It’s not uncommon to have some pain and discomfort during or after an exercise. But when is that OK to push through and when should you back off?
In this week’s episode we talk about some of the reasons why we would modify an exercise based on pain.
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#AskMikeReinold Episode 315: Modifying Exercises Around Pain
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Okay. Val from Chicago says, “I’m often sent people with diagnoses like patellofemoral pain. How do you modify exercises if the person does not have any pain during the exercise but reports an increase in symptoms that night or the next day?”
That’s a great question, and I like that. That’s a good… You know, when you just get started in your career, this is probably something that you come across a decent amount of time. And Val, you said patellofemoral pain, which I guess could mean a lot of different things, but this is pretty common with tendinopathies and that type of pathology. So, no issues during your session and during their exercises, but there’s an increase in symptoms that night, the next day. Who wants to start this one off? Dave?
Yeah, I was just talking to the students about this with back pain, so it’s fresh in mind. They were asking about people who have soreness the next day after exercise in their back, or two days later. A lot of times, people were like, “Oh, I just slept wrong.” In this case it might be, I don’t know, “Oh, I stepped up a stair wrong.” And I just find that’s not true, just because we’re generally more resilient than that. One step probably won’t make your patellar tendinopathy flare up like crazy.
But I think generally what happens is that the accumulation of two to three days of activity, they really don’t realize, because they’re just busy. When you’re doing stuff and you have to carry things or you’re going downstairs or you have to bring stuff in from the car, you don’t notice a lot of that stuff unless it’s really bad. But what happens is that over the course of walking all day, standing all day, doing stuff, and then maybe going to the gym and exercising… It’s like you go to sleep, you wake up and the next day when you’re fresh, and you get up and you’re only focused on your knee, “Oh, my knee’s kind of bugging me right now”. That happens a lot with back pain.
People get two or three days going by… Neck pain that goes by. I’m like, “Oh, I just slept wrong. It’s just a little irritable.” I would say usually it’s a tiny step back like, “Hmm, what are you doing the other three days?” Were there exercises we did maybe that are new in your exercise program? Or we added a new, more knee-based exercise, like a goblet squat versus maybe we were trap bar dead lifting, or something that’s a little bit more loading on the knee. It’s not bad or good, it just is. You can just play around with what happened the last three days and then try to dig through the ideas there about what you can do. That’s usually the most common thing I find.
I feel like you just described my mornings right there. I think that was was perfect. But I like that and I think that’s a good concept here, that people are with us for an hour. They’re not with us for the other times of the days and you have to put all that together. If you didn’t feel it during that exercise, maybe it’s a total combination of some of the things you did. Kevin, what do you think?
Yeah, I was just going to say, related to what Dave said, I think back pain and neck pain is a good example where, sometimes if they have a flexion based low back pain and you don’t necessarily do a great job educating about how to modify positions at home, you see that quite a bit. They’ll go home and sit at work, or they flew over the weekend or something like that, and then their back’s all jacked up.
I think related to knee pain, if it is like a patellofemoral type thing, understanding that you get a lot of that bony contact between the patella and the trochlea when the knee’s flexed. A lot of times those sitting positions… Prolonged sitting is going to flare it up. I feel like with that specific injury, and I’d like, I don’t know, maybe hear your guys’ thoughts, but I think that’s one where you’d probably get some pain during the exercise if you’re getting that bony contact. If you’re doing deep squats and things like that, the person’s… I would think it’s going to feel some pain during activity. If it’s really just later on, then I would really sit down with the person and figure out, “What else are you doing at home that we can try to modify right now?”
And then also just look at your programming and think, “What exercises are putting a lot of stress through the knee joint here?” Sometimes temporarily you’ve got to reduce the amount of knee flexion with things like that, and maybe double down on hip exercises until they start to feel a little bit better, and then add back in some of the more strenuous exercises.
Yeah. That’s a great way of saying it. I would even add, more than just bony articular cartilage and bone type things, but even a tendinopathy, if you sit in a sustained position or if you’re in a sustained posture of any sort for a large amount of time, especially a chronic tendinosis type thing, those first movements are definitely that, “Ah, I got to get that tendon movement again.” So, that’s a great way of thinking of it as well, Kevin. I like that.
Dan, what do you think?
Yeah, I know I’ve talked about this before on the podcast, but I’m just a big fan of the pain monitoring model. This is an educational process for a patient as soon as they walk through the door. Essentially I give us some guidelines in terms of what’s okay from an exercise perspective, and that’s generally below five out of ten. For some people, I take that down a bit.
The other piece is if someone has a red flag, pain is not acceptable. It really depends on the diagnosis. If you have a stress fracture, no pain is okay. I’m not going to use this system. But something like patellofemoral pain, low back pain, lots of research and tendinopathies… One of the first things I tell patients is that we want to make sure the pain is below five out of ten, need you to feel back to your baseline the following day. If you’re not back to your baseline, then we did something a little bit off with your training program. Then to kind of go a step further, it’s not just back to your baseline in terms of how you feel. Generally you select an exercise. Let’s say you have patellofemoral pain. Do a squat. “All right, it’s my normal three out of ten pain.” And then essentially go through your program the next day, you do another squat, and if you’re at an eight out of ten pain now, that was too much.
The other educational process I go through with my patients is I say, “Hey, this is an experimental process. I don’t know how your knee or your back or your neck is going to behave. I’m going to guess with the best to my abilities what exercise is going to be best for you. We’ll see how I feel the following day. We might have to tweak things.”
The other thing I tell patients all the time is that physical therapy is like making soup. You get a little salt, put it in the soup, then you taste it. If it needs a little more salt, you put a little bit more in until you get to the perfect flavor. If you take a whole handful of salt and throw it in the soup, you may ruin it. If you do too much early on, even if it feels really good, the next day just keep in mind that the person might be really sore.
The last piece I’ll say is that oftentimes you can’t get away with no pain the next day. So I just educate patients and say like, “Hey, I’d be really surprised if you weren’t a little bit extra sore tomorrow. We did a lot today.” And I think as long as week to week, month to month, people are making progress, you’re in the right place, and the pain is not as important.
That a great way of thinking of it, Dan, and very helpful I think to a lot of people that are just getting started with these sorts of things. You’re not expected to nail it on your first attempt. We do our best with trying to pick an exercise that’s going to load enough but not under load or overload. You’re trying to figure out the right dosage of our workloads. Sometimes we’re off a little bit and you have to adjust. As long as you pivot, I think that’s fine.
One thing we haven’t talked about is that we’re talking about some symptoms the next day, but there’s a reason why you don’t deadlift every day, just as an example. You’re expected to have a little soreness like Dan said, but if it’s recovered by that second day, I think I would probably feel a little comfortable too. Let me throw this to Mike or Len or one of you guys, but this is a little… I think this scenario, there’s no pain with the exercise, but they’re sore the next day. Do you modify the exercise? Do you think it’s the exercise? I don’t know. What do you guys think? What do you think, Mike?
Oh, again, I think it comes down to the diagnosis, and patellofemoral pain sometimes is like a junk term, where there could be a couple of different things going on. I think you probably would need to know more about what type of symptoms they’re feeling, where they’re feeling it, to really get a better idea of whether exercise would cause that kind of symptom. I don’t necessarily know if I have a great answer for you.
Yeah, it’s acceptable. I mean, we don’t always know, right? “It depends” is a good answer. What do you think, Len?
Yeah, I think it depends. I think it’s them defining what those symptoms are the next day. I think they’re so, I don’t know, mentally freaked out by the pain that they were experiencing, that they feel something the next day, I think they immediately associate that with the negative connotation that their pain is back, their pain is returning. Like Dan said it, “Oh wow, that finished pain-free, thank God.” But defining what they’re feeling and we expect something normally sore after the exercise… But is it that soreness or is it that pain that brought them to see us? They have to define that, to try to define a level of it. And then, yeah, maybe back off a little, but I would reassure them that some of it is normal and we can push through a little bit depending on what we think is going on, and we oftentimes don’t know what’s going on.
But that feeling afterward, to me, it’s a little bit more tendon-y, soft tissuey, where you get like, moving helps create a pain-free environment and then they go to bed and then they wake up and they feel stiff and that soreness. I think that’s whatever inflammatory markers or whatever is going on in that area just needs to be moved and moved out and re-nourished by new fluid and then they oftentimes feel better. Then they’re back feeling good about things again. So, I think it’s coaching them through that. We are literally cheerleaders half the time when we’re trying to add exercise.
I think that’s a good way of saying it though, but that is part of our clinical expertise in what we have to determine, is our judgment call on if that’s an acceptable increase in symptoms, if that was almost an intentional increase in symptoms at the time, or if it’s something else. Mike, what else you got?
Well, I was going to make the flip side argument that it seems like exercise has an analgesic effect. I mean, we’re decreasing your symptoms with exercise, maybe… Obviously you came to us because your knee was hurting. Seemed to have a pretty positive effect with exercise, even though it tends to flare up the next day.
In terms of exercise modification, I would imagine quad strength is a big goal for this patient population. If they can’t tolerate the compression force at the patellofemoral joint in different degrees of knee flexion, this may be a patient where you do a week or two of blood flow restriction training to try and decrease joint stress while also building quad strength, and then revisit your exercises after. If you’ve retested quad strength and you’ve been able to increase quad strength without a ton of joint stress, then see how they tolerate the exercises from there.
That’s a great way to look at it. I think, Mike, too, is there’s probably some fear avoidance going on here. There’s probably some anxiety about these symptoms. Maybe they’ve been going on for a while, maybe they don’t have a high pain tolerance for this sort of thing. I think that’s absolutely right. Anything you could do to keep them moving and to adjust and to do different things would be very beneficial and almost like a learning process for their body.
Great episode. I think it’s good. I think, Val, the important component here is that this is pretty normal. I think we all deal with this almost every day with our patients to some extent. This sort of thing’s normal. I think for you, it just enters into that algorithm in your head of how do you modify and adjust just based on the presentation of the person in front of you.
I think with reps, you’ll start to see what works and what doesn’t work… But I think, overall, that’s the process that we would probably follow is to not panic. I think that’s one thing that the students appreciate from us a little bit here, because I mean, people come in with some really bad stuff with us. They’re Tommy John, like non-op rehab, they throw for the first time, their ligaments are killing them, and our job is to say, “Let’s just see how it is tomorrow.” We’ll get there. We’ll take a step back. We’re not going to panic, although I’m texting my surgeon friends, but whatever. But I’m not going to articulate that to the patient. I think that’s the key component.
Val, great question. If you have a question like that, head to mikereinold.com, click on that podcast link and be sure to subscribe, rate, and review us on Apple and Spotify, whatever it is that you use. We would really appreciate it. We’ll see you on the next episode.