Is “No Pain, No Gain” Good Advice During Injury Rehabilitation?

Abstract

This review examines whether the phrase “no pain, no gain” is useful advice during injury rehabilitation. It distinguishes tolerable exercise discomfort from delayed-onset muscle soreness, short-term symptom flares, and clear signs that loading has become excessive. Drawing on systematic reviews and randomized trials, the article shows why most musculoskeletal recovery doesn’t require complete pain avoidance. Progressive loading guided by pain monitoring supports tendon and muscle adaptation for engineers, clinicians, athletes, programmers, Amazon associates, and other evidence-focused patients. It emphasizes individual differences and the specific responses needed when neurological symptoms worsen or function declines sharply.

The phrase “no pain, no gain” still appears in gym conversations, warehouse break rooms, and software-team chats. A programmer finishing a long day at the keyboard may hear it when their wrist feels tight. An Amazon fulfillment associate may hear it after a shift of repeated reaches and turns. A recreational athlete may hear it the day after a particularly strenuous workout. The slogan works reasonably well for healthy training that produces ordinary muscle soreness. It becomes unreliable and sometimes harmful once an injury or tendinopathy is present.

The scientific record does not support a single universal pain threshold that every person should chase or avoid. Rehabilitation often does not need to be completely pain-free. At the same time, worsening neurological symptoms or a major drop in function require a different response than simply pushing harder. This distinction protects patients while still allowing the mechanical loading that tendons and muscles need to adapt.

What the Evidence Shows About Pain During Therapeutic Exercise

A systematic review and meta-analysis examined whether exercises that allowed or encouraged pain produced different outcomes than pain-free exercises in people with chronic musculoskeletal conditions (Smith et al., 2017). The review included nine papers from seven trials involving 385 participants. In the short term, painful-exercise protocols showed a small but statistically significant benefit on pain scores. Medium- and long-term differences in pain, function, and disability were not significant. The authors concluded that pain during therapeutic exercise need not be a barrier to successful outcomes.

This finding does not mean every painful sensation is beneficial. It means the automatic rule “stop at the first twinge” is not supported by the available trials for many chronic musculoskeletal problems. For tendinopathy specifically, the picture is similar. Protocols that permitted controlled discomfort while loading the tendon have produced meaningful improvements in pain and function without evidence of harm when symptoms were monitored (Silbernagel et al., 2007).

Four Different Sensations That Are Often Lumped Together

Patients and clinicians frequently use the word “pain” for experiences that have different meanings and different next steps. Separating them improves decisions.

• Tolerable exercise discomfort is a mild-to-moderate sensation that appears when a tendon or muscle is loaded and quickly subsides once the set ends. Many successful Achilles and patellar programs deliberately stay inside this range.
• Post-exercise soreness (often called DOMS) appears hours later, peaks in the next day or two, and then declines. It is common after new or heavier strength work and is not, by itself, a reason to abandon the program.
• Symptom flare is an increase above the person’s recent baseline that lasts into the next day or interferes with ordinary tasks. It signals that the recent load dose exceeded current tissue tolerance.
• Signs of excessive loading include sharp, escalating pain; new swelling that doesn’t settle; inability to complete the exercise with control; or neurological changes such as spreading numbness, progressive weakness, or altered reflexes.

No single number on a 0–10 scale works for every person or every tissue. Some individuals describe acceptable loading at 2–3/10; others tolerate up to 4–5/10 provided the pain returns to baseline by the next morning and does not trend upward across days. The useful test is not the absolute number but the 24-hour response and the week-to-week trend.

Pain-Monitoring Models in Tendinopathy Rehabilitation

The pain-monitoring approach popularized by Silbernagel and colleagues remains one of the clearest examples of structured guidance. In a randomized trial of patients with Achilles tendinopathy, one group continued running and jumping under a pain-monitoring model while the other group stopped those activities for six weeks (Silbernagel et al., 2007). Both groups performed the same progressive strengthening program. VISA-A questionnaire outcomes improved substantially in both groups at 12 months, with no negative effect from continued, monitored activity.

Typical elements of such models include:

• Pain during the exercise stays within a previously agreed tolerable range.
• Pain returns to the pre-exercise baseline by the next morning.
• Pain does not rise from one session or one week to the next.
• Function (walking, stair climbing, work tasks): either stays stable or improves.

A later systematic review of 30 studies on lower-limb tendinopathy found that pain-based progression criteria were the most common approach used in published programs, although the evidence supporting any single rule over another remains limited (Escriche-Escuder et al., 2020). The practical implication is that monitoring the response is more important than matching an exact historical protocol.

For Amazon associates who repeatedly change direction, data center technicians who climb ladders, or programmers returning to prolonged typing, the same principle applies: load the affected tissue enough to drive adaptation, then check the next-day response before increasing volume or intensity.

Progressive Loading and Strength Training

Tendons and muscles adapt to the loads they repeatedly experience. Complete rest reduces symptoms in the short term but does not restore the capacity needed for work or sport. Progressive loading—starting with isometrics or slow heavy resistance and advancing toward faster or more functional tasks—remains the intervention with the strongest support for most tendinopathies.

Strength training itself reduces injury risk in athletic and occupational populations when progressed gradually. The key is matching the rate of progression to the individual’s recovery capacity. A warehouse worker who adds heavy carries too quickly may flare up even if the absolute weight is modest. A desk-based engineer who jumps from zero resistance training to multiple weekly sessions may experience the same pattern. In both cases, the monitoring rules above guide the next adjustment rather than an all-or-nothing decision.

Individual Variability and Why One Threshold Does Not Fit All

Age, sleep quality, overall training history, metabolic health, and the specific tissue involved all change how much discomfort is tolerable. Shift workers and overnight NOC or fulfillment crews often have lower recovery capacity because disrupted sleep and irregular meals reduce it; the same absolute load may produce a larger next-day response than it would in a well-rested athlete. Programmers who sit for long periods may need extra attention to hip and thoracic mobility before lower-limb or shoulder loading feels manageable.

Because of this variability, rehabilitation plans work best when the patient records three simple pieces of information after each session: the highest discomfort during the exercise, how the area felt later that day, and how it felt the next morning. Patterns become visible within one to two weeks. Those patterns, rather than a fixed slogan, determine whether to hold, reduce, or advance the load.

When the Response Must Change

Certain findings override the usual monitoring rules and require prompt reassessment:

• New or worsening numbness, tingling that spreads, or true weakness that affects daily tasks.
• Pain that forces a change in gait or causes the person to stop work activities they could previously complete.
• Swelling, redness, or night pain that is increasing rather than stable.
• A sudden sharp pain during a movement that was previously tolerable.

These signs do not automatically mean surgery is required. They do mean you should pause or modify the current loading plan while a clinician evaluates whether the diagnosis, exercise selection, or an underlying medical factor needs attention. Non-invasive options—including chiropractic adjustments, targeted rehabilitation, and, when appropriate, modalities such as shockwave or laser—can often be adjusted before more invasive steps are considered. This approach aligns with the principle of non-maleficence: avoid unnecessary risk while still pursuing recovery.

Applying the Evidence in an Integrative Setting

At Injury Medical Clinic PA in El Paso, the same monitoring principles apply within a coordinated DC, APRN, and MD framework. Structural findings from the chiropractic examination are matched to the patient’s recorded pain and function responses. When metabolic or hormonal factors may be slowing tissue recovery, laboratory evaluation under medical oversight can identify treatable contributors. The goal is beneficence—care that serves the patient’s safety and long-term capacity—while preserving autonomy. Patients receive clear data about their response so they can participate in decisions about progression, temporary reduction, or adding other modalities.

Movement Medicine: Chiropractic Care | El Paso, TX

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Conclusion

“No pain, no gain” is too blunt for injury rehabilitation. Tolerable discomfort during progressive loading is often acceptable and, in many trials, associated with at least short-term benefit. Complete avoidance of all sensation is not required for most musculoskeletal recovery. Practical tools include a simple pain-monitoring habit, gradual load progression, and clear recognition of symptoms that demand a different plan. Individual responses vary; recorded next-day trends are more reliable than any universal number.

If you are an engineer, clinician, athlete, programmer, Amazon associate, or any evidence-focused patient trying to decide how much discomfort is acceptable during rehabilitation, a structured evaluation can turn the general evidence into a plan matched to your work demands and recovery capacity.

Call to Action
Schedule a coordinated assessment with Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, and Dr. Maria Guadalupe Cardenas, MD, at Injury Medical Clinic PA in El Paso. The team reviews your loading response, structural findings, and any indicated laboratory work so you can make an informed decision about progressive rehabilitation. Call 915-850-0900 or use the online scheduler.

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References

Escriche-Escuder, A., Casaña, J., & Cuesta-Vargas, A. I. (2020). Load progression criteria in exercise programmes in lower limb tendinopathy: A systematic review. BMJ Open, 10(11), e041433. https://doi.org/10.1136/bmjopen-2020-041433

Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: A randomized controlled study. The American Journal of Sports Medicine, 35(6), 897–906. https://doi.org/10.1177/0363546506298279

Smith, B. E., Hendrick, P., Smith, T. O., Bateman, M., Moffatt, F., Rathleff, M. S., Selfe, J., & Logan, P. (2017). Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine, 51(23), 1679–1687. https://doi.org/10.1136/bjsports-2016-097383