At Mike Boyle Strength and Conditioning, I get asked rehab questions all the time. In fact, I have rehabilitated athletes in almost every major sport who were told they were “all done” by a doctor or a team athletic trainer. In the process, I’ve become a bit of a patron saint of seemingly lost causes.
Because people know my background in working with injured athletes, they often ask for advice. I’m sure this pisses off a number of physical therapists because I have rehab ideas they don’t like. In fact, a few years ago, a local physical therapist wrote to our company and told us we were not allowed to use the word “rehabilitation” on our website because we were not physical therapists. To avoid a problem, we switched to the word “reconditioning.”
In any case, as strength and conditioning coaches, we’re perceived to be out of our lane when talking about injuries. Just FYI, my educational background is in athletic training, and I maintained my NATA certification until last year, even though I have not formally practiced as an athletic trainer since 1983.
Here’s where I’m going to jump out of my strength coach lane and play physical therapist anyway.Exercise should not cause pain. This seems simple, but athletes and clients ignore pain all the time and then rationalize it, says @mboyle1959. Click To Tweet
If you have an injury and are wondering whether or not a particular 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 with “yes” or “no.” If you answer yes, you are not ready for that exercise, no matter how much you like it.
Not really. I tell everyone I speak with about rehab that any equivocal answer to the “does it hurt” question is a yes answer. Statements like “After I warm up, it goes away,” “only a little,” etc. are all yes answers. I’m amazed by how many times I’ve asked athletes this simple question only to have them dance around it.
The reason they dance around the question is that they don’t want to hear my response. 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 a saying I often repeat: “The secret is there is no secret.” Another wise man, I believe it was Voltaire, said, “Common sense is not so common.”
Pain Is the Problem
Exercise should not cause pain. This seems simple, but athletes and clients ignore pain all the time and then rationalize it. Just to clarify, we aren’t talking about the pain of a blocked shot in hockey or being hit by a pitch. This discussion is about the pain experienced while exercising. This is the knee pain during squats or the shoulder pain during a bench press set.
It’s also important to note that discomfort is common at the end of a set in a strength exercise or the end of an intense cardiovascular workout. Additional discomfort—delayed onset muscle soreness—often occurs during 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 felt in the joints or the tendons.
Pain at the onset of exercise, however, is neither normal nor healthy and is usually indicative of a problem. Just because the pain decreases or goes away as you warm up does not change the thought process. Progression in any strength exercise should be based on being able to go through a full, pain-free range of motion. An exercise can potentially produce muscle soreness, but joint soreness, tendon soreness, or insertion point pain is the sign of a problem. If you need to change or reduce your range of motion, this is also a sign of a problem.An exercise can potentially produce muscle soreness, but joint soreness, tendon soreness, or insertion point pain is the sign of a problem, says @mboyle1959. Click To Tweet
Can we educate the athlete on the difference between pain, discomfort, hurt, and soreness? As I thought about this question, I concluded that we should at least try to educate our clients and athletes about the difference between pain, discomfort, and soreness.
The reality is that there is a bit of subjectivity to the ideas of pain, discomfort, and soreness. I’ll give you what I think are some good working definitions as they apply to rehab and exercise.
Pain is pretty simple. Wikipedia defines pain as a distressing feeling. I feel like pain is easy to understand, even if it can sometimes be hard to describe. Painful exercise is almost always wrong (if we are talking specifically about tendinopathy, that’s a different post).
Also, please don’t give me all the “pain science” BS. I realize pain is not simple, but that has very little to do with painful exercise in a normal, healthy population.
Now, we can really get into semantics when we discuss discomfort. I do think that discomfort is slightly different from pain and probably has a bit more latitude. What really constitutes discomfort? Discomfort is a lack of comfort. I think we generally want to avoid discomfort, also.
Discomfort is probably pain’s next-door neighbor, and discomfort can quickly become pain. This is the gray area. I know that squatting after knee surgery (particularly before all the swelling is gone) can be a bit uncomfortable, but it is probably okay as long as it doesn’t progress to pain. I’ve often found that discomfort decreases with movement while pain increases.
Third, we get to the word hurt. When I think, does it hurt, I think does it cause pain? So, in the case of hurt and pain, they go hand in hand. If something hurts, it’s, by definition, painful. Effectively they are one and the same, at least as it applies to rehab.
Soreness is the last word that came up. Soreness is interesting. Soreness is a response. We have muscle soreness, which is a natural by-product of early exercise and is to be expected to varying degrees. Think of soreness as an after-effect. If someone is doing an exercise and I ask, “Does it hurt?” they sometimes say, “no, it’s just sore.” That might be semantics, but I consider that pain, and we stop or regress the exercise.
For our rehab/reconditioning purposes, pain is immediate, and soreness is residual. I have a standard soreness mini-speech I give to athletes and clients that goes like this:
“Muscle soreness is okay, normal, and to be expected. Generally, muscle soreness will be the worst two days after exercise. It should be gone on day three. The important thing to understand about muscle soreness is that it should be felt in the muscle. Pain in the tendon or the joint is not normal and should be considered a warning sign.”
I usually go on to explain the areas where I don’t want pain. I point out the anterior shoulder, SI joint, and patella tendons as important areas where we don’t want to experience post-workout soreness.
Return to Play
In just about any case, we should avoid pain, avoid exercises that hurt, probably tolerate a small amount of discomfort, and expect post-exercise soreness. However, never try to make it a mental challenge. Never make it about how much the athlete can tolerate.Many therapists say, ‘two out of 10 pain is fine,’ and I vigorously disagree. We shoot for zero. We will modify or outright change exercises until we are at zero and then slowly work our way back. Click To Tweet
Painful exercise is a prescription for failure. I’ve rehabbed just about every injury known to man, armed with some knowledge and the idea of does it hurt. We’ve had great success with simply asking, “Does it hurt?” and then modifying. Conversely, I’ve seen the you need to expect a little pain philosophy fail repeatedly. This is where I draw the line. I’ve seen many therapists say, “two out of 10 pain is fine,” and I vigorously disagree. We shoot for zero. We will modify or outright change exercises until we are at zero and then slowly work our way back.
I have used these simple rules in all of my strength and conditioning and “reconditioning” programs and have been able to keep thousands of athletes healthy. I’m sure the same concepts will help you.
PS: if you want to argue semantics or pain science in the comments, I’ll probably pass.
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