Rehab does not end when pain does

Let’s look at a very common issue that comes up with many rehab situations both athletes and the general population. A person comes in for an issue or concern that they have that is very often related to pain or an injury. I try to make a consistent effort to emphasize that there is more to recovery than simply resolving the pain. Unfortunately, and understandably so very often a patient will have a stint of being pain free for whatever amount of time they feel is perceived as fully recovering and abandon their rehab program. The fact is often times one can be pain free ongoing and still not be back to functional status prior to injury.

When it comes to the general population there are numerous reasons why one should continue their therapeutic exercise. From a clinician standpoint, once pain is under control and any other possible concerns are ruled out I strongly shift the responsibility of recovery to the patient. At this point there is hope fully there is therapeutic alliance where the patient respects and adheres to my advice the best they can. Even with that many will still abandon their rehab.

The first major reason for the everyday person is that the road to recovery is not linear. Above is an excellent depiction of this reason by Adam Meakins (www.thesports.physio) about what perceived recovery is and what reality is. Recovery is very much a two steps forward, one step back approach in a sense. Let’s take a rotator cuff tendinopathy or even partial tear. Initially with good education, and appropriate exercise selection there may be some noticeable improvements in range of motion, which is great progress….. but there’s a bit more pain/soreness because the area is being loaded, still it’s progress. The patient works on the exercises for a few more weeks and begins to tolerate more and more load and eventually they become pain free. Then they try to up their activity levels and flare the shoulder up a bit, this may require slight regression of their exercises and again progressing the load. Then they may return to all normal activities, continually increasing frequency and duration until a few months later then may feel a slight soreness return, they return to the exercises and continue the recovery. It can often be an ongoing process. I always advise people that it wouldn’t hurt to continue the exercises especially strength exercises anywhere from 2-4 months if not ongoing even after I have discharged them.

Next reason is that exercise itself is analgesic, meaning exercise can have a pain reducing affect. This is good because it promotes activity as the main component of the recovery. This can also be misleading as stated previously, the patient has been doing their exercises for a few weeks, pain is gone so they stop the exercises. In this case it may be only to have the pain return later on and be even more so frustrated since they thought the rehab process was done. This can be not only frustrating but it can make the pain worse when it does return possibly if the patient perceives that as being a re-injury as opposed to aggravation of the initial injury.

Lastly, for the general population many of the people I see typically do not meet relative weekly activity guidelines, so reinforcing that it can be beneficial to continue the exercises. This will help build more strength, nothing wrong with getting stronger. Also, since they are now pain free, it is an excellent time to begin building habits. Who knows, maybe them continuing to do these exercises when they would have done nothing may motivate them to get into other activities as they continue to learn and notice the benefits of exercise.

When it comes to an athletic population very similar reasons occur. Beyond those reasons stated above, the high level athlete is that much more reliant on maximal ability. One study looked at Aussie football players, they took athletes that had either not ever had a history of significant hamstring injury and those who had a recent hamstring injury in the past two years in which they had to miss at least a week of training. There were 20 in each group, they performed strength testing both before and after repeated sprints. Remember these were athletes that were cleared to return to sport. When they tested their torque (measure of force/strength) outputs after sprints, the researchers were able to predict 100% accurately who had had a recent hamstring injury and who hadn’t based on strength/torque deficits(1). What does that mean? This could actually mean one of two things. Could mean that the strength deficit played into the injury or the injury left the deficit. Although we do have research that shows that strength imbalances can lead to injury. This includes a study that showed those with hamstring strength imbalances were almost 5 times more likely to have a hamstring injury in that season (2).Either way we have an elite athlete with a strength deficit under fatigue. So one leg will have less capacity than the other leg which sets up for a situation where the athlete can feel they can continue to push the intensity despite one leg/hamstring already having met its capacity and thus susceptible to injury. This is possibly one of the reasons that there is such a high rate of re-injury with many lower body injuries especially hamstrings and including ACL reconstructions. One analysis showed that the re-injury rate of hamstring strains in athletes ranged from 14-63% within two years of initial injury (3). Clearly, the rehab process was dismissed at some point and strength imbalances not fully addressed. If strength imbalances increase risk of injury and injuries lead to strength imbalances, then resolving them should be the focus of any rehab especially with the athletic population.

So the take home here: The rehab process does not stop when pain does. Many injuries, especially traumas will often result in strength imbalances due to relative inactivity during initial phases along with tissue disruption and decreased neuromuscular stimulus and that strength imbalances can be predictive of injury. So if you have an injury, it is highly recommended to continue the therapeutic exercises especially unilateral strengthening of the affected area well beyond the absence of pain at least until you can ensure that the strength deficits have been resolved. There is more to an injury and one’s recovery from it than simply just resolving pain.

Keep moving, keep getting stronger.

Thanks for reading, Vitas

1. Lord et al. “Change in knee flexor torque after fatiguing exercise identifies previous hamstring injury in football players” Scand J of Sports Med. 2017.

2. Croisier et al. “Strength Imbalances and Prevention of Hamstring Injury in Professional Soccer Players” The Am J of Sports Med. 2017.

3. De Visser et al. “Risk factors of recurrent hamstring injuries: a systematic review” BJM. 2012.