How much pain is enough?

Patients who visit West London Physiotherapy are in or regularly experience pain resulting from an injury, operation and sometimes no obvious cause preventing them from doing what they want or need to. Frequently this will be their preferred form of exercise, whether this be running, playing tennis, lifting weights or simply walking to work. Advice on how to deal with pain can be conflicting and our own feelings on how to manage it are affected by context – you expect your excruciating stubbed toe or muscle aches after a tough gym session to settle quickly, but a consistent low-grade pain preventing comfortable sleep can be extremely concerning.

Pain is a definitively unpleasant experience. Physiotherapists guide patients along a complex rehabilitation path of what is normal, should be avoided and can be tolerated to allow prompt recovery. Although traumatic injuries like fractures and tendon ruptures need appropriate rest and protection, the time for thorough exercise alongside discomfort comes eventually, and particularly so in the case of long-standing pain resulting from tendinopathies, osteoarthritis or when returning to sport or exercise. These more long-standing pains and injuries tend to take longer to improve and may not benefit from rest unless especially irritated, as indicated by quite severe and easily provoked pain, swelling or deteriorating function. Pain may or may not improve immediately with exercise, but the benefit will be in improving your capacity to use an affected area or exercise more generally, and in fact these injuries do not usually deteriorate acutely in a structural sense through gradual exercise.

This isn’t to say a “no pain, no gain” approach is the answer. Needing to do difficult or uncomfortable things is a familiar concept when looking to improve, whether this be fitness, language or finances. If you don’t put any stress on something it’s unlikely to improve, but caution is warranted in cases of pain or known injury.

My most common suggestion, and target for tolerance of exercise during rehabilitation, comes from others’ ideas surrounding groin, tendon and muscle injuries, and how hard it is considered safe to challenge painful areas. The central concept is the reaction of pain to exercise is more important than it being painful, to an extent. As such, mild pain which decreases with or does not increase beyond a certain level during exercise; settles quickly after exercise; and isn’t bothersome on waking or more than usual the next day is generally acceptable. It suggests exercise isn’t causing an undue reaction or affecting an injury negatively. Pain which increases significantly during exercise; is aggravated for some time after exercise and worse than usual for longer in the morning or to a higher intensity the next day suggests the exercise is too much.

I find this approach provides opportunity to progress the stresses placed on an injury whilst keeping an eye on signs of being too aggressive. Rehabilitation is about improving the volume, intensity or variety of what you can do and so getting this balance right may be your key to facilitating progress. Long standing pain and injuries (and the person experiencing them!) tend to benefit from continued but modified exercise and so if you’re having difficulty with persistent pain, related to a tendon or lower limb injury in particular, please feel free to contact me for an appointment to see if we can get your symptoms under control and exercise back on track.


Liam McCloskey

Sports and Musculoskeletal Physiotherapist

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