Pain with exercise…. stop or keep going?


“Is pain with exercise OK?”
“It hurts when I run, should I stop running?”
“My knee hurt when I vacuumed the house, how long do I need to wait to vacuum again?”

Questions like these are probably the most common type of questions I get from people in pain.  Patients and clinicians both know the importance of regular activity and exercise, but feeling pain with exercise makes everything a bit confusing.

The first point I want to make is that pain itself is a bit confusing.  Most people believe that feeling pain means something is being damaged.  This is not always the case.  Pain is your body’s alarm system.  Like any alarm system, it’s not 100% accurate.  If somebody breaks down your door, your home alarm will go off.  However, sometimes an overly sensitive home alarm system might go off only when somebody knocks on the door or during a big wind storm.  So, not every home alarm is a serious threat.  Similarly, not every feeling of pain is a serious issue.

So how do you tell the difference between “OK” pain and “bad” pain?

Sticking with our home alarm system example, let’s imagine you get a notification on your phone that your home alarm was set off.  If you rush home and find that your door lock is broken and you have items missing from the house, then you can probably figure out that the alarm was a serious threat.  However, if you rushed home to find that nothing is out of place and your door is still locked but shaking from the wind, then you quickly realize there wasn’t a serious threat and you don’t have to worry.

So we can’t tell whether the alarm was a serious threat or not by itself, we must assess the situation after the alarm.  We must do the exact same thing for pain.  So how do you assess? Let’s go through the steps.

Step 1: Pre-activity: Write down your baseline pain level (on a scale from 0-10) pre-activity.  Also, perform a few movements to “self-check” your painful body part.  For example, if you are dealing with back pain, perform a self-check by bending backward and bending forward and note any stiffness or pain during these motions.
Step 2: Perform exercise/activity and write down the highest pain level experienced during this time.
Step 3: Perform self-check again and note any changes.  If pain did increase during activity, note how long it takes this pain to return back to baseline levels.
Step 4: Perform self-check ~every 8-12 hours for 24 hours.

Example #1: Tim w/ knee pain that started two weeks ago.  He feels pain during any squatting motion.
Step 1:  At rest, Tim rates his pain 3/10.  He can straighten and bend his knee and only feels minor stiffness.  He wants to work on some landscaping on his house.
Step 2: While he’s working, the pain increased to 7/10 and squatting became very uncomfortable.
Step 3: After the landscaping was done, Tim had a hard time bending and straightening his knee.  The pain decreased to a 5/10 but did not decrease anymore over the next 48 hours.
Step 4: That night, Tim still had increased pain with squatting and still felt a decreased range of motion with movement.
Assessment: Tim’s pain and movements became worse after activity and did not return back to baseline anytime soon.  His self-checks revealed that his movement became worse.  Tim had a “red light” response to activity and needs to be evaluated by a professional.

Example #2: Jenny with a 1-month history of shoulder pain during pull-ups
Step 1. At rest, Jenny rates her pain a 0/10.  She has full shoulder range of motion and only feels slight stiffness at the very end-range of her motion.
Step 2: During an exercise class, Jenny feels pain during her pull-ups.  She rates this pain as a 4/10.
Step 3: After the class, the increased pain lingers for about 20-30 minutes.  However, she still has full range of motion with only end-range stiffness.
Step 4: That night, Jenny’s pain had reduced to a 0/10.  She felt the same the next morning as well.  Self-checks were “negative.”

Assessment: Jenny’s pain increased during the exercise but quickly returned to baseline.  No harm was done and her movements and ROM did not change despite the increased pain.  This is a “green light” pain response.  She can continue activity and can add ~5% more volume next workout/session.

Example #3: Barbara with a 10-year history of chronic low back pain.  Due to the pain, she has a very sedentary lifestyle.
Step 1: At rest, Barbara rates her pain 5/10.  She feels increased pain when she bends backward and when she bends forward.
Step 2: With the advice of her clinician or therapist, Barbara goes on a short walk.  Her pain increases to an 8/10 during the walk.
Step 3: Her pain stays increased after the exercise.  Her self-check reveals that she still has the same ROM but slightly increased pain during motion.
Step 4: Barbara’s pain slowly returns to baseline after about 36 hours.  During this time, none of her self-checks reveal any decrease in ROM.

Assessment: This type of response we refer as a “yellow light.”  Barbara needs to proceed with caution.  You may think that this activity was too much as her pain stayed elevated for 36 hours but it’s important to understand that she has a 10-year history of chronic pain so her “alarm system” is very sensitive.  While her pain was increased, her self-checks revealed that her range of motion did not change.  As Barbara continues to become active, her pain response should become less and less active.

If you have pain with exercise, hopefully, these guidelines will give you an idea of how your activity is influencing your pain and whether or not you’re experiencing a green light, red light or yellow light response.  However, not all conditions are easily placed into these three categories.  So if you have any questions about pain with exercise, feel free to contact our office or schedule an appointment.

Jeff Remsburg DC MS DACRB Cert MDT