How To Exercise When It Hurts
You’ve probably heard mixed messages about exercising with chronic pain in the health and fitness world. Advice like “listen to your body”, or “no pain no gain” or “just modify if it hurts”, may be well intentioned, but can be conflicting and confusing, and unhelpful if you don’t know how to modify, or what messages from your body to listen to!
How can you keep taking group fitness classes or working out on your own when your back hurts, your knee and hurts to squat, or you can’t reach overhead because of shoulder pain?
Learning to productively exercise when you have pain is empowering and valuable. Consistent exercise has myriad benefits that we all know about, such as weight loss, blood pressure and blood sugar control, improved physical function, ability, and confidence, osteoporosis prevention/management, anti-inflammation, psychological benefits, social connections, stress management, and on and on. But also, pain relief! What medicine or surgery can do all that?
Disclaimer: if you have an acute injury, or worsening pain that may be coupled with other strange symptoms, and/or don’t feel you have the skills to deal with your issue alone, please seek advice from a qualified physical therapist or medical doctor. In NY state, you do not need a doctor’s referral to see a PT. They can help you decide whether a trip to the doctor is necessary or if PT alone is sufficient.
Key Messages
Before we dive into the nitty gritty, there are 4 key points that, if understood and embodied, will increase your chances of success with your fitness program.
Exercise is the gold standard for the management of chronic pain. NOT opioid pain medications, NOT acupuncture, NOT massage, manipulation or manual therapy, NOT rest! Can you tell I feel strongly? While these other adjuncts do have their place in a comprehensive pain management program, they are often overused, over prescribed and used for too long.
Exercise is safe. Even for you.
Exercise is highly unlikely to “damage” any structures. Even if your form or alignment isn’t perfect and even if your diagnosis sounds scary. Unfortunately, phrases like “slipped disc” or “bone on bone” or “torn rotator cuff” are so commonly used by medical professionals with little or no follow up education, leaving people understandably terrified to strength train their painful areas. For most common diagnoses, strengthening exercise is safe and the most helpful intervention to reduce your pain and increase your function.Pain intensity varies. Continue to exercise (using the advice below).
Your pain intensity fluctuates daily or even hourly based on lifestyle factors such as sleep, stress, daily activity, beliefs, predictions, nutrition, even when there is no other measurable change inside the joint or offending body part! Learning to exercise with your fluctuations, including your flare ups, ensures that you can maintain consistency in your program, progress it as you get stronger and don’t skip days just because your pain is worse.Exercise is a long term commitment.
You are a tortoise, not a hare. Commit to a doable exercise program that becomes part of your life. While some of the benefits of regular exercise are immediate, many of the benefits take months to achieve.
Pain 101: Understanding Your Pain
Pain is most broadly classified as acute or chronic pain. Acute pain occurs with a specific event that initiates the pain response, such breaking a bone, having a surgery or spraining your ankle. It is limited to tissue healing time, which is variable, but usually healed sometime between 3-6 months. Acute pain is NOT the topic of this blog post, and is best to consult with a physical therapist, orthopedist, or other relevant specialist, especially if you’ve had some kind of direct trauma such as a fall or accident.
Chronic pain is pain that persists beyond normal tissue healing time (>3-6 months, many people struggle for years or decades), is present most of the time and/or may be recurrent, such as a “flare up” of some pain you’ve had before, in the absence of new true injury. Examples of chronic pain drivers include, but are not limited to:
● Lower back or neck pain: including herniated discs, spinal stenosis, spondylosis
● Shoulder impingement: a.k.a. subacromial impingement
● Tendinopathy (commonly called “tendonitis”): may occur in various places in the body
● Plantar fasciitis
● Rotator cuff tears or rotator cuff related pain
● Fibromyalgia
● Osteoarthritis: in any joint, but commonly in hips, knees, hands, ankles
● Other types of arthritis, such as rheumatoid arthritis, psoriatic arthritis
● Phantom limb pain for amputees
● Post-operative pain: long term pain after joint replacement, other orthopedic surgeries (newsflash: surgery doesn’t fix everything)
Chronic pain is a highly complex phenomenon in the central and peripheral nervous system and it may or may not be correlated with what is visible on imaging techniques such as X-ray or MRI. It’s possible to have a “normal” or good looking X-ray or MRI and have chronic, debilitating pain. This does not mean the pain is not real. It’s also common to have really ugly MRI or X-ray imaging with lots of arthritis, bony changes, and impingements with no pain whatsoever!
This 5 minute video by the world’s foremost pain neuroscientist Lorimer Moseley is really worth a watch. https://www.tamethebeast.org/#tame-the-beast This is the most up-to-date, evidence based understanding of how chronic pain works, and is refreshingly optimistic about the individual’s ability to break free of chronic pain with exercise and education.
Know Your Coping Style
Before you hit the gym next session or class, reflect on your trouble spots and how you cope when you have pain. Are you an “endurer” or an “avoider”?
Endurer: You push through pain, tend to overdo it in workouts and classes, then get flared up later or the next day. You have difficulty knowing when to stop, modify or vary exercises and just do what the teacher says despite feeling more pain or despite feeling your movement quality suffer due to pain.
Avoider: You tend to fear any provocation of pain, and may even cancel workouts or classes, and/or skip exercises that are uncomfortable. You may skip the gym altogether in order to avoid worsening the pain. You may be more inclined to believe that exercise is damaging to your painful area, or worsening the severity of the problem.
These are extremes, of course, and you likely fall somewhere along the spectrum. Observing your pain coping strategies will help you monitor and adjust your pain management strategies and your exercise regimen. If you find that you’re an avoider, you may push yourself to exercise a painful area to your tolerance, in order to keep it strong and mobile. If you’re an “endurer”, you might apply some of the tweaks mentioned below to learn to control your flare ups, and thus get better control of your symptoms.
Get Your Cardio On
If you have chronic pain of any origin, make sure you are getting adequate cardiovascular exercise, whether it’s walking, running, dancing, biking, swimming, rowing, or any other modality that doesn’t worsen your pain. Cardiovascular exercise has metabolic, anti-inflammatory and analgesic benefits and can help “flush” out cranky nerves, joints, or tissues. The American Heart Association and the American College of Sports Medicine recommend a total 150 minutes per week of moderate intensity cardio, or a total 75 minutes per week of vigorous cardiovascular exercise, including high intensity intervals if you like.
Strength Training Action Plan: 2 Key Questions Then How to Tweak/Adjust
When you’re working out and your pain arrives, ask yourself these 2 questions to help yourself determine whether you should continue your exercise or make a change:
1. Is this pain/discomfort acceptable to me right now, in this exercise?
2. Will I pay for this later?
Will I flare up so much that it affects my daily life and daily function? E.g. Ability to: cook dinner, play with my daughter or take a walk with my spouse later?
These prompts integrate your personality, lifestyle, and your prior pain experience. You know yourself best!
Next, refer to the chart below for how to adapt based on your response to the question. Experiment with this for at least a couple of weeks to get to know yourself and learn some new “tweaks”.
Notice that we may not completely avoid pain during exercise using this model, and that’s OK! As discussed above, pain is not necessarily a sign of damage or harm. If an exercise is not “acceptable” to you today and you need to tweak or change it, this doesn’t mean the exercise is harmful or dangerous. It just means that your system isn’t tolerating it right now. With mindful, consistent training, you will build the capacity to tolerate the exercise soon.
Don’t forget to celebrate your success. The exercise you were able to do is better than not doing it at all. And you’re becoming more creative and adaptable in the process!
The most important message of all: trust that your body is adaptable and resilient and that it is safe to exercise, even with pain. Know that you're giving your body the best medicine there is, just by exercising.
Thank you for reading!
Questions? Feedback? Interested in one-on-one sessions to explore this approach? I’m here to help: