For pain management and performance

Why Managing Pain is Important for Performance


The prevalence of injury in the National Football League (NFL) is 100%. It is therefore reasonable to assume the prevalence of pain is also 100%. In spite of this, players generally do not seek care for pain unless:

  • the pain results in a loss of function/performance; i.e. player has limitations on ability to play;
  • the player perceives the cause of the pain to be serious; i.e. threat to career.

Conversely, players will be less likely to seek care if:

  • there is no loss in function;
  • the player does not want to know the cause of the pain;
  • the player believes he can manage the pain on his own.
  • The player feels disclosure of pain will adversely affect his employment status

If I only knew then what I know now...

I might have done things differently.

Pain and Pain Management

There is no universal understanding of pain, nor a universal solution. The best we can do is manage it. As a result, there are thousands of treatments, so it is imperative that players are educated about their options. For most injuries, time coupled with the body’s innate wisdom, are the most effective therapies. The role of all treatment modalities is to assist the body in healing and restoring function. Despite extensive research (see references) in pain management, the only formal conclusion that can be made is that most interventions help someone, none help everyone, and few help indefinitely.

It is increasingly accepted that a multimodal, patient-centered approach reflecting the biological, psychological, social, and spiritual needs of the player is the most effective way to restore function after injury. A typical treatment for an athletic injury would include medication and/or a physical modality to decrease pain and inflammation, activity restriction to allow healing, and therapeutic exercise to maintain function and promote safe return to play. It is critical that the treatment plan be tailored to the unique needs of each athlete.

If I only knew then what I know now, I might have done things differently.

NFLPA Veterans & Retirees

It is important to note that when selecting which treatments to use, a player considers and understands the cost, risk and benefits of the various modalities. There is no treatment that has been ever developed which does not have risks involved, including serious ones such as permanent disability or death. It is common for those providing treatment to neglect to adequately discuss the risks. It needs to also be mentioned that there may be legal barriers for certain options.

When making decisions, it is important to think beyond the immediate and short term. Life is long, playing time short. It is not always the injury that has long term consequences; certain treatments also have long term ramifications which may seem negligible in the short term but are very harmful in the long term. Too often we here veterans and retirees lament:

"If I only knew then what I know now, I might have done things differently."

Managing Your Pain

Purpose of This Guide

The NFL Players Association (NFLPA) commissioned a committee to create a best practice guide to better inform current and former NFL players, team officials, health care providers, family members, and trusted friends, on the various modalities used to manage pain. In creating this document, we recognize that the incidence of injury in current players is 100%, that the experience of pain is ubiquitous, and the ability to play is paramount. As a result, our focus is on both pain and function.

An exhaustive, comprehensive assessment of all potential modalities is well beyond the scope of this guide. Instead, we have consolidated the recommendations of committee members, active players, and retired players in deciding what modalities to include. This document is meant to be dynamic and through player feedback, we hope to add modalities to our review. We recognize that the state of the art is constantly changing, and evidence is accumulating. Through regular reviews, this document will be modified to reflect these realities.

Our goal is to be objective. Our purpose is to provide succinct descriptions of each modality coupled with references for each. And our hope is that armed with this information, each player may make a more educated decision about managing his unique situation.

Using This Guide

This guide is divided into two sections:

  1. An introductory overview of concepts related to pain, performance, and its measurement and study.
  2. Modalities used to treat pain

A brief description of each modality is provided. References pertinent to each modality

Understand Your Rights and Responsibilities

Illness, or injury, has been described as: a state of disability or distress which becomes regarded as illness when the sufferer turns to another for care and treatment. This definition implies two things. First, injury of medical significance affects function/performance. Second, when treatment begins, a healthcare provider – patient relationship has been created, one with medical, legal, and human ramifications.

There are three types of the provider-patient relationships: Passivity-Activity, Guidance- Cooperation, and Mutual Participation. It is the third, Mutual Participation, we wish to promote. In this model, the health care provider and the patient work together to figure out what the problem is, what caused it, how to remedy and prevent future occurrences of the problem through a comprehensive treatment approach. In order to do this, the player must possess sufficient information so that he may actively participate in decision making.

A player has both rights and responsibilities when participating in his healthcare. All decisions have an effect on the player, his family, and teammates in the immediate term (today’s game or practice), short term (the rest of the season/career), and long term (life after football). The rights and responsibilities include, but are not limited to:

  1. Take an active role in preventing injury. The best treatment of an injury is to prevent it from happening. While it may be impossible to completely prevent injury in football, many injuries can be prevented by learning and practicing proper technique, ensuring proper nutrition before and during all activities, maintaining proper fluid, choosing and wearing the ideal protective equipment, etc.
  2. Understand your limits. Elite athletes have high tolerance for pain. This can be both good and bad. It is good because it allows you to push beyond what most others can tolerate so you and your team can accomplish something great. It is bad because it is easy to go too far when seeking such an accomplishment or when putting the needs of the team above your own. Going beyond your own limits may be helpful to your team, but ultimately harmful to you and your family.
  3. Understand your body. Pain, as described below, is a signal. What does it mean for you; how much are you willing to tolerate; how is it affecting your function, etc.?
  4. Take an active role in your treatment. As mentioned throughout this document, no treatment works for everyone, and treatment plans must involve multiple individualized interventions. All treatments have the potential to harm, and decisions including when to return to play can have significant ramifications. Ask questions; be informed!
  5. Understand your priorities for the immediate, short, and long term. It is normal that these priorities will change over time, so they should periodically be reviewed.
  6. Seek the advice of others. It is always best to seek the counsel of several people. This includes family and friends and others who know you (consult with team union rep). When making medical decisions, it is important to have an understanding of what best practices and evidence-based medicine actually mean and how to obtain that information (see below).
  7. Know what you are putting in your body. You should never take a medication, a supplement, an IV, or put anything in, on, or around your body without knowing what it is, what its potential to help is, and what the risks are. It is unethical to provide care to an uninformed patient.
  8. Know the laws of the state in which you play. While injury is more the rule than the exception in the NFL, it is a workplace injury that falls under the local workers’ compensation statutes. These vary state by state. If you have questions about your rights, consult the NFL PA for information.

Seek the advice of others.

Your family, friends, and union reps know you!

Defining Pain and Performance

When planning treatment for pain, then, it is important to understand what is causing the pain. We can think of the cause of pain in many different ways. For our purpose, we can think of it in terms of the following.

  1. The structure of the body injured
  2. The mechanism of the injury
  3. The time element of the injury.

In creating a treatment plan, it is important to know what structure has been injured, how it was injured, and how long it has been injured. For example, one would treat a 3-day-old knee injury very differently from a 3-month-old knee injury or a 30-year-old knee

Structure and Pain

When we think of structure, we can simplify diagnosis and treatment into three groups, somatic, visceral, and nerve. The following are the sub-groups for each:

  • Somatic structures: bone, cartilage, ligament, tendon, muscle, skin, other soft tissue.
  • Visceral Structures: internal organs, blood vessels, sweat glands.
  • Nerves: brain, spinal cord, peripheral nerves

The way we feel pain is very different for each of these structural types, as such they will require different treatment approaches. In football, most injuries of consequence occur to somatic structures. However, visceral injuries do occur. For example, in 2001, Drew
Bledsoe suffered a ruptured blood vessel in his chest that threatened his life. Neurological injuries such as concussion, post-concussive syndrome, cumulative traumatic encephalopathy (CTE), spinal cord injury, stingers (brachial plexopathy, nerve root injury), and other nerve injuries are common, and all can include a sensation of pain. There is considerable overlap between each of these, and one can look very much like another. It takes a thorough examination to differentiate between these.

Mechanisms of Pain

There are three major mechanisms of pain: nociceptive, inflammatory, and neuropathic.

Nociceptive pain is what we usually think of when we think of pain. A structure is irritated or damaged, a nerve signal is created, and our brain is informed that something is wrong, something we feel as pain. This signal can last anywhere from seconds to forever. If there is sufficient tissue injury, the body responds with an inflammatory response to heal the injured structure. This is a good thing. Increased blood flow brings repair cells and proteins to the area to fix the problem. The acute symptoms of inflammation include pain, swelling, stiffness, and loss of function. As the structure heals, the inflammation goes away, and function is restored. Rest, ice, compression, and elevation (RICE) is the standard treatment for acute inflammation from injury and is used to minimize inflammation not eliminate it.

Inflammatory pain is the result of the inflammatory process going crazy either because of an abnormal neurological response to the acute injury (see chronic pain below), referred to as neurogenic inflammation, or as its own disease. In nociceptive pain, tissue damage causes inflammation. In inflammatory pain, the reverse happens, and inflammation causes tissue damage. This is the case in diseases such as osteoarthritis, Reflex Sympathetic Dystrophy (RSD), Guillain Barre syndrome, and hundreds of other conditions. While these conditions are not common in football players and are not caused by injury, they do play a role in sports. Travis Frederick of the Dallas Cowboys was diagnosed with Guillain-Barre. The golfer Phil Mickelson has psoriatic arthritis. These challenge their ability to participate.

Neuropathic pain is the third mechanism of pain. There are two major types. The first is caused by direct injury to the peripheral nerve, spinal cord, or brain. While this injury will result in inflammation and all the symptoms that go with that, it also can result in a short circuit in the nervous system in which false sensory information is transmitted to the brain. For example, after amputation, phantom pain frequently occurs. The sufferer feels pain coming from a limb that is no longer there.

The second type of neuropathic pain is chronic, pathological pain. It is not a signal, but rather a signal gone crazy. It can occur with any type of structural injury. When a structure is injured and inflammation is created, the pain nerves that supply that structure become hypersensitive. Once they are sensitized, they start firing more regularly and communicate with the spinal cord and brain much more frequently. This excess stimulation has the potential to “wind up” relay centers in the spinal cord and brain, making them more sensitive. Think of the hypersensitivity of touch that occurs with sunburn. When this occurs, sensory stimulation, which would not normally be interpreted as painful, becomes interpreted as pain. In pathological pain, the tissue may have healed, but the sensation of pain persists. Use of the affected area creates pain leading the sufferer to believe he is causing further injury. This creates dis-use which aggravates the problem.

Treatment for all pain must be multimodal and bio-psycho-social (see below). Treatments focused only on the site of pain and not the whole of the pain perception

How can we prevent acute pain from becoming chronic pain?

In the field of pain management, our primary focus is the prevention and treatment of chronic, pathological pain, no matter the structure of origin. In active NFL players, this focus is important, but less common. For them, the focus is on somatic acute pain and
acute pain chronically. In retired players, both chronic non-pathological and chronic pathological pain are of greater interest.

It is generally agreed that the transition of acute pain to chronic pain can be minimized/prevented through:

  • Early mobilization
  • Early, aggressive treatment
  • Comprehensive, integrative, patient centered, multimodal, bio-psycho-social care
  • Avoiding reinjury/repetitive trauma

Measuring Pain

There really is no reliable, objective measure of pain. Therefore, we must rely on what the sufferer tells us as to measure how severe the pain is. Measuring pain is important because the treatment plan varies depending on the severity of pain.

Historically, we have done this by using a variety of numeric rating scales in which we ask someone, on a scale of 0 – 10, how severe their pain is. There are a variety of these scales; The Universal Pain Assessment Tool incorporates several different scales into one and is the most widely accepted tool.

Despite our best attempts to accurately measure pain, our current scales have several limitations. They do not measure function, have little value in comparing one person's pain to another, they do not differentiate between the concepts of nociception and suffering and they are of less value for those with variable pain tolerances who will over/underrate their pain. It is observed that NFL players tend to underrate pain, so, for them, the scales are less reliable. To get around these problems, an important focus is on how pain affects performance. This can be measured through the use of various
functional scales and tests.

Physical, Restorative Modalities

You have options for pain management and rehabilitation

Skilled Manual Therapy

Manual therapy is the skilled application of passive movement to a joint either within (‘mobilization’) or beyond its active range of movement (‘manipulation’). This includes oscillatory techniques, high velocity low amplitude thrust techniques, sustained stretching and muscle energy techniques. Manual therapy can be applied to joints, muscles or nerves and the aims of treatment include pain reduction, increasing range and quality of joint movement, improving nerve mobility, increasing muscle length and restoring normal function. There are three paradigms for its therapeutic effects; physiological, biomechanical or physical, and psychological. Manual Therapy can be broken into three categories: MTI (high-velocity low-amplitude manipulation), MT2 (mobilization and/or soft-tissue-techniques), MT3 (combination of MT1 & MT2) and MT4 (mobilization with movement). Manual therapy is often performed by a range of medical professions including certified athletic trainers, physical therapists, chiropractors, massage therapists and osteopathic doctors.

Instrument Assisted Soft Tissue Mobilization

As research has progressed over the last decade, so too has the utilization of Instrument Assisted Soft Tissue Mobilization (IASTM) within physical therapy. IASTM is one of the most commonly used modalities across the rehabilitation field for scar tissue manipulation and pain management. IASTM is a safe and effective technique that can be utilized for pain modulation as well as soft tissue manipulation. Utilizing an instrument, the clinician will apply the recommended pressure to the area and will begin scraping across the surface of the client. The frequencies and pressure will depend on the goals of the clinician as part of a skilled rehabilitation program.

Myofascial Cupping

Myofascial Dry Cupping has roots dating back to 3000BC with several proposed mechanisms as to how it manipulates the internal environment to produce improvements in reported pain, function and movement patterns. The cup is applied to the skin and with a manual vacuum, air is removed from inside the cup creating the suction to the skin. This vacuum seal then promotes blood flow to the area. Application can vary as some clinicians will leave the cup on the affected area for a short amount of time, to manually moving the cup across the surface of your skin, creating manipulation of the connective tissue. Many therapeutic interventions are compressive in nature, but cupping is one of the only true decompressive interventions. Cupping, utilized for many conditions, is most commonly used for tight/sore musculature alongside a skilled rehabilitation program.

Blood Flow Restriction

Blood Flow Restriction or “BFR” is when external pressure is placed on a proximal limb to promote blood pooling in capillary beds distal to the tourniquet. Studies have shown that muscle hypertrophic adaptations can be induced with much lower intensities than traditional resistance training. This is certainly a modality to consider when training or rehabilitating when heavier loads is contraindicated, e.g. coming back from orthopedic surgery or lower extremity injury. The biggest risk factors of BFR are associated with improper tourniquet use. Utilization of BFR should be done in the supervision of qualified personal alongside a skilled rehabilitation program, as improper use, too much pressure, improper placement, time, etc., can result in severe damage to the tissue.

Intermittent Pneumatic Compression Therapy

Intermittent Pneumatic Compression Therapy is most commonly used in the sports world as a recovery technique. This therapy requires an external unit alongside sleeves that would cover the affected limb(s). Once the sleeves are in place, they are connected to the unit that will sequentially provide compression starting distally and proximally through the sleeve by pumping air into each pocket or segment along the sleeve. As the air pressure increases to its max, the system will move up the chain creating a “milking” effect of the limb. The treatment time can last between 15 and 30 minutes and has been proven to remove the amount of blood lactate after high intensity training as well as reduced select skeletal muscle oxidative stress after heavy resistance training. Intermittent pneumatic compression is also commonly used in treatment in people having edema, or swelling, in the affected limb. Be ensured to follow the safety protocols as variations from this could potentially cause damage if not followed.

Vibration Therapy

There has been a steady increase in popularity and overall usage of vibration therapy in the rehabilitation space since the release of tools such as: Hypervolts, Theraguns, Deep Muscle Stimulators, vibrating foam rollers and balls, and whole-body vibration units like Power Plate. Local vibration therapy devices are relatively new to the general population but are commonly found in the rehabilitation space. There is clear evidence that vibration therapy stimulates the central nervous system to assist with decreasing pain and improving the perception of improved range of motion. Full body vibration therapy has been proven to have a hormonal response but both full body and local vibration therapies still need further research to fully understand the mechanisms behind the results. They are ultimately safe for use, alongside a well-rounded rehabilitation program.

Unweighted Treadmills

Unweighted Treadmills, or commonly referred to as a Lower-Body Positive Pressure Treadmills, is an orthopedic rehabilitation tool that reduces the risks of further injury by decreasing the forces the body must attenuate during impact activities like walking and/or running. There are two types of unweighted treadmills, aquatic or underwater treadmills and an air-pressurized treadmill. Both support the individual’s body weight (BW), reducing overall load on the lower extremities, so that walking movements can be safely repeated, and the quality of movement is improved. The biggest benefit and use for an unweighted treadmill are the ability to remove the amount of body weight from weight bearing activities. This allows athletes recovering from post-surgical or lower body injuries to start rehabilitation from non-weight bearing to weight bearing activities. The use of an unweighted treadmill allows the clinician to progress the rehabilitation program utilizing a portion of the athlete’s body weight and can be adjusted accordingly.

Electrical Stimulation

Electrical Stimulation (E-Stim) has been used for decades in the rehabilitation space. There are many different forms of electrical stimulation utilized for different reasons and goals. A few examples are E-Stim units include TENS, Russian stimulation, IFC, H- wave, and Iontophoresis. The two common uses for E-Stim is for pain modulation or for muscle re-education, depending on the frequency used. There are forms of E-Stim units that are portable and able to be used at-home after proper education from your medical professional. Generally, these units are safe to use but do require yearly maintenance and evaluation to ensure safety.

Hyperbaric Chambers

Hyperbaric chamber therapy is a well-established modality for treatment for numerous medical conditions. Typically, there are two modes of delivery, either in a single person cylindrical tube in which you lay in or in a small room that can hold 3 - 4 clients. Once you are in place, the tube or room is securely pressurized, increasing the atmospheric pressure, allowing your lungs to capture more oxygen. Once the oxygen is in your system it is carried through your body via blood, this increase in oxygen volume allows for your body to release certain growth factors and stem cells to help fight infections and promote healing. There have been two recent studies that show this treatment decreases inflammation and pain. This treatment is generally safe and should be administered by experienced professionals.

Whole Body Cryotherapy

Whole Body Cryotherapy (WBC) is a treatment modality that has recently become more mainstream over the last decade. The treatment typically begins one of two ways, in which you stand solo in a cylinder chamber with your head exposed or in a small room that could hold up to 4 adults and your body is exposed to extreme low (-100°C to - 300°C) temperatures. Treatment time last between 2 and 4 minutes and has been proven through recent research to reduce pain in injured individuals as well as reduce inflammation and markers that indicated cell damage. There are still many variables to evaluate and research is constantly being updated on this modality, but the most recent review of literature showed an 80% reduction in pain.