Does Gaining Range of Motion Really have to Hurt?

Not all physical therapists are created equal. Nor does gaining range of motion have to be extremely painful! Unfortunately there is this idea among the public that physical therapy has to hurt to be effective. In most cases, nothing could be further from the truth. Sadly enough there are plenty of physical therapists out there who also believe "no pain, no gain" to be true.

Before we go any further, I need to clarify that pain is very different then a "stretch", "pull", "pressure" or "fatigue/workout soreness". Just because I don't believe in "no pain, no gain" doesn't mean I'll vouch for laziness or sub-par effort.

So here is why gaining range of motion does not have to hurt:

–  When the brain starts feeling ‘stress’ it goes into protection mode.  A pain response results in signals sent to muscles, fascia, and joint capsule to literally tighten down to protect the painful structure.  So the entire time your PT is cranking on your new rotator cuff repair, knee replacement, or you are cranking on it at home per their instructions. Your brain is busy fighting back.  The result is lots of pain and minimal progress.

– Pain fires up your sympathetic nervous system, the part of the system that handles ‘fight or flight’ situations.  To complicate matters, research has found that a lot of people are already in this sympathetic state even at rest. These individuals tend to exhibit increased stress hormone levels that result in poor sleep patterns and poor recovery from workouts and games (If you are coming off of surgery, I would argue that you are already in this state to some capacity anyway).  This elevated level of stress over the long term can have some serious effects and implications on rehabilitation.

Balance is good!

The moral of the story here is that increased pain levels correlate with increased stress levels which can delay healing and recovery.  Some pain is going to be present when you’re dealing with an injury or surgery, but your therapy should not be making you consistently feel worse! Increased pain is not an ideal situation for someone trying to gain range of motion, strength, and returning to work or athletics.

So how do we avoid the "no pain, no gain" philosophy! For starters, you still need to put forth maximal effort. Laziness will not get you out of pain. If you are post surgery then you should expect some type of "stretching" or "pulling". It is very important to distinguish between this and actual pain. The surgical limb has to move (when appropriate) and move frequently in order to start improving and building back up normal tissue resiliency. However, you want to avoid jamming your limb through further ranges of motion putting yourself into a further stressful (sympathetic) state then you already are post surgery.

Taking this a step further, in both surgical and non surgical folk we want to consider other areas which could be contributing to your overall dysfunction and pain on movement. This means looking at the joints above and below the injured area to make sure they are functioning optimally. Assessing the difference between active and passive movements also plays a role on distinguishing between actual soft tissue restriction or just lack of motor control or coordination in those end ranges of motion.  Muscle strength, endurance, work capacity, and timing are all important factors as well.

Next time you go through a physical therapy treatment, or any treatment for that matter, ask yourself if all these things are being assessed? If your program feels like a cookie cutter program then it probably is! Find a provider that understands pain and will take the time to assess/reassess movement. In most cases, there are better ways to gain range of motion and strength than trying to push through restrictions and pain.

Plantar Fasciitis Treatment – What are my options? Ann Arbor, Mi

Plantar Fasciitis (Ann Arbor, Mi) - Anybody who has ever experienced plantar fasciitis before knows that it can be a very frustrating process. Heel pain impacts just about every daily activity that involves standing or walking. Maybe your pain is not quite as bad, but it has prevented you from running or working out as you love to do so much. It is estimated that approximately 1 million patient visits per year are due to plantar fasciitis. It is also estimated that it may account for 8% of running injuries. 

(The point of this video was not to confuse you. This article is geared towards a more conventional approach to treating plantar fascia. However, I do hope this video opened your eyes a little that there are many more factors influencing plantar fasciitis that you may have never considered before.)

Plantar fasciitis refers to a strain in the muscle tissue on the bottom of the foot. Often times the area that becomes strained is on the inside portion of the heel. This is the area where most of the pain occurs and can often be very sensitive to pressure, touch, or weight-bearing. What causes this painful experience to occur?

Generally, it comes down to three things:

1) A sudden increase in activity that your body was not prepared to handle.

2) A lack of variability in movement.

3) An accumulation of repetitive physical stress without ample rest.

However, once you have reached the tipping point and pain has occurred, your body will start to heal itself naturally through a very normal process called inflammation.

Yes, you read that right! A very beneficial and normal process called inflammation. The inflammation process is needed for the body’s natural healing process to start.  Insulin growth factor is brought to the injured area for new collagen to lay down and build tensile strength back up.

If you never addressed the three causation factors described above, or never did anything to help influence the inflammation, repair, and remodel phases the body naturally goes through; then chances are the pain will linger on longer than normal.

Maybe you have experienced plantar fasciitis for quite some time now, and had an x-ray performed. Upon results of the x-ray, you may have been told that you have a “heel spur.” If you get one thing out of this article, please do not be intimidated or frightened by a “heel spur.” It’s not like what it sounds. I will use quotations around “spur” because you will not hear me say this word.

Understand that a “spur” most likely develops due to a failed healing response. The inflammatory response probably was triggered from one of the three causation factors listed previously. Again, inflammation is good because it will start the healing process. However, if then never allowed or influenced to both repair and remodel, the cycle may restart all over again as the body tries to autocorrect. Multiple restarts during this process can lead to an excessive buildup of osteophyte formation. This excessive buildup can start to form what would be considered a “spur”, but don’t get too anxious on me! Research has shown that this doesn’t necessarily always correlate with plantar fasciitis.  A study by Cornwall & McPoil, reviewed x-rays of 1,000 patients and found only 13.2% had heel “spurs”. Of these, only 39% reported heel pain. Yes, you read that right. Less than 50% of “spurs” caused pain.

So what can we do about all this?

The recovery process can be slow at times. Resolution for a case of true plantar fasciitis has been reported as long as 6-18 months in some cases.  This can become increasingly frustrating when each waking morning you take the first few painful steps. Chances are you have been told that you need better shoes and have to perform a series of stretches religiously throughout the day.

While both are great suggestions and often provide some, if not complete relief in the long term, the short-term results tend to be less than desirable.

High load strength training to the plantar fascia appears to be beneficial as well.

Self-myofascial release also gets a lot of publicity to treat plantar fasciitis. Maybe you have been told to roll a tennis ball or lacrosse ball on the arch of your foot.

This method can be effective, but not for the reasons you may have been told. Contrary to popular belief, you are not elongating the plantar fascia or breaking up scar tissue. Research has shown that it takes 460kg of force to increase the plantar fascia length by 1%6.

I doubt someone’s thumb or a lacrosse ball is going to create this amount of force. Rather, there is probably a neurological mechanism that occurs which temporarily reduces tone/guarding in the musculature.

While the research definitely supports these methods to reduce pain, it still can be a time consuming process. Furthermore, all these strategies can be implemented without a healthcare provider. This is where On Track PT and Performance is different. We know you can perform these methods in the convenience of your home, so we don’t expect you to come in 3x per week and watch you perform exercises that you are already doing at home. We treat patients 1x per week, every other week, or in some rare cases 2x per week.  For treatment, we focus on highly trained techniques with research that has shown to decrease recovery time.

Less therapy visits and a potentially faster recovery time! Sound interesting?

Instrumented Assisted Soft Tissue Mobilization (IASTM)

Again, the chances we are actually deforming fascia are slim here, as mentioned in the research above. If a clinician thinks they need to perform this technique aggressively and cause an excessive amount of discomfort to get results, they should reconsider why they have chosen this treatment modality. Rather, what is probably happening via mechanical stimulus is increasing blood flow, temporarily reducing tone, and influencing cellular mediators to start remodeling tissue in a more resilient way. With all these benefits, it is understandable why this, in conjunction with stretching/strengthening, has been shown through research to possibly speed recovery times.

Dry Needling to the Plantar Fascia

Admittedly, this treatment is not for everyone. Everyone always asks how painful it is? I will start by saying that anywhere I use dry needling; I have personally had it done on myself. So from personal and anecdotal experience, I can say that in some areas dry needling is actually very comfortable. However, the plantar fascia tends to be one of the areas where there are some sore points that elicit a “deep ache” or a “bee sting.”

Physiologically, it has a much greater physiological and neurological effect than IASTM. This is due to the increased stimulation that occurs when a needle penetrates the skin.  Even more stimulation occurs when therapeutic electrical stimulation is then hooked up. Dry needling in conjunction with electrical stimulation has been shown to have an inhibitory effect on pain through opioid release.  These effects can potentially lead to much better short term results.

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About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.


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