Managing Pain During Training: A Practical Guide

By, Dr. Brandon Paulus, PT, DPT, OCS, FAAOMPT, CSCS

As a physical therapist within the realm of human performance, I have had the privilege and opportunity to work alongside strength coaches and other health professionals in the management of tactical athletes. Our vision as physical therapists is to transform society by optimizing movement to improve the human experience. The tactical space is no different, as we work to optimize fitness and performance when dealing with pain or injury. My aim with the information that follows is to provide an understanding and entry point into maximizing as much physical fitness despite pain or injury. This can include when you’re working with tactical athletes who are going through an academy, selection and training pipeline, or if they’re already operational.

Pain and injury, though often linked, are distinct concepts. Pain is currently defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”1 It serves as a protective mechanism, signaling potential or actual harm to the body. Musculoskeletal injury, on the other hand, has a variety of operational definitions, with my current definition being “damage of or interruption to the normal functioning of body tissues that results when mechanical energy transfer exposure exceeds the threshold of tissue tolerance either suddenly or gradually.”2 While injury can cause pain, not all pain is indicative of injury. Understanding this distinction is crucial in managing pain in order to train effectively.

When discussing musculoskeletal pain, there are two main types that are usually time dependent. Acute pain is often a direct response to a specific injury or activity, typically lasting less than six weeks. It is often sharp and severe, resolving as the underlying issue heals. Chronic pain persists beyond the expected period of healing, usually longer than three months. It can be constant or intermittent and may not always have a clear cause. Chronic pain often involves complex interactions of physiological and psychological factors which requires a comprehensive approach to management.

The majority of chronic musculoskeletal pain does not stem from serious pathology. For example, a study analyzing low back pain explored 22 studies with a total of 41,320 patients seeking care for lower back pain within an emergency department, and found a range of 0.7-5.1% of patients presenting with a serious pathology, such as a spinal fracture or cancer(Galliker et al 2020).3 It is often related to overuse (i.e. too much volume, too soon, too fast), poorly managed previous injuries, and/or poor lifestyle factors (i.e. sleep quality, nutrition, mental health, etc.). Conditions like muscular or tendon strains, spinal disc herniations, or ligament sprains, while painful, are typically self-limiting and respond well to conservative treatments such as active rest, modification of activities, and graded exposure to exercise and training. It is essential to avoid catastrophizing pain and instead focus on manageable, actionable steps towards recovery.

One of the most common statements I hear when talking to individuals in pain is “I stopped doing XYZ because it was painful.” A first step in working with tactical athletes who are experiencing pain, is finding an entry point into training. There are many programming variables that can be manipulated to allow the individual to maintain as much physical fitness as possible. When it comes to pain during exercise, a systematic review of 9 studies looking at 385 participants concluded that pain with exercise does not need to be avoided, and actually offers short term benefits over pain free exercise.4

Therefore, the following pain guidelines for exercise are:

1. No more than a 3 out of 10 pain during the exercise or activity: This means that you may be aware of discomfort, but it does not alter the movement or cause you to wince, cringe, or show that the movement is uncomfortable.
2. No worse pain/symptoms 24 hours after a training session: If you’re working out in the morning, the next morning you should not have any increases in pain. This shows that the region being managed has handled the previous days’ load well enough.

Once the athlete understands these principles, we now focus on the following programming variables:

1. Modify Load: You do not need to change the painful movement if the individual is able to complete the movement with a lighter load. For example, a trap bar deadlift that causes lower back pain at 315 lb, is now symptom-free at 135 lb. The focus will be on the above pain principles, while continuing to stay as close to the actual programmed task as possible. The goal will be to work back up to the previous weight as symptoms improve.
2. Adjust Reps and Sets: Historically moving to a higher rep range will inherently lower the weight, which will give the athlete’s pain time to desensitize and keep them moving.
3. Alter Tempo: Slow down the movement to reduce the intensity of the exercise. A 3-count tempo on the eccentric (lowering) and concentric (lifting) phases can make the exercise more manageable.
4. Change Range of Motion: Modify the range of motion to avoid positions that exacerbate pain. For example, performing box squats instead of full squats if full squats cause knee pain. Slowly working back into deeper squats as pain improves would be the focus.
5. Exercise Selection: Substitute exercises that are less painful. If barbell bench press is painful, consider dumbbell bench press or floor press to maintain as much physical fitness as possible.

If running is painful or not feasible, there are several alternative aerobic exercises you can perform to maintain cardiovascular fitness:

• Assault Bike: This low-impact, high-intensity exercise provides a full-body workout without the jarring impact of running.
• Ski Ergometer: The ski erg targets the upper body and core, offering a low-impact aerobic workout that mimics the motion of cross-country skiing.
• Rower: Rowing is a full-body, low-impact exercise that is low-impact that provides an excellent cardiovascular workout.
• Versa Climber: This vertical climbing machine provides a full-body workout that is low-impact and highly effective for cardiovascular conditioning.

By implementing these modifications and alternative exercises, you can continue training effectively while managing and reducing pain. Always listen to your body and consult a healthcare professional if you have concerns about pain or injury.

References

1. International Association for the Study of Pain. (2021, July 20). IASP announces revised definition of pain. International Association for the Study of Pain (IASP). https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
2. Hauret, K. G., Jones, B. H., Bullock, S. H., Canham-Chervak, M., & Canada, S. (2010). Musculoskeletal injuries. American Journal of Preventive Medicine, 38(1), S61-S70. https://doi.org/10.1016/j.amepre.2009.10.021
3. Galliker, G., Scherer, D. E., Trippolini, M. A., Rasmussen-Barr, E., LoMartire, R., & Wertli, M. M. (2020). Low back pain in the emergency department: Prevalence of serious spinal pathologies and diagnostic accuracy of red flags. The American Journal of Medicine, 133(1), 60-72.e14. https://doi.org/10.1016/j.amjmed.2019.06.005
4. Smith, B. E., Hendrick, P., Smith, T. O., et al. (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

About O2X Injury Prevention Specialist Dr. Brandon Paulus:

Dr. Brandon Paulus is an O2X Injury Prevention Specialist. He earned his Doctor of Physical Therapy degree from Radford University. He is board certified in orthopedics, a Fellow of the American Academy of Orthopaedic Manual Physical Therapists, and a Certified Strength and Conditioning Specialist. He holds certifications in dry needling, spinal manipulation technique, and blood flow restriction training. He is currently pursuing a Doctor of Science degree in Physical Therapy through Andrews University. Dr. Paulus is an Adjunct Professor in the Department of Physical Therapy at Virginia Commonwealth University in Richmond, Va. He enjoys treating individuals with a holistic approach, focusing on aspects of injury prevention and reduction, pain management, athletic performance. He has spent the last 7 years working with college and professional athletes, special operations forces, law enforcement/first responders, and CrossFit athletes.

About O2X Human Performance:

O2X Human Performance provides comprehensive, science-backed programs to hundreds of public safety departments, federal agencies, and the military. O2X works with clients to elevate culture, improve mental and physical wellbeing, support healthy lifestyles, and reduce healthcare costs associated with injuries and illnesses. Driven by results and cutting edge research, O2X programs are designed and delivered by a team of Special Operations veterans, high level athletes, and hundreds of leading experts in their respective fields of human performance.