Predictable and Unpredictable Pain

 

Dr. Douglas W. Stoddard, 
MD, M Sport Med, Dip Sport Med, ES
Medical Director-Toronto SEMI
Medical Director-Medion (e load, e load gel, emend, zone caps)

Our Sport Medicine practice at SEMI is filled with daily opportunities to help our patients understand when they can play, exercise or train with pain, and when they should stop and seek professional help. There are times when it is ok to play with pain. This article will focus on two different kinds of pain, how to distinguish them, and when to book into see us for help.

Predictable pain

Predictable, or acceptable pain, is pain we expect, and it's frequency, intensity and aggravating factors are, well, predictable! Two types of predictable pain exist:

The first is Delayed Onset Muscle Soreness (DOMS), andcommon after 'new' exercise, which can either be a new activity, or, an increase in the frequency and/orintensity of an 'old' activity. The operative word here is after exercise, and it is always associated with something new. Therefore, this is also described as 'New activity, new pain'. The constant association with something new is the predictable part. DOMS always resolves without much fanfare, though it may take up to a week to do so. As the name suggests, the onset of DOMS is usually delayed after the activity in question, its' onset usually happening within a few days, but sometimes as early as within 12 hours. It still isn't quite clear what actually happens to the affected muscles, but theories include lactic acid build up, microscopic tears in muscle fibres, and swelling from the healing that occurs when muscles try to regenerate after exercise. Muscle pain that lasts longer than a week should always be assessed formally, as the pain of DOMS should be gone by this point.

Treatment of DOMS includes gentle stretching of affected muscles, ice, anti-inflammatories/pain killers for severe cases, and gentle exercise where pain is not provoked. Unfortunately, there is no magic bullet for the treatment of DOMS. Prevention is even difficult, and is often discovered in hindsight when one assesses the level of activity just done that provoked the problem.

The second type of predictable pain is pain that may happen during or after exercise, and classically happens with exercise that you are accustomed to (opposite to DOMS, which happens only after exercise you are unaccustomed to). This type is also described as 'same activity, same pain'.

This type of pain often afflicts individuals with chronic injuries. By definition, a chronic injury is one that will not completely heal. This can happen for a variety of reasons, including scarring, nerve injuries and degenerative changes such as osteoarthritis. All of these problems may have an irreversible component to them, and another feature of this type of predictable pain is it often accompanies chronic, irreversible injuries. So, predictable pain in the setting of an irreversible injury is acceptable pain.

For example, Dave, who is 65 years old and who has osteoarthritis in both of his knees, knows that he can play doubles tennis twice a week for an hour each time, causing increased pain in his knees that lasts only until the next morning. Once he is out of bed the next day, and after a few minutes of moving about his house, his pain is gone. When he plays doubles tennis again later that week, the same thing happens, and has been happening for about a year now. This is an example of predictable pain in a chronic injury, and is nothing to worry about. This type of pain does not mean a problem is getting worse, and should not be cause for alarm. Having said that, it doesn't mean that there aren't things that Dave cannot do to reduce his pain, and these things can all be discussed in the clinical setting. What it does mean, however, is that this is not pain that should produce anxiety or necessarily lead to a change in activity.

If, however, Dave's pain began to last throughout the next day, changing in it's usual pattern despite no change in the activity frequency or intensity, this would be a reason to seek help, for the changing pattern of pain can be a sign of his condition worsening. At this point, counter measures can be discussed in order to try to bring the problem back under predictable control, which may include various forms of therapy, exercises, orthotic prescription, medications, bracing and injections.

 

Unpredictable Pain

Unpredictable, or unacceptable pain, means a pattern of pain is changing, which can herald a worsening condition needing intervention. This can be described as 'same activity, new pain'. Usually this means that the pain maybe provoked with less and less exercise, or maybe accompanied by new symptoms such as swelling, numbness, tingling, weakness, painful clicks/noises and instability. The key here is that the usual pattern is changing. The first step with unpredictable pain is to modify the offending activity, reducing the time, frequency or intensity, or all three, of the activity in question. Add in some gentle stretching, icing and possibly an over the counter anti-inflammatory like ibuprofen or Advil, and if the pain or new symptoms don't subside within 10 days of their onset, again, it's time to get help.

For example, Sharon, a 40 year woman who loves to swim, has been doing so three times a week for 2 years now. She swims the same distance, same strokes and same intensity every time ( Lately, however, Sharon's left shoulder has been sore after her swims. Initially, her soreness only lasted a few hours, but now is lasting for a few days, even into her next swim. This is an example of unpredictable pain-'same activity, new pain'. It is always the type of pain that should be respected as a warning from your body that something isn't right. Again, initial activity modification (i.e. Sharon may want to try reducing her swimming to twice per week, and cutting down her distance by 25%, as a start), icing, stretching and possibly an over the counter anti-inflammatory are the first steps. If improvements aren't forthcoming, it's time to seek help.

So, in summary, predictable pain has two manifestations: 'new activity, new pain' and 'same activity, same pain'. Both of these are acceptable forms of pain and can be played through. Unpredictable pain is best described as 'same activity, new pain' and if after 10 days of basic interventions the pain remains, let us know.

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For most of my adult life I have dealt with the discomfort of Chondromalacia Patella and Patello-femoral Syndrome. These two conditions effectively ended my competitive cycling and skiing careers. It ultimately became so painful that I thought surgery was the only solution. But thanks to the team of excellent doctors and therapists at Toronto SEMI, I have finally overcome these difficult knee problems without surgery. I am now performing in both cycling and skiing better then I have in years.

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