As Physical Therapists, we get this question ALL THE TIME: "When is pain okay during a workout, and when should I stop?"
This is actually more complicated than you'd think, so here's the 411 on pain during workouts.
The 411
Let’s look at an example of a commonly seen injury in PT: the hamstring strain. Current guidelines to rehabbing a hamstring strain often include pain avoidance (“just take some time off until it feels better”), but these guidelines were created based off of animal studies or clinical experience, rather than true evidence based research (Hickey et al. 2020).
The current landscape in rehab (avoiding pain) is similar to the two routes people often travel down when they experience pain during a workout:
Completely avoid all discomfort and all movements that cause pain
Ignore it and just push through intense pain all the time 🙃
Unfortunately, neither of these paths (avoiding or ignoring) lead to long term solutions. Rather, they usually land clients back where they started pain wise. We want to find the sweetspot somewhere in the middle of those two paths!
👀 The 411? Pain isn't always something we need to completely avoid! Working out with some minimal discomfort can be really helpful to desensitize, retrain our nervous system, and stimulate tissue adaptation which means you get better, faster, and have less long term pain.
A Quick Note on Pain Status:
As noted above, guidelines commonly followed in the rehab world often encourage “no pain,” “0/10”, and “completely pain free” as indicators of success, recovery, or clearance to return to sport following an injury or surgery. And while pain is one of our vital signs to listen to throughout the rehab process, there are times when we can work THROUGH it, rather than avoiding it at all costs.
A recent article summed it up perfectly:
“There is a logical case of a state of “no pain,” but to have no pain is a rare occurrence, only recently made possible by the advent of anaesthesia/analgesia. A state of the continuous absence of any pain at all is profoundly abnormal, appearing only as congenital nociceptor deficiency or dysfunction. It is far from adaptive, notably leading to major clinical problems associated with the absence of defensive responding and learning with a consequent severe shortening of life expectancy” (Eccleston 2023).
Basically, living life on a 0/10 pain scale is unrealistic: pain is an (albeit unfortunate) part of the human experience! This article suggests that learning to work around and with our pain can actually enhance our ability to adapt, get up again after injury, AND went so far as to say resiliency regarding pain may improve our overall life expectancy.
Now let’s be clear: NO ONE wants to be in pain. And at Made 2 Move, we are here to help you work around it, but we won’t lie to you and tell you that we have the magic pill, exercise, or solution to poof your pain away forever. We are going to equip you with the tools and knowledge to know what that pain is trying to tell you. The pain may very well be saying- “Hey back off!!!” but it could also be a case of, “Okay we can push into this sensation a little bit and see how your body responds.”
Pain Free vs. Pain Threshold
Because of these current pain avoidance guidelines in rehab, a group of researchers set out to look at the difference in “pain free” during rehab vs. rehab that worked within an athlete’s “pain threshold.”
43 men with acute hamstring strains were recruited for the study, and although this was a rather small sample size that may not be grossly generalizable, it gives us a good taste of their main point.
The 43 men were divided into two groups:
The pain free group
Instructed to participate in exercises only if it was completely pain free and were allowed to progress once they were able to perform the exercise with a 0/10 pain.
The pain threshold group
Allowed to participate and progress in exercises within the 4/10 or lower pain range during rehab.
Both groups (pain free vs. pain threshold) were instructed on the NRS (numeric rating scale) for pain in which a 0/10= absolutely no pain and a 10/10= worst pain imaginable. Rehab for both groups included hamstring specific strengthening exercises and running progressions (including some sprinting!) done 2x per week until they had met the study’s return to play criteria.
What did the researchers find?
Return to play (RTP) times were the same (15-17 days) regardless of whether athletes were in the pain free or pain threshold group.
Both groups improved in their hamstring strength, BUT the group that rehabbed within their “pain threshold” had isometric hamstring strength 15x greater when they were cleared to return to sport AND at their 2 month follow up when compared with the pain free group.
Risk of reinjury was the same for both groups with 2 men from both groups (4 total) experiencing reinjury to their hamstring.
Researchers concluded, “Allowing exercise to be performed and progressed up to a pain threshold appears to enhance recovery of isometric strength compared to avoiding pain during HSI [hamstring strain injury] rehabilitation” (Hickey et al. 2020). Let’s load up those hammies!
Sooooo - how do we do that? Next week’s blog will dive into the specific 3-pronged approach we use here at Made 2 Move to help clients navigate pain during rehab or workouts in order to help them make the best decisions so they can keep working out AND make progress with their pain. Ready to load up those hammies (or any muscle for that matter)? Reach out to frontdesk@made2movept.com today to set up an eval with one of our PTs!