Pain creates a complex relationship with activity. My patients who are athletes are sometimes the most difficult ones because they are strong willed and motivated to get back to their activities. This can be both positive and negative for activity progression. They are used to working hard to achieve results, but are sometimes blinded by activity goals so they may ignore pain or injury until it is truly debilitating. Self-efficacy is a strong indicator of getting better, but there must be a balance and recognition of one’s limits and abilities. The hardest thing for recovering athletes is patience.
For individuals, especially athletes, with an injury, whether acute or chronic, the most common question is: “When can I start doing _____ again?” Unfortunately, I do not have a simple answer for this. Each individual is different—their injury, their healing timeline, their goals, and therefore their activity progression. Instead of a simple answer, I work with the athlete to develop a graded exercise plan to help them return safely to their activity.
You may have heard the phrase, "no pain, no gain.” THIS IS A MYTH. We must listen to our bodies and perform safe, active recovery. That means a balance between rest and training.
The Traffic Light technique I describe below is based on the one created by Shirley Ryan Ability Lab (https://www.sralab.org/ ) and can be used for return to activity and activity progression for athletes and other individuals recovery from injury or pain. It is broken into three categories, just like a traffic light (red, yellow, and green). Each category includes the pain or symptom level during activity and after activity, the duration of pain, the potential for physical harm or injury as well as an action plan for activity progression. Many patients like to keep a copy of this chart on their phones or in a journal.
First off, become familiar with a numerical rating system for your pain or symptoms. I like to use a 0-10 scale because it is generally easiest to remember and replicate.
A zero on this scale would be no pain or symptoms while a 10 would be the worse possible pain or symptoms imaginable—think of needing to go to the emergency room right this instant! This rating is unique and based on YOUR symptoms and you can use YOUR previous experience with pain or symptoms as a comparison, but try not to compare to what you think others would rate your pain or symptoms.
RED
SYMPTOM LEVEL: Did the activity cause a severe spike in pain (7 or greater) DURING the activity that stopped you from continuing the activity?
DURATION: Did the pain persist for days to several weeks?
HARM CHECK: Was there a major loss in range of motion, strength and/or function? This indicates POSSIBLE injury OR too large of increase in activity level/intensity
ACTION PLAN: Notify therapy team ASAP and STOP activity
a. Seek medical advice regarding injury
YELLOW
SYMPTOM LEVEL: Moderate spike in pain during the activity (4-7/10)
DURATION: Pain persists after the activity by 3 numbers above baseline for…
a. 2 hours if 4-8 weeks post-injury/onset
b. 24 hours if 8-16 weeks post injury/onset
c. 48 hours if 16 weeks (4 months)+ post injury/onset
HARM CHECK: Was there a major loss in range of motion, strength and/or function? This indicates POSSIBLE injury OR too large of increase in activity level/intensity
ACTION PLAN: continue with activity, perform flare-up care if needed (rest, ice, meds), no new activities, do not increase intensity of activity, think and speak positively and avoid negative thoughts and words.
YELLOW LIGHT = SAFE, NO HARM
GREEN
SYMPTOM LEVEL: Low to moderate spike in pain during the activity (4-7/10)
DURATION: Pain is no worse after the activity and back to baseline within…
a. 30 mins if 4-8 weeks
b. 2 hours if 8-16 weeks
c. 48 hours if 16 weeks +
HARM CHECK: There is no change in range of motion, strength, or function
ACTION PLAN: be confident in adding more activity (1-5% per session/day)
This may only be 1 more rep of each exercise, or 30 seconds- 1 more minute on your run
Take away points:
a) DO NOT increase activity by too much! A very common problem that occurs is that athletes feel GREAT and then increase their activity TOO MUCH and move to yellow or even red lights. No matter how good you feel, try to only increase activity by 1-5% per session or day and allow for increased rest as needed.
b) Some pain is OK and not necessarily indicative of injury or tissue damage (Learn more about what your pain means!) You do not need to be afraid of your pain or symptoms, but it is good to be aware of them so you know when you may need to modify an activity. Also take note if you are changing your medication doses in response to activity progression. For example, if your pain has not changed but you require higher doses of your pain relieving medication, then you may have increased the level of activity by too much.
c) Active Recovery is important! Overtraining or increasing activity without adequate rest can increase symptoms. Active rest may be participation in a lower intensity activity such as walking or stretching. Quality sleep is also known to improve athletic performance.
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