| | | Rehab to Performance: How Pain Affects Movement

Author / Matthew Zanis

How many times have you instructed an athlete to hinge over and pick up a barbell, only to see a guarded grimace form over their face? How about watching an athlete squat from behind and seeing their hips shifting, favoring one side? In the first situation, the athlete is noticeably feeling discomfort and not telling you, the coach. In the second situation, you notice dysfunction and the athlete has no idea that it exists. 

The athlete’s relationship with pain and movement is super intriguing, and plays a huge factor in return-to-play or training following an injury. Without understanding what pain is, it is difficult to move forward and discuss interventions, so I encourage you to go back and read my entire series, Pain: This Shit is Complicated, explaining the ins and outs of pain. Influences on pain are widely varied, ranging from social context, belief systems, blood flow, anxiety, inflammation, etc. (3) However, the aim of this article is to extrapolate  on how pain affects your athletes’ movement patterns, and subsequently, their athletic development. 

Directly following an injury, pain from tissue compromise is predominant. As pain persists, especially when the athlete is trying to return to the field, the perception of pain and the state of the heal(ed) tissue becomes more imprecise. As pain continues, the networks transmitting nociception (information signals) to the brain become sensitized (or hyper-active). This is a key concept in understanding the role of movement in pain. Persistent pain can change how the mind views the offending body part.This has implications for coordinated movement patterns (motor control), since it disrupts sequencing of muscle firing patterns, resulting in altered movement, decreased movement variety, and altered body perception.(5)  Instead of learning and expanding their movement vocabulary, athletes reduce their movement out of fear and limit their overall athletic potential. For example, if the brain is having trouble recognizing a back as part of the “self” following a deadlift injury, the athlete will be unable to accurately judge any movement or task that requires any form of hip hinging. This potentially leads to guarding, pain, and compensatory patterning, that if loaded and left unchecked, could result in persistent pain and ingrained dysfunction. 

Damn, that seems like a lot of doom and gloom! Don’t fret. The good news is that these changes can be reversed. It has been demonstrated that these distorted body images in the brain can be reversed through the application of skilled motor training in those with recurrent pain.(2,4) This means the athlete is moving with intention, doing so with confidence, and feeling empowered to make improvements on their movement (write that down). 

Start Novel, Increase Variety

Movement is meant to be explored, not avoided. We know that movement is key to decreasing pain perception and improving athletic qualities. But, what happens when previous skilled movement patterns are now painful, or worse, the athlete is fearful of performing them? Start with the mind. It is a powerful tool and accounts for an appreciable chunk of motor control and movement planning.(1,6) Visualize and attack! Have the athlete imagine their movement, and go into detail. Ask them to feel the ground beneath their feet, the bending of their joint, the stretching and contraction of their muscles. Have them describe their environment, the smell of the grass, the roaring of the crowd, how their clothes feel against their skin. What kind of emotions are circulating in their head? Are they scared and anxious or calm and confident? After all, fear of re-injury is one of the biggest factors why an athlete will not return to the previous level of activity after an injury.

Once the athlete has a virtual representation of their body, introduce movement patterns that don’t reproduce a painful response. Allow the brain to feel comfortable with just moving again. Maybe squatting with their toes forward causes pain on the inside of their knee. Yet, a slight toe out allows the athlete to squat down pain free. This pattern may be new for your athlete and create a beneficial eustress to their nervous system. Use this window of opportunity to sustain a training response while desensitizing pain. You can then progress these patterns by changing contextual variables. Can they now squat toed out with their eyes closed? How about with their head turned to the right or left? This will challenge their vestibular system and balance, two key variables for athletic performance. Finally, add variety to functional tasks. Have them explore a toed-in squat, sumo style, and even a split stance with varying angles of hip and ankle rotation. Can they pull themselves into the bottom of a squat from a bear crawl position? Variety creates new neural networks and connections, giving the athlete more degrees of freedom and resiliency. You can increase their capacity while the level of threat to the nervous system goes down at the same time.

Iso-Stability for Pain Relief 

Our brains have the best medicine cabinet found in nature. We can produce natural opioids that are 50x more powerful than anything we can ingest or inject into the body.(3) Teaching the athlete to access their natural dispensary can be a game changer when returning to sport. One great way to achieve this is through isometrics. Iso-Stability work, like you see in the warm up phases of all Power Athlete programs, teaches isolated control and stability around joints, giving the brain confidence throughout that joint’s full range of motion.

Many times when we feel “tight” or experience a pain response, it is our brain’s protective mechanism coming into play. This alarm signal prevents you from going into a range of motion that your brain perceives that it can’t control and may potentially lead to injury. Isometrics have been shown to release those natural opioids into the system and offer the brain that sense of control, turning off the alarm signal with frequent exposure. 

Reintroduce Movement

Once the nervous system has calmed down and fear of movement has subsided, you can begin to reintroduce previously provocative movement patterns. This form of testing the waters is called graded movement exposure.(3,4,5) Start by varying the angle and range of motion of the pattern. Using our squat example, this could mean returning to a toes forward base of support and limiting knee bend by designated a depth with something like a box squat. We should also assess load. Is this particular pattern limited by a certain amount of stress to the system? The athlete may be able to squat full depth with 135 pounds, yet 145 reproduces their knee pain, even though they have acquired the requisite range of motion in their joints. We would then implement a progressive overload strategy, like Bedrock, to build tolerance over time. 

It is important that the load, volume, and intensity are only three variables that dictate stress to the system. We must also consider other environmental, emotional, and nutritional factors that weigh into the equation. Remember, you only benefit from the training you can recover from the only magic bullet is rest and sleep. When returning to sport following injury and pain, it is imperative to find the athlete’s minimum recoverable volume. In other words, how much can they tolerate (minimum effective does) to provide a high enough stimulus for adaptation to specific traits, while respecting the healing nature of tissues, and reducing the risk of re-injury. This is the process by which our athletes become “anti-fragile,” or capable of handling more stress; the highest of which occurs in sport, not the weight-room.

Master Your Movement: Failure Drives Adaptation 

Lastly, don’t let your athletes become complacent. As confidence grows, it is time to increase the challenge. I like to implement a 70/30 rule. 70% of the time, I expect the athlete to produce well executed movement patterns with minimal coaching. The other 30% is where the magic happens. This is where I expect their skill to breakdown, where the challenge is high enough to produce error without risking injury. Prudent programming that allows for failure forces the athlete to learn from their mistakes and grow. It teaches motor planning and problem solving through failure and adversity. Come game time, we don’t want our athletes questioning their ability to move. In those returning from ACL injury, the athletes with hesitation and nervousness to make a movement were one second slower in the beginning of a muscular contraction, increasing injury risk. 

Working through pain while returning an athlete to sport starts with educating your athlete, and helping them understand that pain doesn’t always equal harm. The goal is to get your athletes to acknowledge pain so that they do not fear it. Once acknowledged, understanding graded exposure to movement and progressive overload strategies based on their goals is necessary to restore previous capacity. Accomplishments made through movement will change the brain, frequent exposure to movement will reinforce the connection between moving and pain reduction, and progressive overload will solidify confidence that their body can return to training and sport.


  1. Bali, A. Psychological Factors Affecting Sports Performance; International Journal of Physical Education, Sports and Health 2015; 1(6): 92-95
  2. Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy. 2010;15(5):410–414. doi:10.1016/j.math.2010.05.008.
  3. Butler DS, Moseley GL. Explain Pain. Noigroup Publications; 2004.
  4. Hodges PW, Tucker K. Moving differently in pain: A new theory to explain the adaptation to pain. Pain. 2011;152(S):S90–S98. doi:10.1016/j.pain.2010.10.020.
  5. Moseley GL. Reconceptualising pain according to modern pain science. Phys. Ther. Rev.2007;12(3):169–178. doi:10.1179/108331907X223010.
  6. Wand BM, Tulloch VM, George PJ, et al. Seeing It Helps: Movement-related Back Pain is Reduced by Visualization of the Back During Movement. The Clinical Journal of Pain. 2012;28(7):602–608.

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Matthew Zanis

PT, DPT, FAAOMPT, OCS, ATC, CSCS Former baseball catcher and an avid outdoorsman. Worked with Division 1 basketball, football, and track and field at the University of Pittsburgh, along with the Pittsburgh Pirates and Arizona Cardinals organizations. Received a Bachelors in Athletic Training from the University of Pittsburgh in 2011 and a Doctorate in Physical Therapy from Duke University in 2014. Is board certified in Orthopedics and a Fellow through the American Academy of Orthopedic Manual Physical Therapists. Is a PT with the United States Olympic Committee and USA Shooting. Currently operates his performance therapy practice in Scottsdale, AZ with Dr. Tom Incledon of Causenta Wellness, and became a Power Athlete Block One Coach in September of 2017.

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.


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