Chronic joint pain can significantly impact athletic performance and quality of life. Unlike acute injuries that occur suddenly, chronic injuries develop gradually over time due to repeated stress on muscles, tendons, and joints. This guide explores the causes, warning signs, and most effective rehab strategies for chronic joint pain and injuries.
The Four Major Contributors to Chronic Joint Pain
Chronic injuries typically develop due to one or more of these four factors:
- Excessive Activity (Too MUCH) – Dramatically increasing your activity level beyond what your body is conditioned for
- Inadequate progression (Too SOON) – Progressing too quickly without allowing proper adaptation
- Extended inactivity (Too LONG) – A substantial gap since you last performed this type or amount of activity
- Insufficient recovery (Too LITTLE) – Insufficient rest and recovery time between training sessions
Goals of Fixing Joint Pain
Effective rehabilitation aims to:
- Reduce pain and decrease symptom flare-ups
- Facilitate a safe and timely return to activity
- Minimise the risk of re-injury during the return process
- Restore function and performance to pre-injury levels
Throughout rehabilitation, it’s essential to:
- Monitor for potential warning signs
- Manage training load and external stressors
- Teach efficient and effective movement patterns
- Establish proper foundations before adding load and speed
Warning Signs: Red and Yellow Flags
Red Flags
Red flags indicate potential biological changes or risks that require immediate attention. These warning signs suggest something may be acutely wrong, such as infection, inflammation, neurological issues, or even cancer. The acronym TUNA-FISH can help remember key red flags:
- T – Trauma, Thoracic Pain (fractures, spinal cord injury)
- U – Unexplained weight loss
- N – Neurological signs, Non-Mechanical Pain, Unremitting Night pain (saddle anaesthesia, bladder/bowel incontinence)
- A – Age factors (<20 or >55 years), AM stiffness
- F – Fever, Flexion loss
- I – Intravenous Drug Use
- S – Steroids; Long Term use
- H – History of Cancer
Yellow Flags
Yellow flags highlight potential psychological or social factors that may affect recovery. These are not diagnoses or symptoms but indicate potential obstacles to typical recovery:
- Belief that pain or activity are harmful
- ‘Sickness’ behaviours (extended rest, excessive time off)
- Low or negative moods
- Social withdrawal
- Using treatments that don’t align with best practices
- Problems with healthcare providers or compensation systems
- Previous history of pain, time off work, or other claims
- Work problems or poor job satisfaction
- Family dynamics (either over-protective or under-supportive)
Significant Factors Affecting Joint Pain
Intrinsic Factors
These factors act from within an individual and typically take longer to address:
- Structural factors: Malalignment, pes planus/cavus, rearfoot varus, tibial torsion, leg length discrepancy
- Muscular factors: Muscle imbalances, weakness, restricted range of motion
- Physical characteristics: Gender, size, body composition
- Biological factors: Genetic predisposition, endocrine and metabolic conditions
Extrinsic Factors
These external factors can have a quicker impact on symptoms:
Lifestyle factors: Psychological state, stress management, nutrition, hydration
Focus on Tendon Injuries: A Practical Guide
Training variables: Volume, intensity, rapid increases, new activities, fatigue
Technical factors: Movement technique, surface conditions, footwear
Recovery practices: Rest periods, sleep quality
Environmental factors: Equipment, climate conditions
Typical Symptom Patterns
Tendon injuries often follow predictable patterns:
- Stiffness during warm-up that improves once the body is warm
- Stiffness or soreness in the evening after activity
- Morning stiffness or soreness following the day of activity
Factors That Typically Increase Joint Pain Symptoms
- Speed of movement
- Volume of training
- Energy storage requirements (actions demanding tendon elasticity)
- Compression of the tendon against bone
Case Examples of Overload
Player 1: Acute Overload
- Typically trains twice per week
- Participated in a soccer tournament
- Played seven 90-minute games over four days
- Result: A significant spike in the amount of activity in a short period
Player 2: Chronic Overload
- Had a three-month summer break with no running or soccer training
- One week before preseason, began running to rebuild fitness
- First week of training involved two high-intensity sessions per week
- Result: A relatively large increase in load placed on a deconditioned system
Progressive Symptom Impact on Performance
As symptoms intensify, performance typically decreases in these areas:
- Sprinting ability
- Acceleration capacity
- Tolerance to certain positions
- Overall playing capacity
Tendon Joint Pain Principles
Sport-Specific Approach
Rehabilitation must be tailored to the specific demands of your sport:
- Identify the highest loading movements for your activity (jumping, running, landing, change of direction)
- Determine which tendons and joints are involved in these movements
- Maintain fitness and strength while offloading the affected joint/tendon
Monitoring Recovery
Two key factors must be monitored to ensure a tendon is coping with current loading:
1. Function
- Ensure the tendon isn’t getting weaker
- Verify it can produce at least the same amount of force (ideally more)
2. Pain
- Monitor that pain isn’t increasing
- Ensure it feels at least the same after sessions (ideally better)
Practical Monitoring Techniques
Short-Term (24-hour) Monitoring
- Daily load response test at the same time each day
- Typically performed 30-90 minutes after waking
- Tests may include:
- Calf raise holds (ankle)
- Hops (ankle/knee)
- Decline squat (knee)
- Adduction squeeze (groin)
- Bridges (hamstring)
Long-Term (weeks and months) Monitoring
- Questionnaires and symptom diaries/journals
- Track pain and function
- Monitor psychological state (confidence, mood, readiness)
- Record activity levels
Joint Pain: Practical Application
1. Load Management
Different tendons require different monitoring approaches:
- Patella tendon: Monitor landings/jumps per session/week (volleyball players may experience up to 300 landings)
- Achilles tendon: Monitor accelerations/km per session/week
2. Slow Progression
- Change only one variable at a time
- Match demands to your current capacity
- Consider both rate and intensity of tendon loading
- Gradually increase volume
3. Rehabilitation Stages
Respect the 3-day healing cycles (approximately 48-72 hours) for tendons. For example, a 10km run typically requires about 2 days for the tendon to return to normal.
Stage 1 – Pain Control
- Focus on isometric strength exercises to settle the tendon and reduce pain
- Perform isometrics 3-4 times daily
Stage 2 – Strength + Range
- Incorporate strength exercises that challenge range and train muscle
- Weekly schedule: Strength/Isometric/Strength/Isometric/Strength/Isometric/Optional
Stage 3 – Elastic Function + Speed
- Challenge the rate of loading with plyometrics and running
- Begin with specific intervals
- Weekly schedule: Strength/Elastic Function/Isometric/Strength/Elastic Function/Isometric/Optional
Stage 4 – Return To Sport
Weekly schedule: Isometric/Strength/Team Training/Isometric/Strength/Game/Rest
By understanding these principles and implementing a structured, progressive approach to rehabilitation, you can effectively manage chronic injuries and return to your sport or activity with minimal risk of recurrence.
