No pain, no gain?

May 2

7 min read

We all remember taking medicine as a child. I’m not referring to the sweet tasting sticky purple stuff, but the strong, disgusting stuff that normally required two spoonful’s. The stuff that tasted so horrible you’d have preferred to go back to school than have to take it again. And when you protested to your mother about taking it, what loving words did she bestow upon you? ‘It tastes horrible because it’s doing you good!’ Given our exposure to these beliefs at a young age, it’s no wonder that we accept the mantra of ‘no pain no gain’ so readily. And it’s certainly true that success always requires at least some level of sacrifice: in order to get that beach body, you need to forego the sugary treats. You can’t be a high level athlete and stay up until 3AM every night playing video games. And if you want to make serious gains in the gym there is going to be an element of pain that you have to endure in the process. But is this a good mantra to live by for rehabilitation after injury?

The issue is, pain is a subjective experience. We’ve all heard stories of soldiers getting shot or seriously wounded and not experiencing pain until they were safely back at camp, or of people winning gold medals despite having a significant injury [1, 2, 3]. We can attribute some of this to the effects of ‘adrenaline’ and other mechanisms, but ultimately the reality is that pain does not correlate with tissue damage. And the longer pain goes on, the less correlation there is between the level of pain and the state of the bodies tissues [4, 5]. This basically means that two people could have the same injury but report different levels of pain. So If pain doesn’t tell us much about the health of our tissues, should we just disregard it and push through it?

Well whilst we cannot often use pain diagnostically, it is still the body’s way of communicating with us. Let’s say you’ve just rolled your ankle and are in pain. The level of pain you are in may give us clues about how severe the injury is (e.g. if the pain is so severe that you can’t stand on it, there’s an increased likelihood of a fracture), but ultimately it is not diagnostic (e.g. a severe ligament injury may also be too painful to walk on). Pain is helpful however when it comes to stopping you from making things worse. If your ankle hurts, you are less inclined to move, use or walk on it, and therefore be more likely to rest it and allow it to heal. If you still having pain 1 year after the injury however, in almost all cases the injured area will have healed (there are rare exceptions). That doesn’t mean you aren’t really in pain, it just means that your pain isn’t due to any significant structural damage. This is often less helpful, as some of the pain is potentially stopping you from doing things may actually be quite helpful for your ankle. So why do we have pain without injury?

We need to be careful with the word ‘injury’. Just because the ligaments, bones, muscles and joints are intact, doesn’t mean there aren’t changes that could cause pain. Without getting too technical, neural sensitisation (ultimately your threshold for pain) can be changed physiologically by injury. This happens all the time – if you’ve ever rolled your ankle you’ll know that immediately after injury your ankle will be very painful, but after an hour or two your whole foot and lower leg can be very sensitive to even the slightest knock, even though there’s been no injury to them. This is your body's way of making sure you really do protect that injured area by making all the areas around it more sensitive too. Another way that sensitisation works is through memory. If you have previously injured your ankle, you may have a lower threshold for pain because your body remembers how severe it was. Lorimer Mosely describes this with his snake bite story. Whilst walking he felt a ‘twig’ hit his leg, which was not ‘painful’, and he continued on his walk and thought nothing of it. As far as he was concerned this was just a twig. A short while later he passed out and woke up in hospital, and it turned out it wasn’t a twig but a snake bite! Several months later, whilst out walking, he felt a similar sensation and immediately fell to ground in agony. This time it was just a twig and not a snake, but his body remembered the event and therefore he experienced significant pain even though there was no tissue damage whatsoever [6, 7]. So sensitisation is a normal process, and is something generally outside of our control. So if pain isn’t about damage, why do we have pain?

There are many more complex processes at play here, but ultimately pain is about protection. Pain stops you from causing further damage to injured structures. Pain stops you from ignoring potentially threatening situations. It is influenced by past experiences (Lorimer Moseley’s snake bite), by our environment (the soldiers in the above example), our beliefs or understanding (muscle soreness after leg day is usually something to be celebrated), and even how much sleep we’ve had (treading on your sons lego always hurts more at 3AM than a Sunday afternoon). Pain is your bodies way of trying to get you to notice something or behave in a certain way, and what’s more, pain is sometimes what we experience when something is different. We may have fractured our ankle 6 weeks ago and now been told that everything has ‘healed’, however after being immobilised for so long, standing, walking and jogging put different forces and sensations through our joints, muscles and nerves and cause us ‘pain’. Our body is telling us that this is new, different and potentially frightening (especially after our last injury), and therefore drawing our attention to it. And this is something that should always be respected. It is easy to look at someone and think that they shouldn’t be experiencing the level of pain that they are claiming (most people with children will understand this more than most), but as pain is influenced by so many factors we need to acknowledge that everyone’s pain experience is real and unique, and we can not and should not make judgements on this. So should we train if we are in pain?

At this point I need to make the point that this article is not medical advice, and if you are ever in pain you should always seek medical advice directly from a professional and not from this article. Generally speaking though, after injury there is always going to be some level of pain during rehabilitation. The approach of waiting for pain to completely resolve before returning to training is often ineffective – as we discussed above pain is the body’s way of saying that something is different or potentially threatening, so if you’ve been in a cast for six weeks any sort of loading is likely to be uncomfortable. What I always advise patients though, is that the discomfort during rehabilitation should be manageable and you should not feel any significant increase in pain that night or the following day. If you’re struggling the next day, you’ve probably overdone it. So some level of discomfort is acceptable during rehabilitation. But?

But this can be a delicate balance. And it is also dependent on the injury, the stage of rehabilitation and the other demands on your body tissues. The belief that pushing through pain, and more pain means more improvement is not correct. Often this will just set you back further, risk more damage, and make your rehabilitation more frustrating. In very acute injuries, we would also want to minimise damage and reduce pain, and so in very early stages (usually no more than 3-4 weeks depending on severity) avoiding pain as much as possible would often be advised. So is it just common sense and trial and error?

To a point, yes. But this is where working with or alongside a professional can be really helpful. When working with clients, clinical experience and knowledge of the up-to-date evidence can help us to know when to push and when to pull back – after all, physiotherapy is just calming stuff down or building stuff up! Having someone who is objective and knows when to push you harder or tell you to stop helps to keep you on track, support with discipline and provide a more individualised programme. Two people may have an identical injury but experience very different levels of pain and need very different management. The ‘cup’ analogy goes some way to explaining this [8]. If we imagine that we all have a ’cup’ which we can fill with stressors, at some point that cup can overflow, which is usually when we experience pain. And these don’t have to just be physical stressors. Lack of sleep, poor diet, work stress, financial worries and other situations all take their toll on us. If you have too many stressors, you don’t have enough capacity to deal with an injury. Therefore a good rehabilitation programme will take this into account. A single parent who works two jobs and sprains their ankle will need a very different rehabilitation programme than a professional athlete with no other commitments. And thus the amount of pain that is acceptable for that person during treatment will be different.

When it comes to rehabilitation and pain, there is no ‘one size fits all approach’. Everyone is unique and needs treatment that is specific to them. As a general rule, anything that causes your symptoms to be worse that night or the next day is usually too much, however some mild discomfort during exercise is usually fine, and often necessary (to a point!). A good clinician will consider your personal circumstances and needs, and help you to balance pain and discomfort with your rehabilitation programme to help you achieve your goals and make sure that you maximise improvements at the right pace for you.

This article is not medical advice. If you are in pain or have an injury seek medical advice. If you have questions about what services you need or have any other symptoms please check the NHS guidance at the following links and follow the advice relevant to your symptoms: Health A to Z - NHS (www.nhs.uk) ; Find services near you - NHS (www.nhs.uk)