What are the rules for playing with pain?
‘No Pain, No Gain’ Is a Myth and So Is ‘If You Feel Pain, Stop.’ So What Rules Should You Follow?
Written by Rajpal Brar
You’re moseying along on your morning run and suddenly you feel a pang of discomfort in your calf. Immediately your mind wanders to the old raggedy T-shirt stuffed in the back of your closet with the “No Pain, No Gain!” slogan plastered across it. However, that thought is interceded by what you’ve been told on your Facebook running group: “If you feel pain, STOP!”
So which side of the argument is the right one? Well, as a physical therapist, I can tell you it’s neither.
Although pain may feel like a linear, passive A to B sequence—I slapped your hand and you felt pain—it’s actually a much more dynamic, active process. My slapping your hand generates an input that enters into the nervous system and then is filtered by the brain based on a number of factors, including past experiences, current mood, attention, and more.
An interdisciplinary review paper from 2013 in the Cognitive Science journal described pain as “a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables.”
That kind of complexity makes pain an unreliable indicator of what’s going on in the body. Chronic pain often exists in the face of no observable structural or mechanical changes. That’s why applying a simplistic model of “no pain, no gain” or “if you feel pain, stop” isn’t valid. There’s significant gray, and to deal with gray, we need a more nuanced approach.
“We try to educate [athletes] on what pain is versus what soreness is—the idea of whether an exercise provides discomfort only while doing it versus if the area is still producing pain after you do it,” says Gerry DeFilippo, strength and sports performance coach who owns Challenger Strength in Wayne, NJ. “If a baseball athlete presents general forearm soreness that is bothersome throughout the day and not directly during throwing, that points to some other factor rather than the throwing itself being the main issue”
Tom Goom, a physiotherapist and running specialist at Body Rehab Studios and creator of running-physio.com, drills that process down even further. “I would often say that mild pain during activity (up to three out of 10) is okay if it settles within 24 hours and the patient is improving over time,” he says. “Of course, there are times when this message will change, for example, if I suspect a bone stress injury or when other signs and symptoms exist such as swelling or giving way.”
Goom uses a traffic light representation to help his patients understand this spectrum of discomfort: If it’s excessive pain that’s a six or more out of 10, that gets a red light and signals you should stop. Four or five is acceptable and gets a yellow light, while three or under gets a green light to continue activity.
“The reality is that, like everything else in medicine, the answer to the question of what to do when in pain or discomfort is: It depends,” says Shounuck Patel, DO, FAAPMR, a non-surgical pain physician at The Patel Center for Functional Regeneration in Arcadia, CA. “If patients are toughing out their ordinary activities despite pain, they may be continuing the actions that got them injured in the first place. On the other hand, if patients become fearful of movements that may cause pain, they can start to develop abnormal movement patterns, and, soon, even normal movement can become painful.”
In other words, fear of movement can lead to compensatory pain and injuries, to the extent that even movement that wasn’t painful before now hurts, reinforcing a vicious cycle.
With the advice of these three experts in mind, along with my own experiences as a physical therapist, and combined with the foundational principles of pain and movement science, I created a four-question checklist to help navigate pain, and understand when it’s safe to keep moving and when you might want to back off.
1. Is the pain a five out of 10 or higher?
The visual analog scale used by healthcare practitioners is shown to be a reliable and valid tool for measuring acute (new) pain: On a scale of zero to 10, a patient rates their pain level, with zero being no pain, five being moderate, and 10 being the worst pain. I think of five as a pain level that overtly changes your mood.
2. Is the pain type radiating and/or electrical in nature? Are there constant sharp pains?
Radiating pain is when the pain or discomfort feels like it’s traveling from one area of the body to another, almost like it’s shooting to a different region. Electrical pain feels like a stabbing and burning feeling and it’s quite demarcated, almost like you could trace its outline with a pencil if asked to. If either of these sound familiar, or if it's constant and sharp, the pain could be hinting at something more serious that needs to be addressed immediately by a medical provider.
3. Has the pain lasted longer than 36 hours?
If the residual pain or discomfort from your activity has lasted longer than roughly a day and a half, you very likely did too much and the body needs more recovery time prior to going back into strenuous activities. Even if you’re only at 24 hours past the activity and having pain, give it another 12 hours and see what happens; strenuous activity can sometimes linger past that one-day mark.
If you’re having pain that came out of nowhere (meaning no particular activity caused it) and it lasts 36 or more hours, that’s a significant red flag that needs to be addressed immediately.
4. Is the pain increasing over time?
Take careful note of the trendline: Is the pain slowly creeping up from a two to a three to a four, is it decreasing, or is it plateauing? If it’s steadily increasing over time, that’s a key sign of persistent overuse and overload without adequate recovery.
What your answers might mean
Answering “no” to all four questions means you’re on the right track with your activity level. Keep going, but continue to be mindful of these questions.
However, if the answer to any of these questions is a “yes,” then your training load needs to be adjusted. I would recommend dropping down your activity levels and seeing how that changes your answers to the questions. If you’re having those sharp or radiating/electrical pains or ramping down activity doesn’t result in a change, then it’s time to see a medical provider.
Remember, pain is a signal, but it’s not a binary one. Be aware of the clues and listen to them.