'No Pain, No Gain' Is Ruining Your Rehab

Somebody says it to me most weeks. I will be guiding a patient through a set of squats, they will grimace, and before I can ask what they are feeling they will grit their teeth and mutter "no pain, no gain" as if apologising for not suffering enough. It is one of the most persistent exercise pain myths in circulation — I hear it in living rooms and gyms right across Liverpool — and in a rehabilitation setting it does real damage. I have watched promising recoveries stall because somebody decided that hurting more meant healing faster. It almost never does.

Let me unpick what the belief actually gets wrong, and give you something far more useful to replace it with.

Where the idea came from

"No pain, no gain" belongs to 1980s aerobics videos and old-school strength culture, and it was never a clinical principle. It grew out of a half-truth: hard training genuinely does require discomfort. To build strength you must load a muscle beyond what it is comfortable doing, and the last few repetitions of a good set should feel horrible in a very specific way — burning, heavy, effortful.

The problem is that the slogan collapses two entirely different sensations into one word. Training effort is not the same thing as tissue pain, and treating them as interchangeable is how people turn a manageable niggle into a six-week problem.

What the evidence actually shows

Modern rehabilitation research has moved decisively away from the idea that pain is a necessary ingredient of recovery. Two findings come up consistently.

The first is that pain is a poor measure of tissue damage. Pain is produced by your nervous system as a protective output, influenced by load, yes, but also by sleep, stress, fear, past experience and expectation. A sore knee that hurts more today has not necessarily been damaged more today. This is why two people with near-identical scan findings can have wildly different symptoms.

The second is that carefully graded loading — often with some discomfort permitted — produces better outcomes than either total rest or aggressive pushing through. Tendon rehabilitation is the clearest example. Research consistently shows that tendons respond well to progressive loading performed at a tolerable level of discomfort, and respond badly to being either wrapped in cotton wool or hammered into submission.

So the honest answer sits between the two camps. Complete pain avoidance is not the goal. Neither is pain as a badge of honour.

The rule I actually use

Here is the framework I teach nearly every patient I see across Liverpool, whether that is a runner rebuilding after a calf tear or an office worker with a grumbling shoulder.

Think of your pain during an exercise on a scale of nought to ten, where nought is nothing at all and ten is the worst you can imagine.

• 0 to 3 — green. Carry on. This is acceptable, and for many conditions it is exactly where productive rehab lives.
• 4 to 5 — amber. Acceptable in some conditions, particularly persistent tendon and joint problems, but only if it settles quickly. Reduce the load if you are unsure.
• 6 and above — red. Too much. Reduce the weight, the range, the reps or the speed.

Then apply the two rules that matter more than the number itself:

1. The pain should settle within about 24 hours. If you are back to your normal baseline by the next morning, the session was appropriate. If you are still noticeably worse two days later, it was too much.
2. It should not be getting worse week on week. A sensible programme trends downwards in symptoms and upwards in capacity. If both are going the wrong way, the plan needs changing, not more willpower.

Soreness is not injury

Delayed onset muscle soreness — the dull, achy, tender-to-touch feeling that arrives a day or two after unfamiliar exercise — is normal, harmless and not a sign that anything is wrong. It is most pronounced when you do something new or eccentric-heavy, like walking down the hills around Everton Park after months of flat ground.

You can tell it apart from injury pain fairly reliably. Soreness is diffuse and affects the whole muscle belly, it feels better once you warm up, and it fades over a few days. Injury pain tends to be sharper, more localised, and often has a specific movement that reproduces it every single time.

When pain genuinely means stop

There is no clever framework that overrides these. Stop the exercise and get it assessed if you experience:

• Sharp, sudden, stabbing pain, particularly with a pop, tear or giving-way sensation
• Pain that makes you limp or alter your technique to get through the set
• Swelling, heat or a joint that locks or catches
• Pins and needles, numbness or weakness travelling down an arm or leg

And seek urgent medical attention the same day for chest pain or breathlessness during exercise, sudden severe headache, loss of bladder or bowel control, numbness around the saddle area, or weakness in both legs. Those are not rehab problems.

What to do instead of gritting your teeth

Replace the slogan with a question. Rather than asking "am I working hard enough to hurt?", ask "am I loading this enough to change it, at a level my body can recover from by tomorrow?"

In practice that means picking a weight or a distance that feels genuinely challenging but repeatable, being honest about your symptoms rather than heroic, and progressing in small steps — around ten per cent more per week is a sane ceiling for most people. It also means accepting that recovery days are part of the programme, not a failure of commitment.

The patients who do best are almost never the ones who push hardest. They are the ones who turn up consistently, at a sensible dose, for long enough for the tissue to adapt. That is unglamorous, and it works.

Getting the dose right

Judging the right level of challenge is genuinely difficult on your own, which is much of what a physiotherapy assessment is for. When I see someone for musculoskeletal physiotherapy, a large part of the session is working out where your current capacity actually sits and what your body will tolerate, then building a progression that respects it. For athletes and gym-goers, sports injury rehabilitation follows the same logic, just with higher end targets.

If you have been pushing through pain for weeks and getting nowhere, that is not a discipline problem. It is a dosage problem, and it is fixable.

Book an assessment at /portal/book or call me on +44 7443 357020. I offer home visits across Liverpool and Merseyside at £90 a session, and online video consultations UK-wide at £60, evenings Monday to Friday, plus Saturday and Sunday daytimes. No GP referral needed.