FREE CHAPTER

What if everything you know about pain is wrong?

 

For starters, pain is not synonymous with being “injured.” It's also not evidence that your biomechanics are "flawed" or your body is "imbalanced." And most important, pain doesn't always mean you have to see a doctor.

 

In Pain & Performance, Ryan Whited and Matt Fitzgerald present a radically new way for athletes to understand and manage pain that exposes the shocking lack of evidence for modern medicine's approach to pain and injury management. Based on many years of research and a greater appreciation of the complexity of pain as a lived experience, Whited's revolutionary “Training as Treatment” method puts you in control of your pain experience as you build mental and physical resilience. Learning this simple, three-step process will start you on a path to better performance and a more fulfilling athletic journey with less downtime, fewer visits to clinicians, less anxiety about pain and injury, and less time and money wasted on treatments that don't work.

 

An elite boulderer and son of a chronically injured professional horse jockey, Whited brings a pragmatic approach to a very complex process. As a trainer, he has spent decades guiding athletes from breakdowns to breakthroughs at Paragon Athletics, a magnet for pain-affected runners, climbers, and recreational athletes who've grown frustrated with the medical system. Pain & Performance makes Whited's unparalleled knowledge of pain science and physiology available to anyone seeking to stay out of the doctor's office and on track toward their goals.

"Pain & Performance will give you great insight into the biopsychosocial approach to training. You’ll expand your knowledge of pain science and your focus will shift from pain to performance!" — Dr. Tim Gabbett

 

Chapter Five of Pain and Performance is made available to you for free below.

Chapter 5: Training As Treatment

A few years ago, I started using the hashtag #trainingastreatment in some of my social media posts. I’m not big on marketing and branding, but I needed a name for my approach to pain management, and what I came up with does a pretty good job of encapsulating my mission to replace medical treatment with physical training as the dominant method for managing athletic pain.

 

My previous approach to helping athletes could have been called training and treatment. Even in the days when I bought into the structural model of injury, I believed that gym work had a significant role to play in athletic pain management. But back then, I saw that role as being distinct from and, in a sense, subordinate to that of medical treatment. It was this way of thinking that led me to decide to collaborate with a physical therapist to work alongside me when Paragon Athletics relocated in 2012. My vision was to make the facility a kind of one-stop shop for musculoskeletal care for athletes. And that’s precisely what it is today—only without a physical therapist on staff. My vision hasn’t changed, you see. What did change was my belief that training and treatment are separate processes, each requiring its own special expertise.

 

The main driver of this evolution was my immersion in pain science. The more I read, the better I understood which methods of athletic pain management were supported by solid evidence and which were not. And the better I understood what does and doesn’t work to manage athletic pain, the less need I saw for a physical therapy partner to fulfill Paragon’s mission. Bruce Lee once said, “Absorb what is useful, reject what is useless, add what is essentially your own.” In living by these words from my childhood hero, I came to see the distinction between therapy and training with pain showed less and less utility.

 

I’m happy to say that I remain good friends with the therapist I wound up partnering with—our subsequent parting of ways was strictly professional. Recommended to me by mutual acquaintances, Jim was exactly the sort of person I thought I needed. A climber himself, he held a doctorate in physical therapy from NAU and had a genuinely caring nature. And he was on board with my vision, so we teamed up. The idea was this: Athletes with injuries or pain experiences would come to us as patients. Jim would treat them, and then, when they were ready, these patients would become athletes again and I would train them. Jim had his role as therapist, I had mine as coach, and together we were like chocolate and peanut butter—perfect complements to each other.

 

One critical change began to occur as my understanding expanded. It was becoming more and more clear to me that the causal relationship between pain and tissue and biomechanics was not nearly as direct as many believe. I was fast gravitating toward an ecological approach to care, while Jim began moving more toward nuances of biomechanics. At the same time I lost faith in structuralism, Jim’s structuralist views moved in the opposite direction, away from the mainstream. Specifically, Jim began using a treatment approach called postural restoration, which is like structuralism on steroids. Developed in the 1990s by Ron Hruska, a Nebraska-based physical therapist, postural restoration rests on the idea that although the body is fundamentally asymmetrical in structure, the more symmetrical one can make it, the better it functions. Practitioners of this discipline fuss over every measurable element of structural and functional balance, from the greatest to the smallest.

 

Even the teeth and eyes do not escape the attention of the therapist trained in postural restoration. Practitioners have been known to adjust a client’s occlusion (bite) and prescribe prism glasses to patients, believing that these minute adjustments would rectify something in the nervous system that was presumed to be the cause of their pain. It wasn’t my place to tell Jim how to practice, and I’ve never doubted his genuine care for people. However, the further I went in my career, the clearer it became to me that simple and practical coaching was the path forward.

 

Breathing is a major concern in postural restoration. It therefore became a major concern for some of the athletes Jim passed along to me after he’d finished treating them. My own take on breathing is that it’s best not to overthink it. If you can breathe in your sleep, it’s a safe bet you’re doing it properly when you’re awake as well. This put me in a tough spot when athletes asked me if I planned to continue the process of “fixing” their breathing that Jim had started with them. On the one hand, I didn’t want to contradict Jim and confuse the athlete. On the other hand, I didn’t want to just let the athlete keep worrying about something I didn’t think they needed to worry about. Such notions can have lasting negative effects on people—not only prolonging their pain but exacerbating it through something called biographical suspension. This is essentially what it sounds like: When a form of treatment is difficult or impossible to complete (Can posture ever be fully restored?), it essentially puts the patient’s life, or significant parts of it, on pause.

 

Jim and I knew we had gone as far as we could in our professional collaboration. He came to me one day and broke the news that he had decided to step away from Paragon, explaining that the gym setting was too “excitatory” for patients with persistent pain. I had to admit he had a point there, what with the high-energy music that filled the space at all hours. So we shook hands and parted ways. There were certainly no regrets on my side. And thus began my wholehearted commitment to a biopsychosocial approach.

 

A NEW PARTNERSHIP IN PAIN MANAGEMENT
I began to make changes at Paragon—tweaks, adjustments, and overhauls that would, over time, evolve into Training as Treatment. The more I learned about the flaws in the structural model of athletic injury and about the new science of pain, the luckier I felt to be a trainer as opposed to any other type of provider. As a trainer, I am barred by law from diagnosing injuries and other medical conditions. I now see this limitation as a blessing, having learned that diagnosis often does more harm than good and should be done as sparingly as possible. I learned too that most of the common treatments for pain and nontraumatic injury are ineffective, but again, as a trainer, it was not my job to practice such treatments anyway. What is effective in managing athletic pain and injury, I discovered, is exercise, which is a trainer’s medium. Also useful is good communication, and there are (thank goodness) no laws forbidding trainers from communicating constructively with athletes. Indeed, all good trainers take the interpersonal component of the job very seriously. I certainly did, but my immersion in the new science of pain had the effect of making me more conscious and strategic in my communication with athletes.

 

Much of what is communicated to individuals in a given environment comes from the environment itself. Before I even open up my mouth to greet a new athlete who’s just walked through the door for the first time, that person has picked up certain messages from the space. And so as part of my new approach to communicating with athletes, I did a little redecorating at Paragon, removing things that conveyed the wrong message, however subtly. An expensive pair of laminated posters showing the locations of trigger points throughout the body came down off the walls. Nobody really knows what these sensitive spots of muscle fascia really are. But that’s not what bothered me about the posters. At issue, rather, was that the posters insinuated their creators (Janet Travell and David Simons) did know what trigger points are. Consequently, having these posters displayed rein- forced the broader misrepresentation that clinicians possess secret knowledge about musculoskeletal care, making athletes dependent on them for pain management.

 

Additionally, I removed a lot of books from the gym. I had all of Dr. Stuart McGill’s works on back pain. Those disappeared along with several volumes on running biomechanics and any other book in my collection that might give athletes the impression that managing pain and injury is complicated, when in fact it’s quite simple. I wasn’t so naive as to think that a few small improvements in my facility’s decor would unwind the programming that an athlete’s mind has been subjected to for many years. But precisely because they had been steeped in the medicalization of athletic pain and injury, I felt the need to consistently communicate the Training as Treatment approach through every available medium.

 

Rearranging the furniture, so to speak, goes only so far to change the athlete-coach experience. Words matter more. Knowing this, I made psychology the next focus of my continual self-education. I read deeply in the field of cognitive behavioral therapy, a type of psychotherapy that uses structured dialogue to help individuals change unhelpful thoughts, emotions, and behaviors. Of particular interest to me was the practice of motivational interviewing, a technique whereby a therapist (or coach, as the case may be) uses strategic questioning to get patients (or athletes) to reflect deeply about what they want, why they want it, and how best to achieve it. The gym might be a less intuitive setting for this type of work, but motivational interviewing is every bit as relevant to athletic goals such as staying healthy, training productively, and improving performance as it is to more conventional therapeutic goals such as processing grief. When I discovered that my friend Buck Blankenship, a Flagstaff-based ultrarunner, was studying motivational interviewing in pursuit of a graduate degree in special education at NAU, I accepted his invitation to take part in virtual classes on the subject and subsequently brought him in to train new staff at Paragon in the technique.

 

AN ATHLETE-CENTRIC METHODOLOGY
Athletes often come to me for help because they feel they need me, and they might be right about that when they are just getting started, but I am determined to get each athlete to a place where they no longer need me to feel confident in working through a pain experience. To this end, I don’t just practice Training as Treatment on athletes; I teach the process as we practice it together. Basketball coach Billy Donovan once said, “Believe in your system, and then sell it to your players.” This is something every good coach does because every good coach knows their athletes get more out of any given training system when they understand and buy into it. The secret sauce in training is believing your training is the secret sauce.

 

Following an initial consultation with an athlete, I hand them a pad and a pen to take notes. I do this not because I’m too lazy to take my own notes but rather to signal to the athlete that I expect them to be an active participant in our partnership. It’s a simple but effective way to start the process of cultivating pain self-efficacy—of teaching athletes how to catch their own fish, as the saying goes, instead of depending on me to put fish on their tables.

 

Another major goal of my communication with athletes is to get them to see the process of managing pain and injury as creative versus rote. Gone are the days when I went out of my way to show athletes how much I knew about the human body in general and about what was wrong with them specifically and how to “fix” them. Socrates said, “The only true wisdom is knowing you know nothing,” and if this is true, then I’m a much wiser trainer than I used to be. I now realize that nobody knows exactly what pain is and what causes it or makes it go away in any particular instance. Furthermore, I know that following an open-ended, rule-guided trial-and-error process is the most effective way for any individual athlete to manage pain. In a sense, I’ve come full circle, returning to the intuitive way of operating that I adopted during my rough-and-tumble childhood and early adulthood, when I managed pain quite effectively in my own athletic pursuits not through academic knowledge but by following a process very much like the one I now call Training as Treatment.

 

Given their past experiences in medicine-centered pain and injury treatment, most athletes start their process of pain management focused on the end point. They want to know where treatment will end and training will resume. But in the Training as Treatment approach, there is no end point because you are always training. Athletes are accustomed to either/or thinking—they are either injured and in treatment or healthy and in training. Training as Treatment replaces this paradigm with an if/then alternative—if you are experiencing pain, then you’re going to use the same tools that would be used for performance, adjusting the load, volume, velocity, and variety of movements as necessary. I tell athletes to think of their bodies as gardens and musculoskeletal care as gardening. A garden has no end point. As a gardener, you want your garden to flourish at all times. You never start or stop tending your garden—you just tend it in somewhat different ways in different seasons.

 

Having said all this, I will now add that if you were to visually compare how I worked with an athlete during my structuralist period to how I now use Training as Treatment, you might not see much difference—other than my gray hair. I still perform certain movement assessments, and of course, I still give athletes exercises to do. But how I communicate with athletes has changed radically. When I worked within the structuralist paradigm, I would start by telling the athlete what was wrong with their movements, describe the structural damage they’ve caused, and explain how to fix it. Today, you would hear me use very different language. Instead of describing an athlete’s biomechanics as wrong or faulty, I explain how they are placing extra demand on certain tissues and propose ways of either reducing this demand, increasing the tolerance of the tissues, or modifying activity. My goal is always to help the athlete think in terms of working with what they’ve got rather than trying to move perfectly. When an athlete sheepishly admits to “cheating” in performing a certain movement (i.e., doing it “incorrectly” to make it easier), I will gently challenge their own language, suggesting that what they call cheating is more accurately labeled kinematic cleverness.

 

Not every athlete is immediately comfortable with me telling them “I don’t know” in answer to questions like “What caused my pain?” or “How do I get rid of this pain and keep it from coming back?” In Chapter 4, I talked about how athletes (including me, at one time) are often willing participants in the theater that is the standard clinical experience. Many would rather hear dishonest certitude from a doctor, therapist, or trainer than honest uncertainty, at least for now. But the truth is that Training as Treatment just replaces one form of certainty with another. When I tell an athlete that I don’t know the answer to their question, I don’t stop there. The full answer is “I don’t know, but we’ll figure it out.” Because it’s true—we will. With Training as Treatment, we trust the process rather than our knowledge. Followed diligently, this process is certain to yield better long-term outcomes for the athlete than applying a one-size-fits-all treatment plan based on “knowledge” of which specific pathology an athlete represents and sticking to it no matter what. And the best part is, after working with me long enough to learn and understand the process, the athlete can practice it on their own in the future.

 

GETTING PAST THE PHYSICAL NATURE OF PAIN
The trickiest part of applying the biopsychosocial model of pain in the gym environment is the psychosocial part. I find it difficult to suggest to athletes that cognitive and emotional factors, such as expectations and stress, might be influencing their pain experience without being misinterpreted. Having internalized the dualistic notion that the body and the mind are completely separate, the one physical and the other nonphysical, many assume I’m suggesting that they’re imagining their pain—or worse, that they have a screw loose. But that’s not at all what I mean. What I mean is that pain is fundamentally an experience. It is not a physical phenomenon that produces a felt experience. Pain has no objective existence outside our experience. And like all experiences, pain is influenced by cognitive and emotional factors. This is true for everyone.

 

To a certain extent, I can manipulate psychological and social contributors to an athlete’s pain experience without them even knowing it. I ask my clients lots of questions that may seem to have no relevance to the particular problem they want me to help them with. I do this partly because research has shown that physicians tend to get better treatment outcomes with patients when they establish and nurture personal connections with them. According to a study conducted by Stanford researchers and published in the Journal of the American Medical Association in 2020, five key practices are helpful in this regard: (1) taking time to prepare for each appointment, (2) listening intently, (3) learning what’s most important to the patient and taking it seriously, (4) connecting with the patient’s “story” (how they see their past, present, and future), and (5) paying attention to and validating the patient’s emotions. I’m not a physician, but the coach-athlete relationship is very similar—I engage in all of the above practices for the athletes’ clinical benefit, and it’s clear they appreciate this human-to-human approach.

 

Where things get dicey sometimes is at that delicate point at which I shift from implicitly manipulating psychological and social factors to bringing these things out into the open. My favorite example is Stan (not his real name), a mountain biker who came to me complaining of low-back pain. He’d been dealing with the issue for seven years, and he was near the end of his rope. Prior to flying in from out of state to consult me, Stan had been to a succession of doc- tors and physical therapists and undergone the usual imaging tests with nothing to show for it beyond a consensus that his sacroiliac joint was messed up.

 

Knowing what I do about the biopsychosocial nature of low-back pain, I asked Stan what else was going on in his life—besides mountain biking, which he’d been taught to regard as the sole culprit vis-à-vis his “injury”—around the time of the pain’s onset. He paused for a moment to rewind his memory seven years, shook his head, and answered that nothing noteworthy came to mind. I pressed a bit, and eventually Stan volunteered that, come to think of it, he had been going through a divorce then. Oh, and also, he was being investigated by the IRS. And he had recently contracted a venereal disease.

 

Now, it so happens that Stan was a psychologist. In light of this fact, I took a chance and suggested that perhaps the stressors he enumerated were contributing to his pain experience along with the physical stressors of riding his bike and whatever else. This did not go over well. Although he did not come right out and accuse me of insinuating his pain was imagined, I could tell by the look on Stan’s face that he was having just as much trouble distinguishing between psychological and imaginary as my athletes who were not psychologists. He did not remain my client for very long before deciding to continue his search for a purely physical cure to what he considered to be a purely physical problem.

 

If that’s as far as I got with most of my clients, I would be looking for work. But in the majority of cases, I’m happy to say, I do a better job of not getting ahead of myself on the psychosocial side of my practice and hence of not scaring folks off before they see its fruits. It helps that the failure rate in pain treatment—persistent pain in particular—is famously high. I’ve built my practice largely on last-chancers—athletes and others whom medical doctors and physical therapists have been unable to help. A number of these professionals now refer these cases to me, regarding me as a clinician of last resort, though it is my opinion that most of them would be better off coming to me, or someone like me, first.

 

DON’T SETTLE FOR PERMANENT PAIN
A typical case is Elano, who came to me as a 32-year-old police officer facing early retirement from the local police force due to knee pain. A competitive tennis player and an all-around superfit dude, Elano had torn an anterior cruciate ligament (ACL) working out. After surgery, he entered physical therapy, where he remained for two years—far longer than should have been necessary for someone in his situation. The problem was not that he couldn’t use the leg—he got most of his range of motion and a lot of his strength back in those two years—but that it still hurt like hell to do anything strenuous like, say, the work of a police officer! Per usual, it was only when Elano was on the brink of being judged a lost cause that he was finally referred to me.

 

The reason therapy had failed Elano was twofold. First, the exercises he was given were specific to his injury, not to him. Each person’s pain experience is unique. This is why managing pain—whether after knee surgery or at any other time—requires ongoing experimentation, adaptation, and learning on the go. Eliminating pain as a barrier to full activity requires that you do the closest thing to normal activity that you can without making the pain worse. The aim is to perform movements that work around and toward the pain, gradually increasing loads and specificity as the pain barrier recedes. Elano’s therapists did not do this.

 

The second reason Elano didn’t get much benefit from physical therapy was that the therapists were too pain avoidant and leaned on primarily passive tools, such as massage, dry needling, stretching, and so on. Many clinicians view all significant pain as a red flag indicating aggravation of underlying damage. But after two years of recovery, there could not have been much tissue damage left in Elano’s knee, so his pain wasn’t necessarily a cue to back off. Knowing this, I started training him, giving him movements that were specific to the tasks he used to perform on his beat and on the tennis court, with loading he could tolerate. Of course, we remained respectful of his pain, but we were not fearful. In the beginning, he experienced a good bit of pain, but I assured him he wasn’t harming himself, and he trusted me. Within six months, Elano was fully recovered and ready for duty, and when I last heard from him, his tennis game was stronger than ever.

 

I can’t tell you how satisfying it is to help people in this way. But I can only help so many. Even though the whole point of Training as Treatment is to empower athletes to manage their own pain, this teaching process has required one-on-one interaction. We need a lot more trainers and physical therapists to accept and master the same approach, and we need a lot more doctors to accept it as well and begin to refer people with nontraumatic musculoskeletal pain and injuries to practitioners like me—not as a last resort but as a first step. Progress in this direction has been frustratingly slow, however, for a couple of reasons.

 

EVANGELIZING A NEW METHOD OF PAIN MANAGEMENT
In January 2017, I invited Greg Lehman to lead a two-day clinic called Reconciling Biomechanics with Pain Science here in Flagstaff. It was at this event that I realized what we were up against in pursuing our shared mission to demedicalize musculoskeletal care. Greg is a skillful presenter who has led iterations of the same clinic dozens of times all over the map. He did a bang-up job at the event I hosted for him, but his message was mostly lost on the 40-ish clinicians and roughly half-dozen trainers (and one yogi, my friend Jules, from whose lips I first heard Greg Lehman’s name) who attended.

 

He kicked off day one by asking audience members—most of them MDs, PTs, and PhDs—to identify musculoskeletal pathologies that, in their opinion, required specific treatment, meaning a protocol tailored to that particular injury or condition. Hands were confidently raised and pathologies assuredly named (“supraspinatus tendinopathy” is the one I remember). Greg then proceeded to coldly invalidate their respective treatment protocols one by one. In each case, Greg cited research demonstrating that the specific treatment for the named pathology was ineffective. Cumulatively, these mercilessly dispassionate refutations made the point that specific treatment protocols are not the proper way to address such pathologies, and even the diagnosis itself has little utility. All the clinician really needs to know, he intimated, is “where it hurts.”

 

On day two, having said enough about the wrong way to address pain and dysfunction, Greg talked about what he believes is the right way, or at least the best way available to us today. In his practice, diagnosis is eschewed on the grounds that it serves no practical purpose and also tends to negatively affect the expectations of the person being diagnosed. Instead of naming the problem causing the person’s pain, he focuses on the person first, pain second, and biomechanics last. Treatment consists almost entirely of symptom modification—helping the person do more with less pain—which is achieved mainly through strength training and other exercise. Along the way, Greg is careful to demonstrate his expertise only to the extent that is necessary to gain and preserve the person’s trust and never for the sake of asserting dominance in the clinical relationship. And he listens more than he talks.

 

As Greg described his biopsychosocial approach to managing pain, I nodded along, recognizing all the key elements of the Training as Treatment approach I practice at Paragon Athletics. It all made so much sense that I failed to notice the blank stares on the faces around me. When the clinic wrapped up, I went around the room asking the attendees what they thought, expecting their excitement to match my own. Almost without exception, these highly trained professionals either hadn’t understood what they’d heard from Greg or understood all too well but refused to accept it.

 

A REVOLUTION IN PAIN MANAGEMENT
I want to live in a world where athletes do not shift from sports training to medical treatment when experiencing pain associated with nontraumatic musculoskeletal injuries but instead train through it either with the help of a coach, trainer, or biopsychosocial-informed clinician or on their own. What bugs me is that I’m not sure I will live long enough to see this world. Progress toward demedicalized pain management has been a lot slower than, in my naivete, I expected it to be when I first recognized the need for it. But there has been some progress. For example, in 2018, the American Physical Therapy Association and the National Athletic Trainers Association announced a new collaborative relationship. More symbolic than substantive, the creation of a direct communication channel between organizations with therapy and training in their respective names is a step in the right direction. In recent years, I’ve also seen slow growth in the number of individual scientists, doctors, and other high-level clinicians who appear to take me seriously, are open to answering my many questions, and seem to be paying attention to what I’m doing at Par- agon. Still, the major impediments to the full-scale revolution that’s warranted—namely, money and professional self-interest—remain in place.

 

Imagine what it was like for carriage builders when the automobile revolution occurred in the early 20th century. That’s kind of what it’s like for clinicians who treat activity-related pain and injury today. Any clinician who doesn’t offer training as a tool to manage these things is poorly positioned to help athletes in the way the new pain science indicates is best. The right thing to do in this situation is to either acquire this tool or refer would-be patients to clinicians who do offer training. But instead, most clinicians are staying the course, continuing to treat patients as though the structural model of injury hasn’t been scientifically invalidated and the biopsychosocial model doesn’t exist.

 

It often happens in science that when a prevailing theory or model’s predictions fail, its proponents, loath to abandon it, try to patch it up instead. Ptolemy’s model of the solar system is the quintessential example of this phenomenon. Not understanding the nature of gravity, the ancient Alexandrian astronomer made his model increasingly complex in reaction to its failure to accurately predict planetary motions. In a similar fashion, the structural model of pain has become increasingly esoteric as its proponents scramble to assimilate experimental findings that challenge its legitimacy.

 

Recently, I witnessed an online forum debate among scientists concerning the validity of the term nociplastic, which refers to pain that lacks an underlying structural source. It went on for nearly a week, back and forth, around and around. I refrained from chiming in, but if I had, my contribution would have been this: Who cares?

 

I’m not suggesting that terminology doesn’t matter—everyone knows that defining terms in science and philosophy is integral to the process. But on the application side of things, fussing over semantics loses the forest for the trees, and in this instance, I saw the semantic nitpicking as emblematic of a larger effort to ensure that clinical pain management is too complex for pragmatists like me to competently practice. And the truth, once again, is that effective management of pain is simple, if not always easy.

 

THE REAL EXPERT ON YOUR PAIN
These days, more and more clinicians refer to themselves as pain experts or specialists. But the real pain expert is you. If you know how to put on a sweater when you feel chilly, you know how to man- age pain. The only difference is that the medical establishment has made you believe you don’t know how to manage pain, which is true to the extent that accepting this doctrine has caused you to forget some of what you used to know. But this kind of knowledge is never really lost. It’s just buried under a bunch of crap.

 

I’m not saying pain specialists shouldn’t exist. There are certain scenarios that demand someone who understands more complex pain processes. For the lion’s share of pain experiences, however, this level of expertise is probably not necessary. Clinicians who hope to help as many people—athletes and nonathletes—as possible should be focused on simplifying pain management, not on doing the oppo- site for the sake of job security, as too many do.

 

A good example of unnecessary complexification in pain and injury treatment involves newer brain-centered methods of restoring function after ACL surgery. It’s been shown by fMRI that there are changes in the brain (specifically the motor cortex) that occur after an ACL repair. To address this problem, scientists and clinicians have developed protocols for zapping the brain with transcranial electromagnetic energy and activating the quadriceps in specific ways intended to restore “corticospinal excitability.” The problem with all of this is not so much that it doesn’t work as that it doesn’t work as well, as cheaply, and as efficiently as good training, as our friend Elano can vouch. Remember, the more sciency way to do something is not always the better way.

 

Could Elano have found his way back to the police force and the tennis court without my help? Maybe, maybe not. But if—heaven forbid—he should ever blow out the other knee, I think he just might be able to train his way back to 100 percent on his own based on what he learned (and relearned) about pain in our time together. And that’s the point. As I said before, it’s not a huge stretch to say that my job, as I see it, is to put myself out of a job.

 

Admittedly, it’s not a job I will ever complete. Athletes do sometimes need expert help in managing pain and always will. The question is, Where do they go for that help? You can answer this question just by thinking about where you have gone in the past. Has it ever even crossed your mind to call a trainer first? Probably not, for two reasons. One is that athletes are taught to seek help from doctors and physical therapists when they’re in pain. The other is that very few trainers practice Training as Treatment or anything like it. I don’t foresee doctors conceding anytime soon that athletes with nontraumatic musculoskeletal injuries don’t belong in their offices. Nor am I holding out hope that the physical therapy profession will get fully on board with Training as Treatment. Given this reality, if the changes I want to see happen are actually going to happen in my lifetime, we need to make them happen without expecting much help from members of the medical establishment.

 

That’s right, I said we. Sometimes change starts at home—or in this case, in the gym. It’s my hope that Pain and Performance will not only help individual athletes self-manage athletic pain and injury but also start a movement. By empowering athletes like you to manage pain on your own or with the help of coaches and trainers, I seek to create a demand for a new generation of trainers and clinicians who base their practice on good scientific evidence and a biopsychosocial model of pain. In a Training as Treatment environment, the professional’s primary “treatment” tools are training and coaching according to the needs of the individual athlete. Your part in this movement is simple: keep reading.