Rethinking Pain During Exercise: What the Evidence Tells Us

For decades, the mantra in musculoskeletal rehabilitation has been simple: avoid pain during exercise. This belief has roots in biomedical logic, where pain is equated with harm, damage, or failed healing. It’s intuitive, protective, and, for many clinicians and patients, deeply ingrained.

But what if that assumption doesn’t hold?

In a new systematic review and meta-analysis, led by Ivy Tran and co-authored by me (1), we examined 16 randomised trials comparing painful and nonpainful exercise in adults with chronic musculoskeletal pain. The findings were pretty consistent: there was no significant difference between the two approaches in terms of pain intensity, disability, fear avoidance, or pain catastrophizing at short-, medium-, or long-term follow-up.

Even more importantly, adverse events were rare and similar between groups. In other words, painful exercise did not appear to be more dangerous. In my humble view, this is a key take home from the study.

This doesn’t mean we must always prescribe painful exercise. Nor should we ignore it. The point is: pain during exercise is not necessarily a sign of failure or threat. For many people living with chronic pain, the experience of moving through discomfort, when framed safely and collaboratively, can actually be part of the solution.

However, nuance is critical. This review focused on chronic pain conditions. In acute injuries, post-operative rehabilitation, or highly irritable presentations, avoiding pain may remain clinically appropriate. Context always matters and something I’ve learned over my research career is that there are very few universal laws when it comes to pain and exercise.

The broader takeaway? There is no single "right" way to exercise with pain. In the absence of clear superiority, we are left with freedom: the freedom to tailor treatment based on preference, beliefs, goals, and clinical reasoning.

As evidence evolves, so too must our frameworks. We no longer need to treat pain during exercise as inherently problematic. Instead, we can meet it with curiosity, collaboration and choice.

Reference:

1. Tran I, Gibbs MT, Yu N, Powell JK, Smith BE, Jones MD. Effectiveness of Painful Versus Nonpainful Exercise on Pain Intensity, Disability, and Other Patient-Reported Outcomes in Adults With Chronic Musculoskeletal Pain: An Updated Systematic Review With Meta-Analysis. J Orthop Sports Phys Ther. 2025;55(8):1-11.