CLINICAL CARE
Why pain can hang around
Most pain settles as the body heals. Sometimes it doesn't, like heel pain that's still there a year on, or an Achilles that hurts long after the scan looks normal.
Understanding why is part of the treatment. People who understand their pain tend to move more, worry less and recover better.
Key points
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Pain is an alarm, not a measure of damage.
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In persistent pain, the alarm becomes oversensitive.
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Working gradually into a little pain is how you get out of it.
Pain is an alarm, not a damage meter
Your brain decides whether you need pain to protect you. It weighs up:
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danger signals from your tissues
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what's happened before and what you've been told
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sleep, stress and worry
That's why a paper cut can be agony while an athlete can finish a game on a broken bone.
In persistent pain the alarm gets more sensitive, so safe movements start to hurt. The pain is real, but it's coming from an overprotective system, not new damage.
The Twin Peaks model
From the book Explain Pain (Butler and Moseley), this model uses two peaks:
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Tissue tolerance: how much load your tissues can handle before they're at risk.
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Protect by pain: the point where your nervous system starts to produce pain, as a warning. It sits just below the tissue peak.
After an injury or long-term pain, the pain peak shrinks much more than the tissue peak. The gap between them is the buffer: it hurts, but nothing is being damaged.
Getting out of the buffer
Stopping at the first twinge keeps you inside the buffer, and over time you get weaker and the alarm gets more sensitive.
The way out is to work into the buffer gradually. This:
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builds your tissues back up
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teaches your nervous system the movement is safe, so the pain peak gradually grows back
That's why I'll often ask you to keep walking, running or exercising with a manageable level of pain, rather than resting until it's gone.
Using a pain scale
Rate your pain from 0 to 10 during activity. As a guide:
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0 to 3: safe, keep going
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4 to 5: monitor, OK to keep going but it should not climb
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6 or more: too much, ease off next time
It should also settle by the next morning, and shouldn't be getting worse week on week.
What the evidence says
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Learning how pain works helps most when it's combined with exercise. Together they reduce pain, disability and fear of movement more than exercise alone, at least in the short to medium term.
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Exercising into some pain was slightly better than pain-free exercise in the short term, and no worse later on.
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In Achilles tendon pain, training within the 0 to 5 rule did no harm and led to the same recovery as resting.
The research quality is mixed, so I treat this as one part of a plan, not a cure.
What turns the alarm up or down
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Up: poor sleep, stress, and worry about what the pain means
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Down: good information, sleep, general exercise, and seeing yourself get stronger
When to seek help
See a health professional if pain:
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is stopping you walking or working
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is getting steadily worse or started after an injury
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comes with heat, redness or swelling
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wakes you at night, or comes with numbness, weakness or feeling unwell
Further reading
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Tame the Beast: a 5-minute animated video on persistent pain, narrated by Lorimer Moseley
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Pain Revolution: free, plain-English Pain Facts sheets
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NOI Group: the team behind Explain Pain and the Explain Pain Handbook
Written by Dr Merridy Lithgow, podiatrist. Last reviewed October 2026. This page is general information and is not a substitute for individual advice.
References
Butler DS, Moseley GL. Explain Pain. 2nd ed. Adelaide: Noigroup Publications, 2013.
Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. The Journal of Pain, 2015;16(9):807–813.
Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, Selfe J, Logan P. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine, 2017;51(23):1679–1687.
Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine, 2007;35(6):897–906.
Thomeé R. A comprehensive treatment approach for patellofemoral pain syndrome in young women. Physical Therapy, 1997;77(12):1690–1703.
Cuenca-Martínez F, Suso-Martí L, Calatayud J, Ferrer-Sargues FJ, Muñoz-Alarcos V, Alba-Quesada P, Biviá-Roig G. Pain neuroscience education in patients with chronic musculoskeletal pain: an umbrella review. Frontiers in Neuroscience, 2023;17:1272068.