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Johns Hopkins Sports Medicine Patient Guide to “Good Pain” and ”Bad Pain” for Athletes

Our Sports Medicine and
Shoulder Surgeons

 

What is the difference between "good pain" and "bad pain"?

It is well known among athletes that some discomfort is part of athletic activities and is necessary for the improvement of performance. For muscle strength to increase, the muscle must see some increase in stress over what it is used to seeing, and this stress is usually perceived as the "burn" in muscle during activity. This mild "burn" is what we call "good pain" and is the basis of the popular phrase, "No Pain, No Gain." This pain should be short-lived and during the activity only.

If there is some discomfort after exercising, it should be short-lived and not carry on for hours or days. Fatigue after a good, strenuous workout is also a sign that the exercise is pushing the limits of the athlete’s physiology, but it too should not be destructive. This fatigue should leave the individual somewhat exhilarated, but not exhausted. Fatigue that lasts days means the individual’s physiology has been excessively challenged, and this means that the muscles and the energy stores are not being replenished after exercise. This more chronic fatigue after harmful exercise is called "over-training," and it is a sign that the individual is doing too much exercise too rapidly. If after appropriate rest the fatigue continues, it may be a sign of other medical problems and you should consult a doctor.

What are the signs of "bad pain"?

The muscles, tendons, ligaments, cartilage and bones of the body are living structures that react to the stress of exercise very slowly. If they see stress too fast, they cannot respond in time and begin to fail. The causes of the failure can be too much stress too fast or it can be accumulated stress over time. When this occurs, each one of these tissues responds a little differently and begins to produce what we call "bad pain."

For example, when muscles that have not been exercised for long periods of time see a lot of stress, they respond by getting "sore." Muscle soreness typically occurs if you do a new exercise to which you are not accustomed or if you do a familiar exercise too hard. This soreness typically begins within a few hours but peaks around two days after exercise. This soreness is called "delayed onset muscle soreness," and it actually reflects muscle damage. A little soreness or discomfort means that the muscle has been stressed, but if the muscle is exercised too much the muscle can become very sore to move and touch, and may even swell. In severe cases, the muscle may be damaged to the point that the muscle starts to die. In individuals who are extremely out of shape, if multiple muscles are exercised too hard and too fast, then as the muscles die they release proteins into the blood stream, which can shut down the kidneys. While it is rare, there have been cases of death due to this extreme over-exercising of the muscles, so it is generally recommended that if you start an exercise program, you begin very slowly and build up gradually. We usually recommend that whatever amount of exercise you think that you can do, cut it by one-third the first few times to prevent this problem with your muscles.

In a similar fashion, the tendons that connect muscle to bones may get irritated if they see too much stress too rapidly. They respond by getting inflamed, which is characterized by pain and sometimes swelling. Tendinitis pain typically occurs during exercise and can continue after exercise when performing activities using that muscle or tendon. For example, tendinitis of the kneecap tendon ("patellar tendon") is frequently seen in athletes who do jumping or squatting activities. The pain is made worse with these activities, but the pain may continue after sports activity when climbing stairs or getting out of a chair. In more severe cases the tendon may become swollen and any movement of the tendon or knee joint can hurt.

The bones likewise need time to respond to new stress. When bones see increased amount of stress, such as an increase in running when preparing for a marathon, they respond by putting more bone in the areas of the bone that are seeing more stress. This response is called "remodeling" and strengthens the bone. However, if the area of bone sees stress too fast, the bone will actually begin to fail. The first sign of this "stress fracture" is pain along the bone, which occurs with activity. As the fracture worsens, the pain continues after exercise. This may lead to a limp and even pain at night. If untreated the bone can actually break, which can be a severe injury depending upon which bone is involved.

Cartilage also needs stress applied very gradually. Cartilage is the white tissue on the ends of the bones at the joint that allows the bones to glide and move smoothly over one another. As a person matures, it is common for the cartilage to see some wear and tear so that it is not perfectly normal. When the cartilage sees too much stress too rapidly, it first causes pain in the joint and secondarily fluid in the joint. Swelling in a joint is a bad sign and means that the cartilage is not happy. If the joint is not rested, the pain and swelling can increase and cause an inability to use the joint for not only exercise but for activities of daily life.

How can these pains be treated?

The treatment for any ache or pain after exercise is to cut back on the exercise for a period of time. How long to rest the area depends upon the severity of the pain. Typically we tell patients not to do anything that hurts. For casual athletes this is easier to do than for highly competitive athletes. It is important to maintain aerobic capacity or stamina when resting a body part, so other exercises that do not cause pain are usually acceptable. For example, if your knee hurts, it is usually reasonable to continue exercising your upper extremities or even to do lower extremity exercises that do not aggravate the problem.

The second way to treat a painful area is by icing. Ice should be used after activity with an ice pack or ice massage for 20 minutes (See Patient Guide to Ice Techniques). This also can be done daily after exercising for several weeks. The old standard of ice for 48 hours followed by heat is no longer recommended. We believe that "ice is your friend." However, if pain persists despite the use of ice, more serious problems may exist and you should consult your physician.

The third thing to do if you have aches and pains after exercise is to continue to move the joint or extremity to avoid stiffness. If the joint becomes stiff over time it will affect the ability of the joint to function normally, and may affect athletic performance as well. Range of motion exercises or stretching to maintain the motion of the joint should not be confused with exercising the joint, which tends to stress the structures and make the pain worse.

The fourth way to treat aches and pains is with over-the-counter pain relievers or anti-inflammatory agents. These medicines include acetaminophen, ibuprofen, naproxen or aspirin, and are believed to be effective at decreasing pain and swelling due to over-exertion. Follow the instructions on the label, and if you have any questions, speak with your trainer, pharmacist or physician. If these medicines do not take care of the pain over a few days then you should consider consulting a health care professional.

In summary, if you develop pain after exercise, you should rest or decrease the activity that is causing the problem, ice the painful area, keep moving the extremity but not stress it, and consider over-the-counter medicines to treat the pain and inflammation.

When should I be concerned about "bad pain"?

Generally there are several things you should look for when judging how concerned to be about your pain. First, the pain should not last long after exercise. Pain that begins to affect your sports performance is not normal, and this may be more of a problem early in an injury for a high-caliber, competitive athlete than for the casual athlete who can more easily rest the injured part. Pain that does not go away with rest is not normal. Pain that begins to affect your function outside of sports, such as walking or sleeping is not normal. Pain that is constant or increasing over time and does not go away is not normal. Pain that does not improve with treatment may be something to be concerned about. Pain that requires increasing amounts of pain medication over time is not normal and you should consider seeing a physician. Pain that begins to wake you from your sleep is also a concern, especially if it does it every night and increases over time.

Another sign that may indicate a more serious problem is the development of weakness of the extremity over time. The development of tingling or numbness, which is the feeling you get when your hand goes to sleep or when you hit your "funny bone" at the elbow, is also not normal and may indicate nerve problems. If you notice that you are gradually losing motion of the extremity you should seek treatment.

Fevers, chills or severe sweating at night are not normal and you should consider seeking evaluation right away.

What about the pain that occurs with an injury?

It is often difficult to know if an injury due to an accident or trauma is serious or not. Signs that the injury is more serious include severe pain which makes the individual nauseated or very uncomfortable, deformity at the site of injury, immediate and massive swelling at the location of the injury, loss of function of the part that is injured, tingling or numbness of the extremity and inability to move the fingers or toes of the involved extremity.

We tell athletes that things do not swell and hurt for no reason. More severe injuries have more swelling and pain. Injured areas that turn black and blue over time indicate that blood vessels have been broken and that there is the possibility of an injury to the bones, ligaments, tendons or cartilage. In most cases where a joint becomes swollen, painful and incapable of movement after an injury, it is impossible to tell if there is a fracture without an X-ray.

While there are some guidelines recommended for the use in the emergency room about who should have an X-ray and who should not, these guidelines are controversial and are recommended for only health professionals with experience seeing these injuries. If you have any question about whether an injury is serious or not, you should seek treatment. Sometimes this is done sooner rather than later in athletic individuals who have a more pressing need to know the severity of the injury, thereby allowing quicker return to sport.

Edward G. McFarland, M.D.
Andrew Cosgarea, M.D.

 

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