How much pain is too much when I exercise?
Last post we discussed the evidence on Kinesiotape and saw that it is not currently an evidence-based treatment versus regular athletic tape. It led to a couple of questions that we will discuss in this post:
Should I still be competing if I need tape to hold me together?
Should I continue to train or compete when I have pain?
This can be a hard thought for an athlete to consider! You enjoy your sport and may be highly competitive. It is a great way to reduce weight and maintain it at a healthy level, or to keep the stress of every day life manageable. Not being able to do your chosen sport for a period of time is a very difficult thing to consider. BUT! as we will see there is a time and a place for it. Defining this time and place is very important. Continuing to participate through a certain level of pain could increase your risk of significant injury. A short period of rest, if not allowed, could become a break from your sport for a significant amount of time, be it weeks or even months!
In the 2008 Summer Olympics, 22% of all reported injuries were due to overuse and most of these involved no time loss to sport1. This indicated that athletes were returning to play before being fully recovered or were playing through injuries. This suggests that continuing to work through a significant level of pain or injury leads to overuse injury. Overuse injuries are chronic in nature and are generally much more difficult to recover from than acute injuries.
So what is a significant level of pain? How do I know when I should stop?
This question is challenging, and to get closer to an answer we need to consider some pain science, including biology/physiology, and psychology.
My achilles hurts?
It used to be thought that pain was simply a direct correlation to the level of tissue damage, i.e. the more damage there is, the more it hurts. However this has been shown to be inaccurate. Pain has been shown to be the body’s reaction to perceived danger and is therefore a protective mechanism. Pain nerves, or nociceptors, around the tissues of the body alert the brain if there is a risk of the tissue getting damaged. In the presence of injury, to the tissue, inflammation makes these nociceptors more sensitive so it sends a heightened message of danger.
My achilles doesn’t hurt, nerves are telling me about risk of injury to it!!!
Now that we know there is a risk of injury, the brain has to make a decision on how it deals with the message it is confronted with! If it choses to attend to the painful messages you will perceive pain and may choose to stop the activity. Or if the brain choses not to attend to pain, i.e. shuts the messages down, you will continue with the activity. This shutting down of the message can either be a self-chosen reaction, or an automatic reaction. A great example of the latter is a soldier who has a significant injury but is still at risk in the battlefield: The nociceptors are shouting “major damage” but the brain replies “risk of death means we continue” and the pain is shut out! A great example of the former is someone running and having the sensation of achilles pain and choosing to not listen to those pain messages. In shutting them out we are disregarding the nociceptors message that there is potential for tissue damage. In shutting the message out injury may occur.
But I’m not going to war; I just want to run, will I not always respond to the messages?
People with a high athletic identity are more prone to continuing through pain than others. Having a high athletic identity means that a person defines themselves primarily in terms of their athletic status, and they place great importance on their success or failure in the athletic realm2. In male athletes, this identity has been shown to be linked to showing a masculine identity. In soccer players, the identity was seen with athletes not wanting to lose the opportunity to play, particularly in important games. One study3 even found that athletes felt so strongly about the negative consequences of playing through injury that they were willing to sign a waiver taking full responsibility for their actions and potential consequences just so they could continue to play. It used to be thought that this was seen in athletes at collegiate level or above, but studies are now finding it at younger ages. Athletes with a high athletic identity are less likely to attend to pain signals and are more likely to get injured.
Perhaps I do have a high level of athletic identity, how do I know what is a significant level of pain?
I have only found one research paper that truly helps us consider this4. This paper looked at people who had chronic achilles tendonopathy. One group was allowed to continue exercises that load the achilles such as running, whereas the control group was expected to rest, each for six-weeks. Both groups followed the same rehab program during the six-weeks. The group who could exercise were allowed to do so up to a pain level of 5/10 as long as it had subsided by the next morning, and was not increasing week over week. They found that the exercise group suffered no adverse reaction to this loading exercise within these pain parameters.
So someone with an injury as significant as achilles tendonopathy could safely run and load the tendon with up to a 5/10 pain as long as it is better by the next morning. This suggests that we can use similar metrics in evaluating pain as we exercise.
But! I would suggest that we make some adaptations to this scale in light of our previous information on the affect of athletic identity. The people studied in this paper had been doing moderate exercise 1-2hr a week, and although not specifically listing athletic identity I would suggest that it was not that high. Someone who has a higher athletic identity will not give such attention to pain and it might be wise and safe to recommend a lower metric.
Therefore I recommend this scale to my athletes, with zero meaning no pain, and ten being ER-level pain:
I have always strongly encouraged athletes to listen to the signals their body gives, but with the possibility of overuse injuries with people of high athletic identity I think it is safer to use a scale such as this. When you listen to the body, the lines can get blurred, whereas this is very defined.
I also recommend considering the duration of any pain – if you have pain during or shortly after your workout, but it has subsided the next day, it is probably safe to continue (with caution!). However, if your pain persists or is gradually increasing as you continue workouts, I would recommend taking a short rest period and seeking medical advice.
If you are experiencing pain from your workouts contact us for a free discovery visit to help determine if Physical Therapy can help or if referral to an MD is appropriate. We also offer injury prevention screening and video running assessment which can help correct form and avoid getting to the mid-to-higher points on the pain scale. Good luck competing!
Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897-906.