I choose ‘no injury’. Using the warning signal of pain as an overuse injury prevention strategy

By Pascal Edouard, MD, PhD, @PascalEdouard42

Overuse injuries are a common issue for athletes,[1–3] and preventing them is a priority in our field. Paying attention to the onset of the overuse injuries is a prevention strategy. The injuries may initially present as small pains that can easily be ignored and not addressed until significant pain or impairment is present.[1] When symptoms, such as pain appear gradually, they should be taken as warning signs by the athlete and acted upon – but this is considered difficult to do in comparison to sudden onset. It really comes down to listening to one’s body and taking any kind of pain seriously.

Pain, in theory…

Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Theoretically, pain is a natural mechanism to protect against injuries and overuse.[4] It alerts us to actual or imminent tissue damage, incites us to seek a cure and compels us to prioritise pain relief above almost everything else.[5,6] However, if in fact the brain concludes that there is something more important than protecting a body part then it makes the executive decision not to produce pain.[5]

 Pain, in (sports) practice…

Unfortunately, pain is frequent in sport.[1,7] Pain could be present as a physiological response to normal training as the tissues adapt to the exercise but without any real tissue damage. There is also the widely known adage of ‘no pain no gain’ which makes this acceptable or even welcome. Yet pain can also be a sign of injury. Pain may be present without injury, may develop or persist independently of the status of injury recovery, and injury may occur without pain.[6] Therefore, it can be difficult for athletes, and it is the main challenge for health professionals, to differentiate “physiological” pain  from “pathological” pain (associated with injury or start of injury): “to distinguish the ‘warning signal’ from the ‘noise’ of pain”. For example, athletes and health professionals should differentiate pain as symptom of delayed onset muscle soreness vs. strain, or as symptom of intense eccentric training vs. first sign of tendinopathy.

To be, or not to be painful

Since pain is a physiological ‘warning signal’, the athlete can react to it or not: Athlete can treat it (signal/pain) or not. Athlete can choose whether to act to protect his/her body or ignore the pain signal and continue their sporting activities with the pain in the hope that the pain alleviates. The brain can thus conclude that sporting practice is more important than protecting the body.[5] Coping strategies and athletes’ alterations of pain perception can increase pain control and lead to the body either suppressing or reducing the pain signals it produces.[4] The athlete is not passive regarding pain but must analyse/interpret the signal and make a decision: athlete has ‘free will’.

To be, or not to be injured

In the context of gradual onset overuse injuries, when athletes start feeling pain during or after their sporting activity they can, after analysing their pain choose either 1) to continue their activity with the pain and take the risk of increasing the pain and consequently risk further damage, or 2) respect the pain, and consult a health professional for advice about the best care or decrease/adapt/modify their sporting activity to the pain. In other words, the athlete can choose to be injured or not.

To use the warning signal of pain as an overuse injury prevention strategy!

Paying attention to the pain occurring during or as a consequence of sporting activity and taking into account the ‘warning signals’ can help athletes prevent overuse injuries. This is both ambitious and complex, especially in the context of elite/professional athletes, since pain is frequent, may be present without injury, and subjective. Although pain is frequent in sport, this should not be the normal condition. Although coping with pain is an integral part of athletic training and coping skills are important features in the development of athletic character,[4] pain should not be trivialized.

Thus, the question for athletes (and coaches and health professionals) is: How to differentiate pathological from normal pain? How to differentiate the ‘signal’ from the ‘noise’ of pain?

It is our role as sports health professionals, as guarantor of athletes’ health, to 1) help in this diagnosis (as earlier and as precise as possible), 2) inform athlete (and coach by keeping the medical secret) on the benefice/risk balance regarding continuing practice, 3) educate athletes not to hide, neglect and trivialize their pain, and 3) educate athletes and their coaches to analyse/interpret and to use pain as relevant feedback.

For athletes and coaches, some tips of practical strategy could be: not to neglect and trivialize pain, at best discussion between athlete, coach and medical staff about the best strategy (diagnosis, sport practice…), at least adapt/modify sporting activity (type or load) with the goal of reducing pain (during, after, and next day of sporting activity – ideally to be pain-free or at least minimal pain (defined as 3/10 or less[8,9])) and without more than 3 days with pain.

Do you think that it is realistic and feasible? Do you have other proposals?

Pascal Edouard MD, PhD, IOC Diploma Sports Physician, is an assistant professor and works as sports medicine physician at the University-Hospital of Saint-Etienne, and as researcher at the University of Lyon (Inter‐university Laboratory of Human Movement Science EA 7424), France. His main research interests include sports injury and illness prevention, especially in athletics.


1         Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med 2009;43:966–72.

2         Clarsen B, Rønsen O, Myklebust G, et al. The Oslo Sports Trauma Research Center questionnaire on health problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med 2014;48:754–60.

3         Alonso J-M, Jacobsson J, Timpka T, et al. Preparticipation injury complaint is a risk factor for injury: a prospective study of the Moscow 2013 IAAF Championships. Br J Sports Med 2015;49:1118–24.

4         Tesarz J, Schuster AK, Hartmann M, et al. Pain perception in athletes compared to normally active controls: A systematic review with meta-analysis. Pain 2012;153:1253–62.

5         Moseley L. Pain: Why and how does it hurt? In: McGraw-Hill, ed. Brukner & Khan’s clinical sports medicine. Australia 2016. 55–63.

6         Hainline B, Turner JA, Caneiro JP, et al. Pain in elite athletes—neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Med 2017;51:1259–64.

7         Harringe ML, Lindblad S, Werner S. Do team gymnasts compete in spite of symptoms from an injury? Br J Sports Med 2004;38:398–401.

8         Malliaras P, Cook J, Purdam C, et al. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sport Phys Ther 2015;45:887–98.

9         Thorborg K, Branci S, Nielsen MP, et al. Copenhagen five-second squeeze: A valid indicator of sports-related hip and groin function. Br J Sports Med 2017;51:594–9.


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