Understanding Pain and Exercise: When to Push, When to Pause
By Daryl Cole, Chartered Physiotherapist
As physiotherapists, one of the most common conversations we have with patients is about pain and exercise. Pain is complex—it’s not always a sign of harm, and it doesn’t always mean you need to stop moving. In fact, in many cases, some pain during or after exercise is not only acceptable, it’s expected.
So how do you know when pain is okay—and when it’s a red flag?
The Nature of Pain
Pain is an output of the brain, not just a direct response to tissue damage. It’s influenced by biological factors, but also by our thoughts, emotions, previous experiences, and even our sleep and stress levels. The landmark research from Moseley and Butler (2017) in Explain Pain Supercharged shows us that pain is more about protection than damage. In other words, just because something hurts doesn’t mean it’s harmful.
Pain During Rehabilitation: Often Normal, Sometimes Necessary
In many rehabilitation settings—such as tendon rehabilitation, osteoarthritis, or chronic low back pain—some level of pain during exercise is acceptable and even encouraged. A 2020 systematic review in Journal of Orthopaedic & Sports Physical Therapy (Smith et al.) found that for chronic musculoskeletal pain, exercising into pain (within tolerable limits) resulted in better outcomes than pain-free exercise.
This is especially true for tendinopathies like Achilles or patellar tendon issues. Pain during loading exercises is often part of the process of retraining and strengthening the tendon. Rather than avoiding pain entirely, we help patients learn to differentiate between acceptable discomfort and problematic pain.
When Is Pain a Problem?
Not all pain should be pushed through. Here are some signs that pain during or after exercise might be a problem:
● Pain that worsens significantly during or after exercise, especially if it doesn’t settle within 24–48 hours.
● Pain that is sharp, catching, or causes you to compensate in how you move.
● Pain associated with swelling, bruising, or joint instability.
● New, unexplained pain—especially in areas that weren’t previously involved.
A rule of thumb often used in physiotherapy is the “traffic light” system:
● Green: Pain is mild (1–3/10), settles quickly, and doesn’t impact function—keep going.
● Amber: Pain is moderate (4–6/10), lingers for a day or two, but doesn’t worsen over time—monitor and possibly modify.
● Red: Pain is severe (7+/10), escalating, or affecting how you move—stop and reassess.
When Pain Is Acceptable—and Even Helpful
In chronic pain conditions, complete avoidance of pain can sometimes reinforce fear and disability. A 2018 article in British Journal of Sports Medicine (Silbernagel et al.) emphasizes that educating patients to understand their pain, rather than fear it, is critical. Pain does not always mean harm, and avoiding movement altogether can delay recovery and reduce physical function.
Helping patients reframe their pain experience—understanding that some pain is safe—can build confidence and restore activity levels. Graded exposure to movement, in this context, is key.
Take-Home Message
● Pain and exercise have a complex relationship—pain isn’t always a reason to stop.
● For many chronic or persistent conditions, some pain during exercise is acceptable and can lead to better outcomes.
● Recognising signs of problematic pain is essential to prevent injury or flare-ups.
● If in doubt, speak with a physiotherapist who can guide you through safe and effective movement strategies.
Exercise is medicine—but like any medicine, it needs the right dose. The goal isn’t to eliminate pain entirely, but to build confidence and capacity through movement.