Athletic development specialists dedicated to the art and science of excellence in movement

Pain Avoidance and Movement Implications

One frequently overlooked injury component is fear of movement (kinesiophobia).  We often treat and exercise the mechanical structures, but overcoming fear (whether conscious or unconscious).  Pain signals a threat, so it’s only logical that pain perception is linked to fear of movement.  People have been conditioned to expect that adding more pain through aggressive treatments, but they often forget about reeducating the brain to move appropriately. 

Most research in this area deals with the low back.  If you’ve had low back pain, you’ve likely experienced the fear that comes from wanting to avoid any dreaded spasms, where going to the bathroom and sneezing qualify as epic crises!  This fear, whether manifesting consciously or subconsciously, can permeate all movement.  Even more vexing is that pain and fear can occur even without structural injury. 

Thomas (2007) studied individuals performing a reaching task at different speeds and at different heights and found, “Individuals with high pain-related fear adopt alternative movement strategies and avoid motion of the lumbar spine when performing a common reaching movement.  Identifying how pain-related fear maps to actual motor behavior (i.e., alternative movement strategies) is a crucial first step in determining how pain-related fear and motor behavior interact to promote or delay recovery from acute low back pain.”

Others have used experimentally induced pain via exercise to examine how fear can affect movement.  Trozt (2011) studied healthy subjects performing a trunk extensor test to create muscle soreness.  Pain related fear before the test was not related to test performance.  However, after the test, “pain-related fear predicted reduced maximal strength production, individual decrement in maximal strength performance, and increased pain-related interference in life activities.”  Trozt (2012) conducted a similar study but only found post activity differences in lumbar flexion but not thoracic or hip flexion.  As with the previous study, post activity fear was linked to reduced movement but only at the lumbar spine. 

This phenomenon is not limited to the low back.  Lentz (2010) studied patients with foot and ankle pathology (runners take note!).  Authors examined several variables to predict disability: Pain intensity, range of motion (ROM) deficit, age, chronicity of symptoms, and score on the Tampa Scale of Kinesiophobia, the latter of which is a fear measurement.  Age, chronicity of symptoms, ROM deficit, fear of movement scores all significantly contributed foot and ankle self-reported disability. However, “pain-related fear of movement was the strongest single contributor to disability in this group of patients.”  Lentz (2009) conducted a similar study on shoulder patients and found, “Presence of symptoms longer than 3 months, average pain intensity, flexion ROM index, and fear-of-pain scores all contributed to baseline shoulder function.”

What does this mean for exercise?  These results highlight the value of graded exposure to increasing movement demands so the brain builds confidence to move better.  There’s a reason movements like rolling and crawling can aid the transition to pain-free upright locomotion.  The mechanisms are still unclear, but helping body learn to trust itself is an important component to ensure whatever medical intervention that was delivered actually sticks and the patient/athlete is not on a never ending revolving door into the clinic. 

In fact, selecting exercises is the easy part once you appreciate what actually needs to be accomplished, which is retraining the brain to accept pain free movement.  Oftentimes it’s not the choice of the exercise but how it is done.  Rather than chasing the magic exercise, instead consider things like breathing patterns, posture, and cadence of what exercises are chosen.  If you can manage these variables appropriately, the correct exercises will be more readily apparent.

Finally, this information also should guide how we view “playing through pain”.  Yes, there’s a difference between reckless playing through pain versus the softness taking an off day just because you feel less than 100%.  We often worry about structural damage that comes from painful movement, but the neuropsychological scars are even more concerning. Know that fear of movement is real and is often a major foe when seeking long term change in musculoskeletal health.  In other words, don’t train like an idiot!


Thomas JS, France CR.Spine (Phila Pa 1976). Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain.2007 Jul 15;32(16):E460-6.

Lentz TA, Sutton Z, Greenberg S, Bishop MD. Pain-related fear contributes to self-reported disability in patients with foot and ankle pathology. Arch Phys Med Rehabil. 2010 Apr;91(4):557-61.

Lentz TA, Barabas JA, Day T, Bishop MD, George SZ.  The relationship of pain intensity, physical impairment, and pain-related fear to function in patients with shoulder pathology.J Orthop Sports Phys Ther. 2009 Apr;39(4):270-7.

Trost Z, France CR, Thomas JS.  Pain-related fear and avoidance of physical exertion following delayed-onset muscle soreness.Pain. 2011 Jul;152(7):1540-7. Epub 2011 Mar 17.

Trost Z, France CR, Sullivan MJ, Thomas JS. Pain-related fear predicts reduced spinal motion following experimental back injury. Pain. 2012 May;153(5):1015-21. Epub 2012 Feb 28.


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