When to Push Into Pain
Updated: Jun 18, 2020
Note: This post is intended for educational purposes only. It should not be taken as direct medical advice. There is never a one-size-fits all approach to recovery. If you are injured and need individual guidance, feel to get in touch with me at firstname.lastname@example.org. How much pain is okay? This is probably the most frequent question I get from my patients. Sometimes, I see people who have been injured for weeks or months who haven’t been moving much at all. Sometimes they believe that its still too soon to move, and unnecessary movement may aggravate their situation. Some have been told that they will develop painful arthritis down the road if they go back to their usual activities after an injury. Others just don’t like experiencing pain. Then there are always those who are moving too much, pushing well beyond their limits on a regular basis, and falling short of ever making a complete recovery. Pain is a complex physical, mental, and emotional experience. It can serve as a very useful defense mechanism against injury and external threats. It can indicate that we are overdoing it. However, sometimes pain can work against us.
Pain does not always mean tissue damage, or that further injury is about to happen. Consider pain to be like an alarm system inside your nervous system that is trying to protect you from harm. Most of us are going to get some warning signals before tissue damage actually starts to happen. Imagine if you if you were to bend your finger backward repeatedly—it would start to get a little sore, but well before any damage occurred.
Pain will always try to protect you. It doesn’t want you to injure yourself again. It wants you to survive. After an injury, the pain response is a normal way for your body to tell you to take it easy and allow some time for healing.
For a lot of people, things will resolve on their own and the pain will go away within a few days or weeks and they will get back to their normal routine. However, this is not always the case for everyone.
Maybe the injury is pretty severe, like a full-thickness muscle tear, and has really impacted your function. Maybe its been a minor injury that just keeps getting re-aggravated over months and years. Since we just can’t seem to escape hurting ourselves, we may start to avoid doing the movements that don’t feel comfortable all together, in an effort to protect ourselves from making it worse.
The longer that we hold off on getting back to doing our usual activities, or the longer that the cycle of re-aggravation goes on, the more this defense mechanism may continue to cause you to hold off on doing the things you want to do. Usually, the more often you injure an area, or the longer that pain goes on, the more sensitive the pain response gets—even coming on well before we get close to doing any harm to our bodies. Avoiding getting back to normal, or doing less than we used to because we keep aggravating an area, or because we have been told we have arthritis and degenerative change going on, can set us down the wrong path.
Now let’s talk about tissue stress. Our bodies’ tissues, whether they be bone, muscle, ligament, or cartilage, are stimulated and grow in response to stress and loading. Along with promoting healing after injury, tissue stress, in the right doses, can also make our tissues more resistant to re-injury. This is a fact, with strong scientific evidence to support it.
Just like in our day to day life, a little stress will make us stronger and more resilient, while too much stress is unhealthy for us. Mild stressors to our injury will encourage healing and recovery. Over stressing tissues will prevent healing, or even lead to further breakdown.
Did you know that regular recreational running has been shown by research to actually cause knee cartilage to thicken a little over time? It's only when we run with poor mechanics, without enough recovery time, or for distances beyond our current capacities, that our knee joints break down. Its sort of like how a callous will form in response to long-term, gentle repeated exposure, while a blister forms from intense, short-term, repeated exposure.
Movement is required for healing and recovery. This is undeniable. The reality is that there is usually going to be some pain as we get back to normal, but our bodies’ pain system doesn’t want us to stop moving all together-- it just wants us to be careful.
Waiting for the pain to just go away before we get back to moving doesn’t often help, and when it does, recovery is usually short-lived. We need to stress the injured tissues to make them stronger, to fully heal, and to prevent re-injury. Most injuries and pain conditions will require that we push into pain a little. Even with a severe injury, once the acute inflammatory stage is over (usually within just a few days) you’ve got to get moving. If you have arthritis or degenerative change, movement in the right doses actually makes the affected joints and tissues get stronger and healthier. So, knowing all of this, what’s usually the most appropriate level of pain to work through?
When pain is okay during movement or exercise: For most injuries, I usually tell my patients that pain is okay during a movement when it stays within manageable limits, or generally up to a 3-4/10. It is okay to feel some pain, providing it doesn’t interfere the quality of their movement or get so painful that others around can see that they’re hurt. Pain should settle shortly after they have stopped what they’ve been doing-- it should be back to its baseline levels in about a day. Their overall condition should either remain stable or improve after days or weeks of continuing with the said movement. If not, they are doing too much.
The movement in question could be anything—walking or running, lifting your arm over your head, getting back to lifting weights in the gym, doing yoga, recovering from a rotator cuff repair surgery, or bending over to tie your shoes, and so on. The same principles usually apply.
People with chronic pain conditions, such as those that have been diagnosed with fibromyalgia, may not feel much pain during movement. Sometimes, the pain associated with movement comes on some time afterwards. In this case, the same rules work—just take note of what you did earlier, and modify accordingly as needed.
What are the signs that we pushing it too much? Even though movement is very important after an injury, we should still take a measured approach. A telltale sign that we are overdoing it is a significant increase in acute inflammation. Not every pain or flare-up is a sign of inflammation; what to look for is swelling, throbbing, or increased warmth to the touch around the injured or painful area. Inflammation usually gets worse around bedtime and through the night as we sleep.
Chronic inflammation is a little different. If you usually have some swelling already present, it is usually okay to keep moving, providing it doesn’t increase dramatically during or after the activity. Pain that is unusual to what you are used to, or pain that is sharp, stabbing, or feels like tearing sensation, is usually something to be avoided as well.
Pay attention to your overall level of function. This can be a more accurate measure of recovery than pain itself. If there is a decline in function, i.e. it’s the next day and you are having more trouble doing your usual activities, its harder to walk, or lift your arm over your head, etc., or the pain comes on a lot more sooner than the last time you did the movement in question, you have likely overdone it.
Never call it quits.
What’s most important after you experience these warning signs is that you don’t just stop what you’re doing altogether and go back to rest for too long. Give yourself just enough of a break to let your condition stabilize, then modify your approach—decrease the intensity, the level of load, distance, or the frequency of the movement, whatever it is, and get back to it. Keep trying.
Remember that recovery is not a linear process. You will have ups and downs, good days and bad. Pay attention to the overall trends over weeks and months.
Sometimes I see patients in a lot of pain who have more chronic injuries, or they have been told that they have bad arthritis and degeneration in their joints. Sometimes no one can find anything wrong, and they have just been in pain for a very long time. With the right guidance, a lot of these people end up being able to do much more activity at a sustainable level, but the pain itself doesn’t improve much in the first few weeks or months. I tell them that this is still often a very positive result. Why?
The pain hasn’t gotten worse, but they are safely doing more. Their muscles and joints are getting the movement they need to stay healthy and resilient, even if the pain alarm system is still malfunctioning and going off a little. They might also be getting more whole-body exercise in general, which is important to our health on many levels. This is a win! Once people get back to your normal activities with confidence, pain can fade into the background, and often even go away altogether. Sometimes the pain doesn't go away, but being able to do more is always better than sitting out on doing the things you enjoy completely.
There are two types of people in physiotherapy. Those who need help and encouragement to get moving again, and those who need to slow down and take it easy. Most of us already know which category we fall into. If you’re hurt, be mindful of your attitude, and ask yourself if you are acting in your best interests, whether it's staying on the couch or overdoing it. I tell my patients to challenge themselves but to mainly just use their common sense.
Just like we need to lean into painful situations in real life to overcome our challenges, we need to lean into pain a little to get our muscles and joints to heal and recover. This is rehab in a nutshell! Remember that movement is safe, that movement is needed for healthy muscles and joints, and that movement is medicine for your whole body.