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Physical Therapy for the Injured Athlete: How Much Pain Is Okay Before Return to Sports?

More than a question of asking "Does it still hurt?"


Following an injury, whether it be shoulder tendonitis or ACL reconstruction, athletes, parents, and coaches usually look to the medical professionals involved in an athlete's care to decide when an athlete can return to play, and how much residual pain is acceptable.

Because doctors, athletic trainers and physical therapists don't always agree, even among themselves, I can only speak about how, as a physical therapist, I view residual pain and the methodology I employ.

Hopefully, by doing so, athletes, coaches, and parents will have a better understanding about how pain affects return from a sports injury.

All pain is not created equal

Ask athletes if they are ready to return to sports following a serious injury and most of the time their answer will be yes, even if they are still experiencing pain, and know that admitting to pain will likely mean continued physical therapy and a delayed return.

This puts a physical therapist in a difficult position, and forces the PT to dig deeper to find out what kind of pain the athlete is still experiencing.

The amount of subjective pain an athlete experiences varies according to the:

  • injury severity
  • body part injured
  • injury history 
  • hormone levels 
  • mental factors, such as an athlete's 
    • general state of mind
    • mood
    • desire to return to play
    • fear of future injury
    • level of parental support
    • degree of pressure the athlete feels to return from their coach and/or teammates and/or
    • concern an athlete has about "letting the coach and team down."

Because every injury varies, the question "does it hurt?" barely begins to scratch the surface in fully understanding just how much pain an athlete is really experiencing, and the extent to which it should, or should not, rule out a return to play. Physical therapist examining knee

Thus, in assessing how painful an injury is a physical therapist will ask an athlete the following important questions:

1. What caused the injury?

The mechanism of injury is critical to understanding the nature of the pain. How the injury happened gives a physical therapist a general framework for assessment.

Injuries occur in many different ways, including as a result of:

  • Blunt force trauma
  • Falling or landing awkwardly 
  • Twisting 
  • Repetitive motion (e.g. overuse injury) 
  • Chronic pain/injury 
  • Overexertion 
  • Intense athletic movements (sprinting, jumping, swinging); or
  • No known reason (Idiopathic).

2. Where does it hurt?

The PT will ask whether the pain is in a joint, muscle, tendon, ligament and ask the athlete to point to the area pain, whether the pain is generalized, or radiates from a particular point. The location gives a therapist a ballpark of where to start therapy. Injuries involving lumbar spinal discs may cause no pain in the back, for instance, but cause a burning sensation in the foot, while a thigh contusion from blunt force trauma as a result of contact with a football helmet generally results in pain in the area of contact.

3. What does the pain feel like?

The characteristics of pain are important in helping a physical therapist get a better handle on the pain mechanism.

There are five basic criteria that physical therapists will look for.

  • Characteristics: Sore, stabbing, aching, burning, catching, tearing, grinding?
  • Frequency: How often does it hurt?  Is there a particular time of day the pain is more intense? 
  • Duration: For how long does the pain bother you? 
  • Intensity: On a scale of 0 to 10, how bad does it hurt? 
  • Instigator: Does it just hurt to touch? Is it more painful while sitting or standing? Are you able to run?

4. What are you able to do? (quality of movement)

To appropriately return an athlete to sports, a proper progression of pain free or minimally pain-affecting motions and tasks needs to be successfully completed. Quality of movement is defined as the ability to perform various motions, such as walking, squatting, throwing, jumping, etc. mechanically appropriate with an acceptable level of pain and without deviation of movement, or compensatory pattern.

Baseline Activities:

  • Sleeping
  • Sitting 
  • Stair climbing 
  • Sit to stand 
  • Rolling over 
  • Walking

An athlete who wakes frequently due to pain, and cannot walk or stand for more than 5 minutes without having to sit down is not able to progress to playing a 48 minute football game.

Simple Athletic Movements

  • Single Leg Balance
  • Lunging 
  • Squatting 
  • Heel/Toe Walking 
  • Reaching Overhead 
  • Bend back forward/backward/side-to-side/rotate 
  • Push ups 
  • Leg Lifting 
  • Abdominal crunches

An athlete able to achieve this level of movement suggests an ability to perform the basic building blocks of normal athletic movement. A baseball player who says he is "good to go, no problem" but cannot stand on one leg or lunge without falling over is not ready to return to the diamond.

Complex Athletic Movements

This element is what most are familiar with as "strength and conditioning." It includes:

  • Sprinting
  • Cutting 
  • Sliding 
  • Punching
  • Kicking 
  • Throwing 
  • Jumping

Most intense workouts involve a mixture of power movements, endurance training, and weight lifting that are the sum of these movements. They generally involve working multiple body parts at fast speeds, meaning the simple athletic movements must be achieved before progression is possible. Generally, if an athlete is cleared for this level of participation it means they are close to being ready to return to practice and game play, they just need to get back into game shape.

Sports Specific Movements

Every athlete, of course, wants to get back to this level as soon as possible:

  • Throwing a baseball
  • Swinging a tennis racket 
  • Hitting a golf ball 
  • Punting a football 
  • Kicking a soccer ball

Sports specific movements all involve getting back to the basic mechanics. This is very particular to athletes that have suffered an injury from the sports-specific movement itself. For example, a golfer that pulled an oblique muscle swinging may speed through the previous levels but slow down at this stage, since it is the complex movement required by a golf swing, involving both the upper and lower body in a specific pattern of motion, which caused the injury in the first place. Therefore, it is going to take some time to return to full form.

Practice and Play

Practice is defined as "game like" situation while play is "the game." Too often, athletes try to skip this step, and get right back to playing, but it is very important to have some practices before returning to competition. Practice is a necessary step which facilitates working on areas of weakness and getting the athlete prepared, not only physically, but mentally, for the intensity of game action. Throwing a still-recovering athlete straight into the game not only risks physical re-injury but damage to the athlete's psyche, when the athlete realizes they are way off the top of their game.

What parents need to know

A good physical therapist will develop a treatment plan for your athlete and constantly adjust that plan over the course of therapy to take into account:

  • The athlete's general disposition during therapy
  • The mechanism of injury and location of pain 
  • The athlete's subjective descriptions of pain;
  • Their ability to perform the various tasks listed in this article; and
  • The amount of pain they experience performing each task.

This is why it is important to trust the suggestions of and guidance from a medical professional during the injury recovery process. It takes years of analyzing injuries to make these decisions and for a physical therapist to understand all aspects of your child's specific situation. They want your child to succeed in all their athletic endeavors while minimizing injuries that are more serious down the road.

When it comes to pain, a physical therapist is not only looking at the injury of today but also doing their best to prevent the injury of tomorrow.

Posted December 20, 2012