As we learned in Power Athlete Episode - 251 with Adriaan Louw, working with athletes in pain is a tricky business, but one that has fast become an integral component of today’s training environment.
As strength and conditioning coaches, physical therapists, or sport coaches,we will encounter men and women who are managing some sort of pain, and the effectiveness of this management factors into the successes and failures of our programs. Therefore, in order to help these individuals, we need to truly grasp the concept of pain and understand how it affects our athletes on both a physical and mental playing field. Is all pain the same? What happens when pain persists? Such questions quickly lead us down a rabbit hole, attempting to seek complex answers from medical providers who may not have the slightest clue about the athletes we work with.
The aim of this article is to answer those questions, explain the difference between acute and chronic pain, and provide insights into how to manage athletes in pain depending on where they fall on the pain continuum. As a coach, you can make a huge difference by decreasing unnecessary medical costs and laying a positive mental framework for their pain experience. Ultimately, this will impact performance and athletic potential.
Acute Pain is How We Work Around the Problem
Acute pain is usually the result of some kind of tissue damage due to a one-time injury. Think about how many fitness athletes at regionals last year hurt their shoulder performing dips and muscle ups: they likely felt a “pop,” a “pull,” or a “snag” during the movement, trying to get just one more rep for the scoreboard. Visualizing pain this way can be described as a “bottom-up approach;” the stimulus created in the tissues of the body (tearing the pec) activates a neurosensory cascade that relays nociceptive information to the brain.9 This process is driven by intensity where the greater stimulus, the higher a threat level is perceived.1 As a protective behavior, body will enter into a pseudo “survival mode”, where the brain will automatically alter movement patterns (like elevating the shoulder and keeping the arm close to the body) to prevent more damage and seek recovery.10 This change may be so subtle that the athlete in the heat of competition might not even perceive the new movement pattern.
Alright coach, time to act. You are on the front lines and will likely have an immediate impact on how your athlete handles their pain experience. Your athlete is at a fork in the road: do they take the path of anxiety about the cause of their injury, or do they take the path of knowledge in order to understand their pain and what it means to their well-being? Research has shown that teaching athletes about pain and more importantly helping them understand it, results in a positive influence on movement, performance, and recovery.4,11
It’s imperative that you explain to your athletes that they cannot expedite the healing process.1,7 Tissues in the shoulder need to recover, and the body needs time to effectively make those repairs. However, training doesn’t stop!! Movement is a necessary component of the healing process for the athlete; it helps decrease pain, sharpen neural pathways, and prevent “learned non-use”, where the brain’s map for the injured muscle or muscles becomes fuzzy and unclear.12 This is also known as the “use it or lose it” phenomena, and if you’ve ever been sidelined because of an injury, you probably have firsthand experience with it.5 Armed with that knowledge, the aftermath of an athlete’s injury becomes an opportunity to reassure them, and set their expectations for what is to come. You can alter their belief system from “my fitness career is over” to “this is a learning experience, and I can come back from it.”13 There may be pain accompanying the journey, but that is to be expected. By preparing them for this, you can bring focus to training and getting them back to competing by teaching them what can be modified to continue making progress. While this is going on, you as their coach should step back and take a look at your programming leading up to the injury event, and ask yourself one very important question: is there something you could have changed that may have prevented this?
Should training be painful? No. But don’t make the mistake of confusing pain with discomfort.13,43 Your athlete needs to become comfortable with being uncomfortable. It is important to reintroduce tolerable movement over time, and to help them set achievable, task specific goals, to rebuild confidence and enforce a sense of control over their pain experience.4,5 For that fitness athlete who hurt their shoulder, break down the full movement pattern into chunks, then help them rebuild the components they were deficient in that led to injury in the first place. A great place to start is spinal posture and breathing with Dead Bugs. Help them master the basics to come back stronger and healthier.
Chronic Pain is How We Work Through the Problem
Chronic, or persistent pain, is when the alarm system in the body won’t shut off.4 It is highly variable and subjective with each athlete, as it is based on their individual collection of experiences. Think about the scenario above: What if they were finally making progress towards their ultimate goal of becoming an elite athlete, an apex predator in the fitness jungle, when all of a sudden, with the snap of a blown pec, their world comes crashing down. Hopes and dreams are crushed, and fear and anxiety over their unknown future settles in. They begin to blame others for what happened, and all they can think about is sending fitness competition programmers a Go F*ck Yourself mug for programming that workout.
Thirty percent of persistent pain is shown to be emotional in nature,8 which means what an athlete thinks and believes will strongly dictate their pain perception.4,10,11 If an athlete’s identity is wrapped around their sport, the fear of losing this identity is distressing and is perceived as a threat.10,13 Hormonally, the body doesn’t distinguish different kinds of threats; to it, a threat is a threat, whether it’s running from a bear or the feeling of losing control. The response to both is the exact same – an onslaught of stress related hormones is released into the body and danger messages are activated all over the brain.
This stress response often leads athletes to the belief that "The sky is falling, the SKY is falling!!!”, and they begin to feel helpless and “broken”. Their doctor may have told them it’s “the worst” shoulder injury they’ve ever seen.1,7,15 They view their current situation as impossible; in reality, it’s just uncomfortable. They may have given up, and consequently all pain, no matter how inconsequential, becomes bad. Normal habits and behaviors prior to pain are altered. They can’t sleep, diet and hydration fall off the rails, and the intimacy and bonding of their relationships disintegrate.4,14
Six months have gone by for our fitness athlete, and their shoulder still hurts. At this point, the original tissue damage is no longer the source of pain.7 However, merely stepping foot into the gym is relaying a distress signal to the brain, so forget about grabbing a barbell! This is because persistent pain is task specific, and associated with the movements or environment related to the original acute injury.2 The athlete remembers what caused the injury, and has created an association between the activity and the pain; if you’ve ever been through an extended rehabilitation period, you can probably relate to this experience, as well.
What does the athlete usually do? More often than not, they will shut down to avoid similar situations and movements that bring them back to that unpleasant emotional experience. How many of us have seen an athlete hurt himself or herself doing gymnastics, and then decide instead to “focus on weightlifting”? Our brain has a detailed map of every part of our body, and pain has a very real impact on how well this map works.4,5, When in pain, or when we stop using a particular body part, those maps become distorted and difficult to read, and the brain gets confused and struggles with how to identify and properly recruit the body part that was injured.11 This increases the perceived threat level and the brain ramps up the nervous system to try and gather more information, which leads to more pain.8,10,11
Managing your athlete's pain
Coach, how do you handle this? Telling your athletes, "pain don't hurt" probably won't do much for buy-in. Pain management is a tough one because it involves a “top-down” behavior change, starting with the brain.9
Human Behavior Flows From Three Main Sources: Desire, Emotion, and Knowledge - Plato
Knowledge: Educate Them About Their Pain Experience
If pain has been persistent for a long time, do not assign a structural label to their problem.15 This can potentially create a false mental model of the situation and jacks-up their own perception of what is going on, which in turn impedes performance and our ability as a coach to be empathetic towards their problem.3 This also amplifies anxiety if progress isn’t made with training, creating a hyper-vigilant state of awareness about their pain. They become fixated, unable to focus on anything else but their pain, and a negative feedback loop is created.14
Emotion: Challenge vs. Threat
Appeal to the athlete’s emotion and reframe the problem from a threat to a challenge. Take their anxiety and instead turn it into excitement. After all, butterflies in the belly and a racing heart are signs of both stress and excitement; the only difference is how you interpret them.
Show them manageable goals and celebrate attainable victories. Heavy resistance training has been shown to have better effects than cardio in treating persistent pain, and isometrics have been shown to have an analgesic (pain relieving) effect.12 Low back pain? Dead Bug. Just do it.
Desire: Goal Setting
Getting out of pain should not be the only goal of your athlete. Remember, pain is normal. Instead, help them define a goal that makes them want to get out of bed in the morning. A great way to gather insight is to ask them: What would you do again if the pain would magically go away? Use that information to help them put together a structured plan that progressively exposes them to movement and load. A great place to start when returning from injury is the Bedrock program, because it is designed to progressively breaks down barriers to any fear of movement that may have developed and sets the standard for proper movement parameters. It also builds reassurance that what they are dealing with is not the end of the world, and they will improve over time.
Master Your Movement: Accept Pain
Don’t mistake the power of the medical system to make you worse. – Dr. Tim Flynn
The keystone to working with athletes in pain is to develop an alliance.6 This is a collaborative and effective bond between the coach and the athlete, and this alliance is able to effectively produce positive outcomes because it is centered around the athlete’s goals: improving performance, productivity, and allowing them to take ownership of their pain and injury. On the other hand, the passive modalities employed by most healthcare providers have a high risk of creating dependency, preventing the athlete from seeing the pain as their responsibility to fix.
Need a place to start? Try having the athlete conduct a self assessment during their dynamic warmup, learning how to attack limiting factors, and learn when to call an audible if experiencing pain. Help them learn to trust the process of well thought out program. Accepting pain, whether acute or chronic, and taking control of it, will shift the mindset from victim to empowered athlete.
You want the best way to manage pain? Here is the prescription: lift some heavy shit, get adequate sleep, drink plenty of water, and get laid.
- Beecher HK. Relationship of significance of wound to pain experienced. JAMA. 1956 Aug;161(17):1609–1613.
- Chapman CR, Vierck CJ. The transition of acute postoperative pain to chronic pain: an integrative overview of research on mechanisms. J Pain. 2017;18:359.e1–38.
- Cohen M, Quintner J, Buchanan D, Nielsen M, Guy L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain medicine (Malden, Mass.). 2011; 12(11):1637-43.
- Louw, Adriaan et al. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation 92:12 , 2041 - 2056
- Louw A, Zimney K, Puentedura E, Diener I.The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature, Physiotherapy Theory and Practice, 32:5, 332-355.
- Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology. 2000; 68(3):438-50.
- Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000.
- Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain. 2015 Jun.
- Nicolardi V, Valentini E. Commentary: Top-down and bottom-up modulation of pain-induced oscillations. Frontiers in human neuroscience. 2016; 10:152.
- Parr JJ, Borsa PA, Fillingim RB, et al. Pain-related fear and catastrophizing predict pain intensity and disability independently using an induced muscle injury model. Pain. 2012 Apr;13(4):370–8
- Puentedura, Emilio & Louw, Adriaan. (2012). A neuroscience approach to managing athletes with low back pain. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 13. 123-33.
- Rio, E., van Ark, M., Docking, S., Moseley, G. L., Kidgell, D., Gaida, J. E., … Cook, J. (2017). Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain. Clinical Journal of Sport Medicine, 27(3), 253–259.
- Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med 2017;51:1679-1687.
- Sullivan MJ, Thorn B, Haythornthwaite JA. Theoretical perspectives on the relation between catastrophizing and pain. The Clinical journal of pain. 2001; 17(1):52-64.
- Toye F, Seers K, Allcock N, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829–41. PubMed #24351499.
Dr. Zanis utilizes the Power Athlete Methodology to optimize performance, reduce injury risk, and rehab his clients and athletes through movement assessment, coaching, and individualized program design.