Does It Hurt?

This is another of my previously published pieces reprinted for your reading pleasure:

I get asked rehab questions all the time. I have rehabilitated athletes in almost every major sport who were told they were “all done” by a doctor or a team trainer. Because people know my background, they often ask for advice.

Most of the time they ignore the advice because the advice does not contain the answer they want. They say “it only hurts when I run”, I say things like “don’t run”.

A famous coach I know once told me “people don’t call for advice, they call for agreement or consensus. If you don’t tell them what they want to hear, they simply call someone else”. His advice to me, don’t bother wasting your time with advice.

Here I go again wasting time.

If you have an injury and are wondering whether or not a certain exercise is appropriate, ask yourself a simple question. “Does it hurt”? The key here is that the question ‘does it hurt?” can only be answered yes or no. If you answer yes, then you are not ready for that exercise, no matter how much you like it. Simple, right? Not really. I tell everyone I speak with about rehab that any equivocation is a yes. Things like “after I warm-up it goes away” etc. are all yes answers. It is amazing to me how many times I have asked people this simple question only to have them dance around it. The reason they dance around the question is that they don’t like my answer. They want to know things like “what about the magic cure that no one has told me about?”. What about a secret exercise? I have another saying I like, “the secret is there is no secret”. Another wise man, Ben Franklin I think, said “Common sense is not so common”.

If you are injured and want to get better, use your common sense. Exercise should not cause pain. This seems simple but exercisers ignore pain all the time and rationalize it. Discomfort is common at the end of a set in a strength exercise or at the end of an intense cardiovascular workout. Additional discomfort, delayed onset muscle soreness, often occurs the two days following an intense session.  This is normal. This discomfort should only last two days and should be limited to the muscles not the joints or tendons. Pain at the onset of an exercise is neither normal nor healthy and is indicative of a problem. Progression in any strength exercise should be based on a full, pain-free range of motion that produces muscle soreness without joint soreness. If you need to change or reduce range of motion, this is a problem. Progression in cardiovascular exercise should also be pain free and should follow the ten percent rule. Do not increase time or distance more than ten percent from one session to the next. I have used these simple rules in all of my strength and conditioning programs and, have been able to keep literally thousands of athletes healthy. I’m sure the same concepts will help you.

27 Responses to “Does It Hurt?”

  1. Like many of your readers, I’m jumping in from BOTH a clinician’s point of view as well as a that of a strength coach. In addition, I have yet to read the previous comments, although I do know that there is a “debate” going on.

    What I would like to point out is that I don’t think we can effectively generalize whether or not “pain” is permissible when either working in the rehabilitation setting or in a performance setting. Although these two may overlap and are indeed a continuum, they are still apples and oranges.

    I also think everyone participating in this discussion is intelligent enough to realize that each scenario we’re presented with is different and therefore, each session should be individualized. We just can’t make general comments like “never accept pain” or “pain is ok”.

    Ultimately, we simply have to ask ourselves:

    In the gym: Are we putting this athlete at risk of (further) injury?

    In the rehab setting: Are we putting this athlete at risk of (further) injury?

    And therefore…

    1. If we are not sure, we better damn well look it up.

    2. If we didn’t ask ourself that question (“are we putting ___ at risk…”), we better damn well leave the industry!

  2. Interesting discussion.

    We have learned a ton about pain in the past 20 years. I go agree that the “Neuromatrix of Pain” is the best theory out there and explains pain as a multi faceted beast. Everyone’s pain is individual.

    I agree that we should not have anyone move in pain. The brain is highly predictive and associative. Moving in pain is literally teaching your brain “movement is painful” We do NOT want this at all. We want the opposite, esp. for high level athletes. As Charlie pointed out, the translation is that no athlete can exert their maximal performance when they are in pain.

    I agree that there are times when almost all movements are painful. While this is rare and is the case in more chronic pain cases, then it may be useful to use a continuum of pain (is this movement less painful than your normal pain).

    I remember Dr. Cobb saying “If movement can get you into pain, movement can get you out” The trick and art is finding the right movement (mobility, eye movements, vestibular inputs, etc).

    Pain is just another way of saying poor athletic performance. As pointed out, it is a continuum.

    Good discussion!
    Rock on
    Mike T Nelson PhD (c )

    I recommend following the traffic light system above. ROM exercises for capsular limitations will be painful, but dynamic higher intensity conditioning or sport should never be painful (certain types of pain that is). Very complicated.

  4. John D'Amico Says:

    Apples and Oranges: Athletes and Patients

    Andy said it best. Common sense dictates that a healthy athlete should not have pain. If an otherwise healthy athlete has pain for no apparent reason it is an indication that there is an underlying issue that needs to be addressed, regardless of the veracity of the centrally mediated component or emotional overlay. However, by the time athletes and non athletes usually get to the PT clinic the therapist is seeing an apple that turned into an orange. Think of this issue as a continuum.

    For Mike:
    In regards to exercise enthusiasts who refuse to modify their activity in the face of pain “we are the lifeboat and for some reason they feel compelled to drown.”

  5. Mike,
    I remember that post/blog/article from previously which means either my memory ain’t so bad after all or I have a penchant for minute details. In any event, in regards to energy system work (my resolution for 2010 is not to use the word “cardio”!) we adhere to the 10% per week rule: no increase of volume/intensity of greater than 10% per week. Some may view that as overly cautious but it has worked for us and our clients for years.

  6. […] Michael Boyle’s Blog Day to day thoughts about strength and conditioning « Does It Hurt? […]

  7. mboyle1959 Says:

    You are obviously intelligent and advanced and, you are right I do have a following. I guess that is why my advice is always simple. Remember the Hippocratic Oath? Not sure if PT’s have to take it. “First Do No Harm”.

    Although you may be right in your practice I think the general recommendation is dangerous and empowers the less skilled of the world. I think more PT’s need to avoid pain than to ignore it.

  8. Mike, you do have to remember, you have a big following. Is it your philosophy or the client’s expectations? Remember what I said about the brain? There can be an immediate type of an effect just with expectations and perceptions. Another aspect to consider – the client came and chose you. I think that is another big difference. The client was sold on you the moment the client walked in the door. I own my own clinic now and I wish there was a way to capture that kind of qualitative data… but there does seem to me to be a huge difference in the patients that come in actually choosing me over my competitor. It feels like there is a positive edge right in the beginning of the relationship. It feels so different when the patient walks in, wants to meet me, and seems to know more about me than I do! No data… just gut thoughts from being employed in different settings/locations.

    You also have to consider the experience the prior patient had in physical therapy… who treated? Did a PT, did a PTA, did a tech? How was the patient delegated if other staff were involved? How often was a PT involved? Was the patient consistently seen by the same person. Oh, my, I’m going to open a can of worms next… did passive interventions make up the bulk of the treatment sessions? Research strongly indicates passive interventions can decrease the likelihood of a positive outcome. Positive outcome basically defined as improving function. Did the physical therapist use evidence to guide clinical decisions. The recent literature out there focusing on outcomes adds a different dimension than just a single component of the physical therapist not recognizing or flat out ignoring the patient’s pain.

    You bring up a definite, interesting point. How do physical therapists respond to a patient in pain? What philosophies about pain exist in the physical therapy world? You could be right because I too have had patients report how a previous physical therapist killed them or tortured them (too much pain). They tell me my approach is different – I do allow pain, but I ask a lot of questions and I implement what I do know about pain, the pain matrix and how the body responds to help improve neuroplasticity in the brain.

    I’ll try some searching on pain beliefs in the physical therapy world… could prove to be interesting. If I can’t find anything, I’ll follow what Mike Scott has done and fire off an email with 10-15 physical therapists and get their thoughts/responses. I’ll just blog ’em up. 🙂


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