in and cause infections. Getting a burn hurts because it damages your tissues permanently—cooking is fun! Getting cooked, not so much. Those examples are obvious, but what about those psychological factors I mentioned? Well, if you roll your ankle and you’re an office worker, its going to hurt and suck for a few weeks, but its not the end of the world. However, if you rolled your ankle the exact same way, and you were a gymnast 2 weeks away from qualifying for the Olympics, and this injury means you’re going to have to wait a whole 4 more years before you get to go, you’re going to likely have a lot more pain because this injury is career threatening. That kind of makes sense, but what about the social factors? Well, if you’ve ever seen a toddler run and fall, you may have noticed that the first thing they do before crying is look around. They’re looking to see your reaction before they react, because they want to know if you think they’re hurt or not. Freak out and they’ll freak out. Stay calm and do nothing, and they’re likely to get up and keep playing. Another example you may notice after reading this is when you stub your toe. If people are around, you’re much more likely to be loud about it than if you know no one can hear you. Why? Well there are evolutionary advantages to signalling to others that we are hurt so that they may help and support us.
Pain is much more complex than can be summarized in one article, but I hope you’re starting to get the idea that pain is not simply a sign of damage to your body, but rather a sign that something is threatening your body and it wants you to pay attention. Understanding this may help you understand that sometimes there can be “false alarms”.
What is Bad Pain?
Bad pain is pain that is intolerable and/or long lasting.
Intolerability is subjective, and its okay for you to be the judge of what that means, but generally intolerable pain is pain that causes you to move differently (think limping, or taking weight off of one limb, or avoiding the use of that limb). If numbers is more your thing, intolerable pain is in the 4 to 10 on 10 range.
Even if your pain is tolerable, you don’t want it to last a long time. So if you do an activity that hurts, and that heightened pain is then lingering for 20-30min up to even days -> that’s too much.
Why Avoid Bad Pain?
The reason you want to avoid bad pain in training and rehab is simply because its not worth it. The benefits your gain are outmatched by the downsides. The downsides being:
1. An increased chance of the pain being caused by damaged tissue
2. An increased chance of further damaging the affected tissue
3. Even if there isn’t any physical damage, you can further sensitize the injured structure or the nervous system causing a more “sensitive alarm system” that goes off easier
4. The increased and/or prolonged discomfort will likely lead to less compliance with your exercise and/or rehab program, which entirely defeats the purpose.
What is good pain?
Good pain is tolerable and short lasting.
Just like intolerability is subjective, so is tolerability. Tolerable pain is pain that you perceive as being tolerable and pain that does not cause you to want to move differently to avoid it. Tolerable pain is more in the 1 to 3 on 10 range if numbers are more your thing. Its up to you to decide what qualifies as tolerable pain.
Even if your pain is tolerable however, it can’t be long lasting to be considered good pain. If you get a tolerable amount of pain and it goes away instantly, or at least after a few minutes it is completely dissipated, this is pain that is WORTH pushing through.
Why Push Through Good Pain?
“No pain no gain” Attributed to Hesiod (c. 750-650 BC) who originally said “But before the road of Excellence the immortal gods have placed sweat.” Sophocles further expressed the idea in the 5th century BC by saying “nothing truly succeeds without pain”. We could keep nerding out about this “gym-bro” phrase, but there is a lot of value behind this sentiment.
If you only ever do exercises that don’t cause discomfort, the likelihood that your get better is much lower. It will take much longer to recover from an injury if you avoid all pain and discomfort. It is important to push through the tolerable discomfort, because while your body is an incredible healing machine, it needs guidance. By doing the things that are uncomfortable, you are teaching your body what you need it to be able to do, and allow it to prioritize sending resources to heal that area, as well as allowing your brain to understand that these things aren’t as threatening as you thought, allowing the pain experience to dissipate over time.
If you can rehabilitate yourself and train without pain, then that is obviously great! However, most people who are recovering from an injury or chronic pain don’t have such a luxury, and avoiding ALL pain is only holding you back. That is why I want you to know that if you exercise through good pain, you are doing yourself a favor, not a disservice.
How do I turn bad pain into good pain?
Two words: Load Management.
Simply reduce the load of the exercise. Sometimes this means reducing the resistance you’re using, but when that’s not possible, you want to find a different way of making the exercise easier, such as doing less repetitions, changing your positioning, reducing range of motion, regressing the exercise to an easier one, etc. If you can achieve this on your own, then keep at it. Often times however, this part can prove quite difficult to figure out, and this is where I come in. Consulting with an expert who knows how and when to deload and re-load exercises can prove invaluable to your rehabilitation and training goals. So if you cannot figure this out yourself, it is worth consulting an expert like myself.