People respond to pain differently and develop different coping strategies and habits around that. Some people tend to keep going - they stay active despite symptoms and may be reluctant to back off. Others tend to pull away - they reduce activity, avoid painful movements, and may become increasingly cautious about what they think is safe to do. Neither approach is inherently wrong, but either can become a roadblock to your rehab progress if it becomes too dominant or rigid, even after your circumstances or needs have changed. When you’re dealing with pain, the answer isn’t always to push through it or stop doing everything. The most useful strategy is knowing when to do more and when to do less.
The Endurance Coper
“It hurts, but I’m not letting it stop me.” Endurance copers tend to remain active despite there being pain with their activity, either with or without modifications. They continue to do the activities they enjoy, whether it’s because they’re determined to maintain their fitness and participation or simply because they’re stubborn and believe things will improve on their own over time. Likewise, they aren’t afraid of pain or movement, even if they aren’t aware that pain doesn’t necessarily mean tissue damage.
For certain conditions or stages in rehab, these can be very useful behaviours and a good approach. An example of this would be for tendinopathies, where best practices recommend continuing loading the painful tendon rather than resting it. But the mindset of, “if some activity is good, more must be better” can be problematic. If someone continues to run, throw, or lift, especially if symptoms are worsening, they may simply not be giving their body enough opportunity to recover and adapt to the load they’re applying. A good example of this would be a runner with a stress fracture, where continuing to run would be making their condition worse.
The Avoidance Coper
“It hurts, so I don’t want to make it worse.” Avoidance copers tend to back off of physical activity, usually in its entirety, as they do not want to make their injury worse. Not only will they avoid activities that are painful, but they may even avoid everyday movements that aggravate their pain. As such, they’ll develop strategies or compensations to avoid poking into pain. Again, this strategy can be very useful. If someone has just sustained an acute injury, like a ligament sprain, modifying or temporarily avoiding aggravating activity is completely reasonable. An example would be using crutches after an ankle sprain; if walking is particularly painful or difficult initially, temporarily reducing the amount of weight placed through the ankle can help manage symptoms. If an injury is highly irritable, doing less for a period of time may be exactly what that person needs to calm it down.
But again, too much of one thing, even a good thing, can be a bad thing. For avoidance copers, the risk is that temporary protection becomes permanent avoidance. We sometimes see this in people who have low back pain, particularly when bending forwards is painful. Even when pain subsides, they may still continue to avoid bending forward for fear of re-aggravating their pain. The problem is that this fear-avoidance behaviour, sometimes called kinesiophobia, can become a downward spiral or self-fulfilling prophecy. They do less and less because they’re worried that movement will cause damage. This can reduce their tolerance for movement and confidence, potentially reinforcing their fear.
It’s Not All or None
Endurance and avoidance coping strategies lie at opposite ends of the spectrum. But one strategy is not inherently better than the other, and you’re not permanently assigned to one strategy. That also doesn’t mean that the answer necessarily lies in the middle. Rather, the question is whether the behaviour matches what the person and their injury need at that point in time.
For a runner with an ankle sprain, they will probably be avoidance-heavy immediately after the injury due to the pain, swelling, and not wanting to make it worse. As the initial pain settles, they should start to gradually increase activity, starting with some ankle circles for range of motion, using a resistance band to start strengthening, and walking and doing balance drills. Ideally, they would then start to develop a more endurance-oriented approach continuing with these exercises to strengthen the ankle, despite some pain still being present. The pain they’re experiencing may reflect the sensitivity of the injured joint, rather than further damage from the exercises. Ideally, any discomfort settles afterwards, and they start to notice a trend of less pain and improving function overall. As they progress and get back into running, they may inadvertently overreach and cause a flare-up and revert back to some avoidance coping strategies to calm their ankle back down to avoid a major setback.
The Importance of Being Flexible
As I’ve previously written about, being flexible and adjusting your rehab strategies as things change is key to a successful recovery from injury. Sometimes the answer is, “let’s back off”, but then a few days later it’s, “let’s keep moving.” But it can also be tough to admit when the same strategy you’ve been following for several weeks isn’t actually helping, whether that’s continuing to push through pain or continuing to avoid it.
For those who have felt stuck with their rehab progress, taking a step back and looking at their program can be valuable. What are you currently doing for your injury recovery? That might be certain exercises, activity modifications, or even just complete rest. An athletic therapist can help you work through your program and provide an outside perspective on your recovery. You may not realize how much activity you’re actually doing, and that taking a step back is what you need. Or you may not realize that you are actively avoiding certain movements and that it’s actually safe to perform them even if there is some pain. Throughout rehab, it’s a mix of doing more and doing less, and an athletic therapist can help you find the right amount.
