We are living in an era where often disparate fields of medicine, rehabilitation, pain science, and strength & conditioning can communicate freely and openly, ultimately improving human performance. This post is an example of such. I am happy to share an open letter from Leda McDaniel - a bright, thoughtful CrossFit athlete and coach I recently met - who has dealt with several orthopedic injuries and the pain that ensued. After reading her thoughts on this subject, I felt compelled that she share it on this site. This letter (in my opinion) applies to not only healthcare providers but coaches and athletes as well, with the intent to stimulate a more open discussion on chronic pain and managing it in our athletes.
How to read this post: 1) a little more background on Leda, 2) her open letter, 3) a few of my thoughts on the subject.
Leda McDaniel played basketball and ran track/cross country at Trinity University, a Division III school in San Antonio, TX. She has been involved with CrossFit both as a coach and athlete, competing in the 2010 South Central Regionals and 2011 NorCal Regionals. She graduated in 2008 with a degree in psychology and is currently applying for physical therapy programs.
A Letter About Pain: A Patient’s Request for Open Dialogue
I am writing with the intention of creating a better standard of care for future orthopedic patients. More specifically, I am interested in stimulating a constructive dialogue between patients and caregivers around the issue of pain. I believe that managing and trying to explain this sensation, for patients, is integral to successful rehabilitation from injury. Furthermore, I feel that there is a real need to acknowledge the mental and unconscious factors influencing pain. Through my recovery, I have found that compartmentalizing physical pathology or injury with the exclusion of a psychological component will lead to mediocre treatment at best and iatrogenic effects at worst.
For the past year, pain has become a daily truth for me as well as a source of continued anxiety. The pain was initiated when I tore the ACL in my left knee playing soccer. I had reconstructive surgery, a patellar tendon autograft, and experienced post-operative pain. This was expected, of course, and I tried to manage this with medication, and the standard dosing of R.I.C.E., however, the pain has persisted and become chronic. In my search for health, I have sought treatment from orthopedists, physical therapists, chiropractors, massage therapists, psychologists, herbalists, and an acupuncturist.
Throughout this process, I’ve had mostly a bipolar response from the healthcare community on what to do about pain. These two responses have been:
1- The “deal with it” approach
(i.e., The pain you’re experiencing is normal post-operative pain), you need to regulate it better and/or tolerate it)
2- The “listen to your body” approach
(If it hurts, don’t do it. You need to avoid pain-inducing movements)
The problem with these two approaches is that they infer that pain is a pure case of sensory and perception signal transmission. This is a commonly held view and it was a fine explanation for me up until the onset of chronic knee pain. You see, I had experienced pain with injuries and that pain had subsided as those injuries healed. I even had the same ACL reconstructive surgery on my other knee (right knee) a number of years ago and felt post-operative pain and its gradual decline with healing. I thought I knew that pain was a reliable indicator of injury or tissue damage. This view, according to pain researcher Patrick Wall, is incorrect. Pain does not necessarily indicate damage. There are instances of tissue damage without pain (those with very serious injuries, in shock, reporting no pain) and there are instances of people in agonizing pain without any obvious tissue damage (most chronic pain conditions, e.g., fibromyalgia).
If tissue damage isn’t the culprit, then what is the cause of chronic pain? Well known pain researcher, Louis Gifford explains it like this: there is mechanical pain (reflecting tissue damage/injury) and learned pain, which refers to sensitization of tissues and can be a cause of chronic pain conditions.
Obviously, pain is more complicated than just an indicator of injury. I am not asking medical professionals to know exactly what is going on, but I am asking that they make an effort to learn more about pain and communicate with their patients about it. After all, it is a big part of why patients seek treatment in the first place and, I contend, why patients follow the instructions of those in the medical community. If prescriptions and treatment plans are followed and pain does not dissipate (and there is no explanation for why or what pain is all about), trust in the person delivering that treatment erodes very quickly.
The two approaches that I’ve encountered have been unhelpful for me for a few reasons. First, the idea that “you’re going to feel pain, so just deal with it” suggests a level of helplessness surrounding the pain but also a complete dependence on symptom-relieving analgesics (e.g., pain medication) instead of alterations in activity or a deeper understanding of the meaning of pain. This can lead to negative outcomes like: engaging in physical activities that can ultimately be more damaging (i.e., pain is indicating further trauma) or the development of maladaptive cognitive coping strategies such as learned helplessness (i.e., the belief that “nothing I do can free me from pain, therefore I won’t try to get out of pain”). Learned helplessness factors into the high co-morbidity seen with depression and chronic pain. Okay, so clearly, there are problems with ignoring pain or even dealing with pain purely from a “deal with it” symptom relief perspective.
The alternative view, “If it hurts, don’t do it,” has problems as well. These have to do with the process that Gifford describes in which tissues and nociceptors can become hyper sensitive to stimuli and create pain signals that are not reflective of actual damage, but just a misfiring of the system. Lorimer Mosely describes this phenomenon as “central sensitization,” and uses metaphors to explain this idea to patients who are entrenched in the common structural-pathology paradigm. This was one of the most ideologically shattering ideas for me as someone experiencing pain. Do you mean that pain does not necessarily equate to bodily harm/injury? Just learning that pain could be due to hypersensitive nerve tissues and not be signaling damage decreased my anxiety and fear A LOT.
So, if the pain is not harmful, how do we deal with pain that doesn’t reflect physical injury? It can’t just be ignored. As Physical Therapist Gray Cook says, “The first rule of movement is this: pain changes everything.” Our bodies institute unconscious compensatory behaviors (e.g., muscle tightness or stiffness) to protect the painful area. Just because our brain logically understands that pain may not be harmful does not make our body react differently. Gifford eloquently describes one approach to this type of pain, saying, “The thinking has shifted from mechanical fault-fixing to ‘desensitizing’ – using movement, or mechanics, to alter pain processing that’s stayed sensitive too long.” The approach he is advocating for is the gradual introduction of movements that elicit little pain and retrain movement patterns as “safe.” I have since realized that my experiences in physical therapy have reduced some of my pain, utilizing this powerful tool of desensitization.
Finally, without a more in depth discussion of pain, the patient is left feeling helpless, frustrated, and distrustful of medical professionals who may dismiss the pain as “in your head” or “normal”. Again, I think it is very important to note that pain is neither purely physical nor purely psychological. The first attribution dismisses the validity of past experiences on present felt pain and the second trivializes a person’s very physical feeling of pain by labeling it, “psychosomatic.” Furthermore, there is no such thing as “normal” pain. In his book “Pain: The Science of Suffering,” Patrick Wall contends that pain is a conscious experience that necessarily includes an unconscious evaluative component. This is a view shared by researcher Lorimer Moseley and expressed in his book, “Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain.”
My hope is that we can use this complexity of pain to better communicate to patients the idea that they have agency to change potentially pain-inducing behaviors with the equally important message that the pain they are experiencing is not their fault.
I truly believe that there needs to be more open discourse on pain between patients and practitioners. The perpetuation of pain as a taboo topic is a nonscientific approach. Pain should be discussed openly and the intricacies of pain acknowledged. Only when patient and practitioner can speak about pain honestly and intently will the shame, frustration, and stigma dissipate. The more we can all learn about this construct, both scientifically and within felt experience, the closer we will be to finding more effective treatments for pain. I hope that your reading of this was relatively pain-free and I thank you for taking the time to read and keep an open mind.
Seth's thoughts: Fantastic piece, Leda! I agree there are plenty out there who do not understand, or are unaware of, the various pain constructs and their impact on daily and athletic life. It is critical that we acknowledge the fact that there really is no such thing as "normal pain". Clinically, many athletes I see report normal pain during or after their sport - this is not okay, people. It means that movement has already lost its integrity and often represents a threat to tissues and/or the nervous system, whether that threat is real or perceived. Furthermore, sensitization fundamentally changes movement patterns even after the painful stimulus is gone.
So if pain changes movement as Leda described, perhaps changing the movement pattern may modulate pain. As Gray Cook states: "perception drives movement behavior and movement behavior modulates perception". It's no surprise that a graded exercised program can improve function and quality of life in those with chronic back pain because, in part, it changes how the brain perceives movement. Lorimer Moseley discusses movement as the brain's perception of the demand and the capacity to meet it - we can change that capacity by retraining safe movement patterns.
Coaches are often the catalyst here as we see pain often at its earliest prior to going to the physio or MD. We all need to educate ourselves and our athletes/clients on the importance of pain because it ultimately keeps us from realizing our potential. We are much better off understanding and respecting pain than pushing through it - it's our ultimate protective device. If you don't understand the athlete's issues refer them on - we can't screw around with this stuff.
Pristine movement without pain is, or should be, the goal of sport and performance.
HUGE thank you to Leda for sharing this - you can contact her at firstname.lastname@example.org.
P.S. Watch this fantastic lecture by physio Lorimer Moseley on pain. His group has some of the best stuff going right now: