The 3-level pain scale: managing pain quickly in training & competition
When a new athlete arrives at our doorstep to train with us, whether literally or digitally, we spend a solid ten minutes of our first meeting discussing the Pain Scale and how to use it.
After years of using the 1-10 scale for ranking pain and giving the instructions “tell me immediately if it hurts” hundreds of times, only to be hit with “yeah, and that really, really hurt, but I kept going, and now everything really hurts, so…” a day or more later, we nailed down an agreed-upon system at White Lion for teaching athletes how to perceive their pain - and how to determine if it’s actually pain, or something else.
Pain management, for all its buzz-wordy character, is an essential part of rehabilitation, but also - and I am positive that all White Lion staff and most of our athlete would agree - it’s a critical part of mental health.
Being in pain for any reason is uncomfortable, often miserable, and sometimes also disheartening. By discussing pain early and bringing it into daily awareness (as opposed to prioritizing it), our goal is to give athletes their autonomy back.
Because pain itself is an output (reaction) of the nervous system and not an input, it is not a sign that something is immediately wrong or that injury has already occurred. Rather, pain is a threat-alarm system of sorts, signaling that something feels off, and something may be wrong… but not yet.
Treating pain like an input and prioritizing its presence in rehabilitation or training with questions like “does that hurt?” and “how painful is that?” is, in my experience, counterproductive in just about every way. The athlete’s first response becomes “DID THIS HURT OMG” , the first thought they filter every movement through, and making pain the center of attention is actually the last thing we want.
Rather, I want our athletes to treat pain like the alarm that it is, understand it as a sort of moving target (aka: where it hurts isn’t always where the “issue” is), and make their own decisions about whether or not they can continue training or competing responsibly in light of that pain. This gives our athletes autonomy, self-awareness, and provides fertile ground for learning to trust one’s own body - this is something many athletes, who are always told what to do and how, lack in both theory and practice.
PAIN VS. DISCOMFORT
The first layer of the Pain Scale is learning to distinguish pain from discomfort, exhaustion, or muscle soreness.
Is it painful or just uncomfortable/tiring/sore? is one of the most commonly-used questions in both my repertoire and my daily life.
And this is important to distinguish, because most people don’t notice the difference until they are asked. Most often, any member of the general population might feel something abnormal, strenuous, or potentially threatening, and reflexively respond with “ouch!”, as if it were painful, and fail to look deeper.
Athletes, on the other hand, tend to be much more familiar with the difference between fatigue and pain. Where the lines blur, however, are between soreness, the discomfort of new movements, and pain. Severe DOMS (delayed onset muscle soreness) may at first glance feel like injury or illness, and the internal load of learning new motor skills might resemble pain, when the movements are simply unfamiliar and challenging.
In my experience, people create a criteria for and develop differences between their understandings of pain vs. discomfort in a matter of hours to weeks. With continual reminders of “is it pain or discomfort?”, this first layer develops quickly.
If the athlete names the feeling as “discomfort” instead of “pain, the Pain Scale ends here - keep it pushing!
If the athlete names it as “pain”, however, we descend to the second layer of the scale.
4/10 RULE
With the categorization of “pain”, we now want to know “how much”.
On a 1-10 scale, if the pain can be ranked over a 4 of 10 (or 40% of 100%, if you prefer that), it’s time to stop immediately and let your coach know.
Why 4 and not 1?
As mentioned above, pain is the brain’s output when it feels threatened. A 4 of 10 is a safe line between “this is nagging and annoying, but actually fine” (low-level threat) and “this is seriously a problem” (high-level threat).
Stopping too early will ensure that our nervous system stays uncomfortable with a particular set of movements and the feelings that accompany them for an extended period of time. In fact, pain under 4/10 is often a habit already; for example, if an athlete had a previous knee injury, their brain is likely going to trigger pain around the knee and hip for a while, until their nervous system learns that all is indeed well and good.
It is also hard to accomplish anything of quality or quantity if you interrupt a movement or workout at the slightest perception of pain.
However, anything over 4/10 could be a danger zone, and not something I am willing to risk. First, do no harm.
Additionally, athletes are used to living with more pain and discomfort. It is worth taking this into account when considering a Pain Scale; an athlete’s “4” is likely higher than your standard, sedentary Average Joe’s “4”. Pain looks and feels different when your hobby is physical and mental training and competition.
Side note: before 2019, I used a different version of this second layer to qualify and quantify pain. We would ask “what does the pain feel like?” (i.e. stabbing, aching, shooting) and letting athletes decide their fate with the question of “do we need to stop?”. We abolished these rules for a few reasons.
One: it’s too many questions and takes too much time. We can ask what the pain feels like later. But, first, we need a cut-off. At 4, you stop.
Two: it’s easier to explain. Everybody can generally grasp what a 4/10 is. Thank you, Paul Schlütter & FundamentalKraft, for using this terminology first and sharing it with us!
Three: to be 100 with you, most people do not know when to stop. Yes, there’s the athlete who will absolutely overdo it and say “nope, I don’t need to stop!!” until somebody has to drive them to the hospital. And there’s just as many people who say “yes, I need to stop” to the absolute minimal level of pain or suffering that exists in this world.
That’s fine. Different tolerance levels are to be expected. That is why we educate on pain and use a scale to manage it: everybody knows what four out of ten stars look like.
NAGGING PAIN
Lastly, we follow up the ranking system with the question, “did it stop?”
If pain ceases and desists as soon as an athlete stops doing a movement or exercise, we’re good. We know it’s very unlikely to be an injury or something worth fretting about. Either it was discomfort, fatigue, or soreness after all, or we need to check on our load management and make sure the athlete is getting enough rest.
However, if the pain persists after stopping a movement or workout, this is worth taking into account. If the same or similar pain (NOT soreness!) is also there the following day or after a substantial yet normal recovery period, it’s time to consider this a potential issue, assess as needed, and likely even shift into rehabilitation mode.
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Adding in a Pain Scale, to which all of our athletes are wedded, has had a dramatic impact on multiple aspects of White Lion’s business.
First, it allowed us coaches to give our athletes a ton more autonomy and trust. If I know a player will actually stop when they have pain, I am willing to push them more in training, instead of requiring more regular check-ins or being more stringent in managing load.
Second, it boosts the coach-athlete relationship. Our athletes know we won’t strip down their workouts to boring rehab exercises, just because they mentioned having pain once or twice. Rather, it allows them to be honest, qualify their pain and explain it more accurately, and we can adjust workouts appropriately (and often rehabilitate more quickly!!) from there.
Last, but not least, it provides our athletes with self-awareness and a sense of their bodies. Our mission at White Lion is for athletes to graduate; we don’t want to keep them - like, seriously. I want our athletes to understand their bodies so well and possess such a solid grip of sport science and training that they can manage their training themselves. Empower them. Give them choice. But all of that requires building self-awareness.
Use the Pain Scale. It’s good.