Painful Movement & Exercise

It is very likely you have been advised or recommended to exercise to help with pain. However, when you try it, it results in the pain worsening? You might be wondering, is this a sign you should stop? Is this a sign of damage? Is it okay to have this pain? Should you push through the pain? You might in the past have been told to stop when it hurts by a healthcare professional while the next one has told you it is okay to experience pain.

If you have experienced this you are not alone.

So what are the answers to these questions? 

Well in all honesty this is a major gray area and a significant gap in the existing research. This was highlighted by the authors Smith and colleagues in their great paper released in 2020 (Smith et al., 2020). Since then there have been some trials and efforts to look into this further (Kjaer et al., 2024).

While there is ongoing research into the area, there are a few things that we do know on the subject.

Pain is not always an indicator of damage, especially when it becomes more persistent.

Painful exercises in rehabilitation also do not result in worse outcomes and may even slightly outperform pain-free exercises (however, only very slightly)(Smith et al., 2017). It is important to note that people in these studies had persistent musculoskeletal pain (e.g., lower back pain, shoulder pain, Achilles pain, Planat Fasciitis, lasting >3 months).

A systematic review of several studies also found that the best treatment to reduce pain with movement is … exercise (Leemans et al., 2022). Yep, seems very strange but in the long term practicing the movement that is painful can reduce this pain (when safe). There are several mechanisms that may be able to explain this, firstly exercise has an anti inflammatory effect it may also release analgesic substances and lastly, it may act on the central nervous system (Leemans et al., 2022)(Nijs et al., 2012)(Sluka et al., 2018).

Some tips for exercising with pain

Ensure that the pain is in fact not causing any damage. This is best done by consulting with an appropriate healthcare professional such as an exercise physiologist or physiotherapist.

Start slow and keep sessions short, it may be more useful to work on consistent short bouts of movement vs inconsistent long exercise sessions. An exercise physiologist or physiotherapist would be able to guide you through this process.

“The type of exercise may be less important than the act of doing exercise.” (Sluka et al., 2018).

“Knock on the door of discomfort, but don’t barge in”

“You want to flirt with the pain, don’t take it out to dinner”

Remember, pain does not mean that there is further damage in a lot of cases.

References

1. Kjær, B. H., Cools, A. M., Johannsen, F. E., Trøstrup, J., Bieler, T., Siersma, V., & Magnusson, P. S. (2024). To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial). Trials, 25(1), 135. https://doi.org/10.1186/s13063-024-07973-6
   

2. Leemans, L., Polli, A., Nijs, J., Wideman, T., den Bandt, H., & Beckwée, D. (2022). It Hurts to Move! Intervention Effects and Assessment Methods for Movement-Evoked Pain in Patients With Musculoskeletal Pain: A Systematic Review with Meta-analysis. The Journal of orthopaedic and sports physical therapy, 52(6), 345–374. https://doi.org/10.2519/jospt.2022.10527 
   

3. Nijs, J., Kosek, E., Van Oosterwijck, J., & Meeus, M. (2012). Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise?. Pain physician, 15(3 Suppl), ES205–ES213. 
   

4. Sluka, K. A., Frey-Law, L., & Hoeger Bement, M. (2018). Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain, 159 Suppl 1(Suppl 1), S91–S97. https://doi.org/10.1097/j.pain.0000000000001235 
   

5. Smith, B. E., Riel, H., Vicenzino, B., & Littlewood, C. (2020). Elephant in the room: how much pain is ok? If physiotherapy exercise RCTs do not report it, we will never answer the question. British journal of sports medicine, 54(14), 821–822. https://doi.org/10.1136/bjsports-2019-101289 
   

6. Smith, B. E., Hendrick, P., Smith, T. O., Bateman, M., Moffatt, F., Rathleff, M. S., Selfe, J., & Logan, P. (2017). Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British journal of sports medicine, 51(23), 1679–1687. https://doi.org/10.1136/bjsports-2016-097383

This blog was written by Samuel Bulten