Is It Normal to Feel Pain During Physiotherapy Exercises?

If you are starting physiotherapy and worried about pain, you are not alone. Many people fear that treatment will be painful, or that they should push through pain to get better. The reality is more nuanced — some discomfort is normal, but pain is not something to ignore.

The question "should physiotherapy hurt?" is one of the most common concerns patients have. The outdated "no pain, no gain" mentality has caused many people to fear rehabilitation or push themselves too hard. Modern physiotherapy takes a different approach — one that respects pain as a signal, not something to be overridden.

The difference between discomfort and pain

Not all sensations during exercise are the same. Understanding the difference helps you know when to continue and when to stop:

The 3 out of 10 rule

A widely used guideline in physiotherapy is the 3 out of 10 pain rule. On a scale where 0 is no pain and 10 is the worst pain imaginable:

• 0 to 3: Acceptable discomfort during exercise. This is the productive zone where tissues are being challenged without being harmed.
• 4 to 5: Caution zone. You may need to reduce the intensity, range or number of repetitions.
• 6 and above: Stop. This level of pain means the exercise is too aggressive and may be causing harm.

This rule is a guide, not a strict rule for every situation. Your physiotherapist will give you specific guidance based on your condition. For example, some conditions (like Achilles tendinopathy) use a slightly higher threshold, while post-surgical rehabilitation may require a lower one.

Why some discomfort is necessary

Rehabilitation works by challenging tissues beyond their current capacity so that they adapt and become stronger. This process inherently involves some discomfort:

• Stretching tight tissues: If a muscle or joint is stiff, stretching it will feel uncomfortable. Without this challenge, the stiffness will not improve.
• Strengthening weak muscles: Working muscles harder than they are used to causes fatigue and burning. This is how muscles grow stronger.
• Mobilising stiff joints: Manual therapy can be uncomfortable as restricted joints are moved through their range.
• Relearning movement after neurological injury: After a stroke or other neurological event, using affected limbs can be frustratingly difficult and uncomfortable.

The key is that the discomfort should be productive — it should be the kind that leads to improvement, not the kind that causes further damage.

When pain is a warning sign

Certain types of pain during physiotherapy should never be ignored:

• Sharp, stabbing pain: May indicate tissue damage or irritation
• Pain that worsens with each repetition: The tissue is being overloaded — stop and reduce
• Pain that radiates down an arm or leg: May indicate nerve involvement — tell your physiotherapist immediately
• Pain accompanied by numbness or tingling: Possible nerve compression — stop and report
• Pain that changes your movement pattern: If you start limping or compensating, the exercise is too hard
• Pain lasting more than 24 hours after exercise: The session was too aggressive — your physiotherapist needs to know

Delayed onset muscle soreness (DOMS)

One type of post-exercise pain that is normal is DOMS — the muscle soreness you feel 24 to 48 hours after unfamiliar exercise. DOMS feels like a dull, aching soreness in the muscles (not joints) and is a normal response to new or increased exercise. It typically fades within 2 to 3 days.

DOMS is different from harmful pain:

• DOMS is in the muscle, not the joint
• DOMS is bilateral (both sides if both sides exercised)
• DOMS eases with gentle movement, not worsens
• DOMS peaks at 24 to 48 hours, then improves

If soreness is getting worse after 48 hours, is in a joint, or is one-sided, it may be more than DOMS — contact your physiotherapist.

What to tell your physiotherapist

Your physiotherapist relies on your feedback to adjust treatment. Be honest about what you are feeling:

• Where exactly you feel the pain (muscle, joint, specific spot)
• What type of pain (sharp, dull, aching, burning)
• When it starts (immediately, after a few repetitions, the next day)
• How long it lasts after you stop
• Whether it is getting better or worse over sessions

Saying "it hurts" without elaboration is less helpful than "I feel a sharp pain on the outside of my knee when I bend past 45 degrees." The more specific you are, the better your physiotherapist can adjust your programme.

Common scenarios

After knee replacement

Some discomfort is expected, particularly when bending the knee or doing extension stretches. The 3 out of 10 rule applies. Sharp pain at the incision site or inside the joint should be reported. See our guide to managing swelling after knee replacement.

With chronic back pain

For chronic back pain, some discomfort during exercise is normal, but the goal is to gradually increase activity tolerance without flaring pain. Your physiotherapist will guide you on which sensations are safe to work through.

After a stroke

Rehabilitation after stroke involves repetitive practice that can be tiring and uncomfortable. However, pain in the affected limb (particularly the shoulder) is common and should not be ignored — it may indicate subluxation or improper handling.

With arthritis

Exercise with arthritis often involves some joint discomfort. The rule of thumb is that pain should not exceed 2 to 3 out of 10 during exercise and should settle within an hour of stopping. If pain lasts longer, reduce the intensity next time.

With fibromyalgia

For fibromyalgia, the pain system is sensitised, so even gentle exercise can feel painful. The approach is very gradual — starting at a level that does not trigger a flare-up and building extremely slowly.

What to do if your physiotherapist pushes too hard

A good physiotherapist will always listen to your feedback and adjust accordingly. If you feel that your treatment is too painful:

• Say so during the session — do not wait until afterwards
• Ask why a particular exercise or technique is being used
• Request modifications or alternatives
• If your concerns are not taken seriously, consider seeking a different physiotherapist

You are always in control of your treatment. A physiotherapist can recommend, but you decide what is acceptable.

Tips for managing discomfort during exercises

• Warm up first: Gentle movement before exercises reduces stiffness and discomfort
• Use heat before: A warm pack on the area for 10 minutes can relax tissues
• Use ice after: 15 minutes of ice after exercise can reduce post-exercise soreness
• Pace yourself: It is better to do 5 good repetitions than 10 painful ones
• Breathe: Holding your breath increases tension — breathe out during the effort phase
• Take pain medication if needed: Taking prescribed pain relief 30 minutes before exercise can make the session more comfortable (discuss with your GP or physiotherapist)

Frequently asked questions

About Saleh Musmari

Saleh Musmari is a Chartered Physiotherapist with a PhD in Sports, Exercise & Rehabilitation Science and over 3 years of post-graduate experience across musculoskeletal, neurological and orthopedic care. He is HCPC registered and a CSP member, providing home physiotherapy visits across the West Midlands.

View Saleh's profile