Pain is Part of the Picture, But Not the Whole Picture
Pain is real, but pain is weird. This past week in my baseball game, I had to dive back to first base for three pick-off attempts, and then I stole second base, and I came out of it with a scrape on my right knee. The rest of the day and into the next, it was throbbing and painful, with a tearing sensation while bending my knee. But it got me thinking, “this is just a scrape to the outer layer of my skin, why does this hurt so much?” That is because pain tells us something has happened, but it doesn't necessarily tell us what has happened.
Pain is very abstract, and it can be difficult to describe and quantify, yet it is usually the central theme during injury assessment and rehab. The textbook definition of pain is an unpleasant sensory and emotional experience linked to actual or potential damage; the keyword being ‘linked’ and not ‘the result of’. It’s why a paper cut can be quite painful. But it’s also why diagnostic imaging can reveal rotator cuff tears or knee osteoarthritis in people without pain or other symptoms. Two people can have similar degrees of degeneration (or as I prefer, age-related changes), yet one has very minimal symptoms and one has debilitating symptoms. Pain reflects your experience, but not necessarily how much harm has occurred. A 1/10 pain doesn’t mean a 10% tear and an 8/10 doesn’t mean an 80% tear.
So why is pain so variable among people? Pain is influenced by numerous factors. One of those factors is, of course, what is happening at the tissue level. But also think about your previous experiences with pain, your current level of stress, your sleep quality, your level of concern about the injury, your expectations about your pain, and what you think your pain means, just to name a few. All of these factors can change your experience of pain, either turning up or down the volume knob on your injury.
Pain is useful because it usually forces us to change something. If there’s a stone in our shoe, we stop and take it out. If I scraped my knee, I’m probably not going to kneel down on it. Pain after an acute injury can help us protect the area while it heals, but that doesn’t mean we have to stop everything we’re doing. Though the individual nature of the injury and pain matters, we can still generally do some activity as long as the pain is tolerable. At the same time, no pain doesn’t mean everything is fully healed and you’re ready to go. My knee could be pain-free, but the scab is still forming and therefore highly susceptible to re-injury.
When it comes to assessing an injury and developing a rehab plan, there is more to it than just, “how much does it hurt?” I ask a lot of questions that paint a more complete picture of your injury beyond just pain. Was this a traumatic injury or something that slowly developed? What can you currently do? What is your pain preventing you from doing? What impact is your pain having on you day-to-day? What impact is it having on your physical activity? Is your pain getting worse or changing at all? Does your pain make sense to you? Can you control your pain? How confident are you that this will improve? These questions give me WAY more information than simply describing your pain. They tell me about the impact it is having on you, as well as your views and outlook on your pain. This paints more of a complete picture than a 5/10 dull aching pain.
My scraped knee reminds me that pain is weird, but it doesn’t accurately reflect what’s going on. This scraped knee made running feel really weird, but I’ve previously been able to play baseball with a full-thickness rotator cuff tear. It may help to think of pain, not as an indicator of what we’ve done to ourselves, but as a volume knob that gets turned up and down to reflect our experience.
