Pain in Sport: 8 Principles for Non-Traumatic Pain

 In Exercise and Health

Non Traumatic Pain

Pain is a unique and complex experience. We know that pain doesn’t always mean that there is tissue damage (i.e an injury). Pain can occur due to actual or potential tissue damage. Yes, that’s right, we can experience pain if our brain detects something that may be a threat to our safety.

For context to this article it is important to understand that there are three main distinctions as to why someone feels pain (1):

  1. Nociceptive Pain – this is the early warning system pain caused by sensing noxious stimuli such as holding your hand too close to fire. It plays a protective role against real or possible injury by causing unpleasant feelings and activating the withdrawal reflex.
  2. Inflammatory Pain – the aim of this pain is to enable healing by discouraging movements and contact after actual tissue damage occurs. The immune system has been activated in this state.
  3. Pathological Pain – this type of pain is a maladaptive process and is an abnormal nervous system function. It can be triggered by neuropathic (nerve damage) or dysfunctional pain (no tissue damage). The nervous system is creating pain that exceeds what is biologically necessary.

With the above definitions in mind, this blog post is a summary of a newly published editorial paper which developed guidelines in the treatment of acute non-traumatic musculoskeletal pain in a sporting context.

In the absence of trauma, do not assume that pain indicates tissue damage

If there is no pathoanatomical basis for the athletes pain it should not be labelled as an injury. Wording such as ‘overuse injury’ can be associated with tissue damage when none has occurred.

Do not refer for imaging unless it will directly influence care, or when there is suspicion of serious or specific pathology

Abnormal findings are very common and are likely present in athletes who have no pain.

Imaging should only be used in the presence of red flags or the suspicion of a specific pathology that requires imaging. Unnecessary imaging increases the risk of mislabelling the cause of pain and may lead to invasive procedures.

Explore biopsychosocial factors that may contribute to pain

Pain is complex and multi-faceted experience and is often not simply caused by tissue damage. An array of biological, social and psychological aspects influence pain which can include but not limited to training load, conditioning, levels of fatigue, sleep quality, mental health, and abdominal obesity. The cup theory for pain (pictured) is a great example of the complexities of pain. The more components you have in your cup, the more potential drivers there is for pain.

Cup theory for pain

Image: The cup theory of pain – potential drivers of a person pain experience. Note that tissue damage is only one component.

Deliver positive messages about pain during examination and treatment

The way practitioners discuss pain and injury can influence the athlete and their recovery. Pain should be framed as ‘tissue sensitivity’ rather than ‘damage’. Positive language encourages validation of their experience and a reduction of the threat of pain. Hopefully, this will reinforce the concept that the body is strong as opposed to weak and damaged.

Improve tissue tolerance to load and sports exposure

Pain doesn’t mean the removal of activity. Rehabilitation should commence in a graded manner, continuing to load the athlete to achieve their sport-specific strength and conditioning requirements. This can be an opportunity to build some mental and physical resilience and address drivers such as stress and sleep hygiene.

Use passive treatments only as an adjunct to active management

Whilst such techniques can be effective for short-term pain relief, they should not form the foundation of treatment. This includes manual techniques such as massage, mobilisation, manipulations, dry needling etc.

Use shared decision-making to build self-efficacy

Allowing the athlete to engage in informed decision-making builds self-efficacy. Athlete education and engagement empowers the athlete and allows them to communicate effectively with practitioners, coaches, sponsors and other stakeholders in regard to their own care. 

Use an interdisciplinary approach to deliver a unified message

Ensuring health messages are uniform from all relevant stakeholders requires cooperation and clear communication between coaches and medical staff.

Guide care of acute non- traumatic pain in sport

All credit for the above eight guidelines given to the authors of the paper; “There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sport”, published in the British Journal of Sports Medicine, 2020


James Gardiner
POGO Physiotherapist

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  1. Woolf C. J. (2010). What is this thing called pain?. The Journal of clinical investigation, 120(11), 3742–3744.
  2. Caneiro JP, Alaiti RK, Fukusawa L, et alThere is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sportBritish Journal of Sports Medicine Published Online First: 09 September 2020. doi: 10.1136/bjsports-2019-101705

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  • Ethan Taylor

    Hey James, it was great reading this post. You’re so right about pain being multi-faceted and it’s a terrible idea to wait too long for medical advice in case of persistent pain. I completely agree with what you’ve mentioned about not stopping activity due to pain. In fact, the right exercises can relieve pain.

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