So I recently had a patient who came in with knee pain. Her knee was mildly swollen and she had difficulty bending it. As many people do, she had been babying it for the past couple months but it had not improved. She had a very clear fear of moving it because she was afraid that she would hurt it more. She had fear avoidance.
This is a very real fear for many people – if I move what hurts, it might cause more pain and a worse injury. There is a term for this in the medical field. It is called fear avoidance and it is associated with chronic pain and poor outcomes in physical therapy which means that they are not likely to improve.
As a physical therapist, I have a unique relationship with pain. I don’t have the same type of fear of it as others do. I tend to cause quite a bit of pain practicing physical therapy but I use the patient’s pain to help determine what and how to treat. Where does it hurt? What is the intensity of the pain? What is the type of pain? Do certain movements, exercises or manual techniques increase or decrease the pain? All of these answers will help me locate the injured tissue or joint, determine how bad the injury is, and develop ways to treat it. In fact, in our profession, pain is a crucial tool in helping our patients improve and get on with their life pain-free.
Back to my patient with the knee injury. I spent a good portion of her first visit on educating her on the importance of movement and on a different way to think about pain. I am not a big fan of “babying” a hurt joint or tissue unless it is essential for healing. For most injuries, it is important to keep the area moving. This keeps good blood flow to the area for faster healing and prevents it from becoming stiff and weak. 
For these reasons, I tell my patients to practice relative rest when recovering from an injury. Relative rest is basically continuing to do all the activities that do not irritate the injured area. For example, if walking doesn’t bother the knee, continue walking as you would normally. However, if walking does increase your pain but biking doesn’t, then limit your walking but continue biking.
A different way to think about pain
I try to get my patients to think about pain in a different way. Pain is a way that your body can communicate to you about an injury or a potential injury. I tell my patients to be pain detectives and find patterns with their pain. This includes when the pain occurs. How long does it last? Does it increase or decrease as you continue to do the activity? What type of pain is it? For example, is it sharp, shooting, burning, aching, or dull? Has the pain increased, decreased, or stayed the same since the injury? Paying attention to the information that pain is relaying to you will allow you to know what to do and what to avoid. 
For instance, if you initially have a low level of dull pain when walking but it goes away after about 5 minutes and doesn’t return afterwards, it is a pretty safe bet that walking is not going to exacerbate the injury. If you begin walking without pain but 5 minutes later you start to feel pain that is gradually increasing, then there is a good chance that walking is probably going to irritate the knee. Sharp, shooting pains should be avoided but low, level dull, achy pain that does not get worse during activity is usually okay. Using pain as a messenger from the body, rather than as something to fear and be avoided, is much more useful for staying active and healing quicker.
Find patterns in your pain
Knowing your pain pattern also gives the healthcare provider more information and clues about the probable diagnosis. It is much harder to evaluate a patient who simply states that their knee hurts everywhere, all the time, and with every type of movement or non-movement. Usually this is a red flag of fear avoidance. This patient might equate pain with injury and be hypersensitive to all pain. Even if the pain is constant, it will probably still be more or less severe with different movements and actions. However if the patient is afraid that any pain will cause more injury, they might perceive even slight pain as severe.
Also increased fear avoidance is also associated with chronic pain and changes in the brain that cause even slight pain to be felt as severe. Once there is central sensitization of pain (changes in the brain) in an injured area, it is very difficult to recover. Continued pain, to a lesser degree, would be expected even after the tissue is healed and the person is discharged from physical therapy. This is a situation that is best avoided, if at all possible. I recently evaluated a teenage girl who came in with a MCL tear a year ago. The MCL is healed but now she has chronic pain and is scared of moving the knee. She has all the hallmark signs of central sensitization. Her pain, disability, and prognosis are worse now than during the initial injury.
Don’t fear your pain
Luckily, my patient with the knee injury, was very open to my explanation about not fearing pain but using it as a way for the body to communicate. She had increased anxiety with pain but I was able to help her control her anxiety. I assured her that the pain she felt during the manual therapy was normal for her condition and that she would feel some soreness with movement
because the knee is still stiff. The patient felt significantly better after the first treatment and really took everything I told her to heart. She was walking her dog 2 miles a day and going to yoga 3 to 4 times per week after just a few treatments. The most beneficial treatment for her was education about pain. Understanding her pain but not fearing it, was essential in her recovery.
In review
- Don’t fear pain – think of it as a way your body is communicating with you
- Not all pain equals injury – having pain doesn’t mean that you are making your condition worse
- Be a pain detective – find patterns in the pain
- Practice relative rest – keep moving in ways that do not increase your pain
- Go see your healthcare provider – the earlier an injury gets treated, the easier the recovery
If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional Resources
https://www.medicalnewstoday.com/articles/central-sensitization-syndrome