Infographic

Br J Sports Med: first published as 10.1136/bjsports-2021-104633 on 16 September 2021. Downloaded from http://bjsm.bmj.com/ on April 26, 2023 at Universidad Europea de Madrid.
Infographic. Pain or injury? Why differentiation matters in
exercise and sports medicine
Morten Hoegh  ‍ ‍,1 Tasha Stanton,2 Steven George,3 Kristian Damgaard Lyng,1,4 Sabina Vistrup,4
Michael Skovdal Rathleff1,4

‘Pain’ and ‘injury’ are not, and of the spectrum: (1) anterior cruciate strategies targeted to the findings are
should not, be considered ligament tear (confirmed sports-­related essential for optimal outcomes and
synonymous injury with sports-­related pain), (2) return-­to-­sport.
Successful management of tissue injury patellofemoral pain (sports-­related pain Differentiating between sports-­
cannot rely solely on pain responses during certain activities in the absence of related injury and pain, and carefully
because tissue healing is not directly definable sports-­related injury) and (3) considering the contribution of each,
related to pain. Pain without identifi- patella tendinopathy (sports-­related pain may lead to better care for all stake-
able pathology is common in athletes,1 and clinical evidence of sports-­related holders (ie, athletes, clinicians, and
and as a result medical labelling remains injury). For all three cases, individually researchers) in the sports medicine
an ongoing challenge. Therefore, we tailored information and management community.
argue that, for the benefit of athletes,
there is an urgent need for a clear
distinction between pain and injury (see
Infographic).
Synonymous use of pain and injury in
research and clinical practice may nega-
tively impact clinical management. First,
benign and normal fluctuations in pain
may be seen as signs of sports-­ related

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injury, which could impact performance
negatively. Second, viewing all pain as
a direct sign of tissue injury may lead to
underprioritising of psychological and
social aspects of return-­ sport. Third,
to-­
athletes being told they are ‘injured’ can
lead to unnecessary assessment and inter-
ventions,2 particularly when a clear clinical
diagnosis is lacking yet the reports of pain
remain severe. Last, when pain is linked to
unconfirmed injury, fear and anxiety may
be heightened. Indeed, current evidence
shows fear avoidance, fear of reinjury
and pain catastrophising are common in
response to an injury in athletes.3 Thus,
a clearer distinction between pain and
injury, paired with a person-­centred and
educational approach, seems necessary.

New terminology
Given that (1) tissue injury is nearly always
accompanied by pain (ie, consistent with
injury models)4 and (2) pain is not always
accompanied by evidence of tissue injury
(ie, consistent with contemporary science
models of pain as a marker of protection
or nociplasticity),5 we propose two new
semantic entities that may co-­occur, yet
also be operational for both clinical and
research purposes: Sports-­related injury
and sports-­related pain (see Infographic).

Sports-related pain or injury: a

spectrum, not a dichotomy
Here, we propose three stereotypical
cases, representing different aspects

Hoegh M, et al. Br J Sports Med March 2022 Vol 56 No 5    299

 Infographic
1
Department of Health Science and Technology, Aalborg
University, Aalborg, Denmark
2
IIMPACT in Health, Allied Health & Human
Performance Academic Unit, University of South
Australia, Adelaide, South Australia, Australia
3
Department of Orthopaedic Surgery and Duke Clinical
Research Institute, Duke University, Durham, North
Carolina, USA
4
Center for General Practice at Aalborg University,
Aalborg University, Aalborg, Denmark
Correspondence to Dr Morten Hoegh, Department
of Health Science and Technology, Aalborg University,
9100 Aalborg, Denmark; ​msh@​hst.​aau.​dk
Twitter Morten Hoegh @mh_dk and Kristian
Damgaard Lyng @_Kristianlyng
Acknowledgements  The authors would like to
acknowledge Ms Madeline Thorpe, a graphic designer,
for her assistance in creating the infographic.
Contributors  MH and MSR were involved in idea
generation. All authors contributed equally to writing
and reviewing the editorial, appendix and infographic.
Funding  TS is supported by a National Health
& Medical Research Council of Australia Career
300
Development Fellowship (ID1141735). Duke University
has received support for Prof. Steven Georges’ salary
from NIH grants (outside of this work).
Competing interests  MH has received support from
professional and scientific bodies (reimbursement of
travel costs and speaker fees) for lectures on pain, and
he receives book royalties from Gyldendal, Munksgaard
Denmark, FADL and Muusmann publications. TS has
received payment for lectures relating to pain and
rehabilitation.
Patient consent for publication  Not applicable.
Provenance and peer review  Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2022. No commercial
re-­use. See rights and permissions. Published by BMJ.
To cite Hoegh M, Stanton T, George S, et al.
Br J Sports Med 2022;56:299–300.
Accepted 6 September 2021
Published Online First 16 September 2021
Br J Sports Med 2022;56:299–300.
Hoegh M, et al. Br J Sports Med March 2022 Vol 56 No 5
Br J Sports Med: first published as 10.1136/bjsports-2021-104633 on 16 September 2021. Downloaded from http://bjsm.bmj.com/ on April 26, 2023 at Universidad Europea de Madrid.
doi:10.1136/bjsports-2021-104633
ORCID iD
Morten Hoegh http://orcid.org/0000-0002-9724-767X
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