Is It Dangerous to Train With Pain – or Is It Often Completely Safe?

Many people who experience musculoskeletal pain become uncertain about whether they should continue exercising. The question “should I train when it hurts?” is among the most common in physiotherapy practice. Fear of worsening an injury leads many to stop training altogether or drastically reduce activity. However, contemporary pain science and exercise research show that the relationship between pain and injury is far more complex than once believed. In many cases, training with pain is not only safe—it is a key part of recovery.

Pain Does Not Always Mean Tissue Damage

A widespread misconception is that pain always signals ongoing tissue damage. While pain can indicate acute injury, research consistently shows that pain in many musculoskeletal conditions is strongly influenced by nervous system sensitivity, prior experiences, stress, sleep quality, and expectations. In long-standing or nonspecific pain conditions, the intensity of pain often correlates poorly with the degree of structural damage.

Imaging studies illustrate this clearly. Findings such as disc bulges, tendon changes, or degenerative joint changes are frequently present in people without pain. This does not mean pain is “imaginary,” but rather that pain does not necessarily reflect tissue damage that will worsen with movement or load.

Exercise as Treatment, Not a Threat

For most musculoskeletal conditions, graded exercise is one of the most evidence-based interventions available. Research in low back pain, knee pain, shoulder disorders, and tendinopathies demonstrates that appropriately dosed loading can reduce pain, improve function, and increase tissue tolerance over time. These benefits are driven by both physical adaptations in muscles and connective tissue, as well as changes in how the nervous system processes pain.

In contrast, prolonged avoidance of activity can reduce strength, decrease load tolerance, and increase pain sensitivity. This may create a vicious cycle in which fear of pain leads to inactivity, further deconditioning, and worsening symptoms.

When Pain During Exercise Is Acceptable

A key principle in modern rehabilitation is distinguishing between “acceptable pain” and warning signs. Mild to moderate pain during or after exercise is often considered acceptable, provided it is temporary and does not result in progressive loss of function. Many clinical guidelines recommend using pain as a guide rather than an absolute stop signal.

Exercise should be modified or paused if pain escalates sharply from session to session, persists well beyond expected recovery time, or is accompanied by significant weakness, numbness, or neurological symptoms. In such cases, clinical reassessment is warranted.

Fear, Safety, and Confidence in Movement

How pain is interpreted plays a crucial role in training outcomes. Fear of injury can amplify pain perception and reduce the effectiveness of exercise. Patients who understand that pain is not necessarily harmful, and who feel in control of their training load, tend to have better outcomes than those who avoid activity out of fear.

This is where physiotherapists play a critical role: helping individuals identify safe loading levels, progress gradually, and rebuild trust in their bodies. Training is not about pushing through pain indiscriminately, but about using pain as information within a controlled and structured process.

Summary

For most musculoskeletal conditions, being completely pain-free is neither required nor realistic before exercising. Pain does not automatically indicate harm, and well-designed, progressive exercise is often essential for recovery. What matters most is how training is performed, not whether some discomfort is present. With appropriate guidance, gradual progression, and clear boundaries, training with pain is frequently both safe and effective.

Sources

• Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … Woolf, A. (2018). Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet, 391(10137), 2368–2383. https://doi.org/10.1016/S0140-6736(18)30489-6

• O’Sullivan, P., Caneiro, J. P., O’Keeffe, M., & O’Sullivan, K. (2016). Unraveling the complexity of low back pain. British Journal of Sports Medicine, 50(24), 1473–1474. https://doi.org/10.1136/bjsports-2016-096148

• Smith, B. E., Hendrick, P., Smith, T. O., Bateman, M., Moffatt, F., Rathleff, M. S., & Selfe, J. (2019). Should exercises be painful in the management of chronic musculoskeletal pain? British Journal of Sports Medicine, 53(16), 1025–1032. https://doi.org/10.1136/bjsports-2017-098241

• Vlaeyen, J. W. S., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain. Pain, 153(6), 1144–1147. https://doi.org/10.1016/j.pain.2011.12.009