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Pain and fatigue in sport: are they so different?
  1. Kieran O’Sullivan1,2,
  2. Peter B O’Sullivan3,4,
  3. Tim J Gabbett5,6
  1. 1 Department of Clinical Therapies, University of Limerick, Limerick, Ireland
  2. 2 Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  3. 3 School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
  4. 4 Bodylogic Physiotherapy, Perth, Australia
  5. 5 Gabbett Performance Solutions, Brisbane, Australia
  6. 6 Institute for Resilient Regions, University of Southern Queensland, Ipswich, Australia
  1. Correspondence to Dr Kieran O’Sullivan, Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar; kieran.osullivan{at}

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Pain and fatigue are common reasons for athletes to avoid, or reduce, sporting participation. Despite commonly coexisting, they are usually treated as distinct entities. Both sensations are often interpreted by medical staff as indicating that physical activity should be reduced or avoided, either due to tissue damage (pain) or excessive training (fatigue). But paradoxically, that management plan—relative rest—means that athletes avoid what keeps them healthy, fit and resilient—physical activity.

Coaches sometimes view the sensations of pain and fatigue as indicators of physical and/or psychological weakness; they should be ignored to ‘toughen up’ athletes, sometimes leading to athletes unhelpfully provoking symptoms. These opposing views between medical staff and coaches—which often reflect limited understanding regarding the interaction of training load, beliefs and other external factors on pain and fatigue—often place the athlete in a conflicted state. ‘Should I tell (the medical team) or should I remain stoic’ (figure 1). We discuss the parallels between pain and fatigue, and how their management reflects the lens through which these sensations are viewed.

Figure 1

Parallels between the interpretation of pain and fatigue.

Neither pain nor fatigue always indicate impending disaster

Both pain and fatigue are potentially important signals that the body perceives danger. There are scenarios when these sensations should cause the athlete to cease the provoking activity such as in the case of demonstrable tissue injury linked to trauma (eg, fracture) and/or underlying systemic illness (eg, infection). However, in the absence of pathology, or obvious signs and symptoms of maladaptation,1 these sensations can be misinterpreted as tissue injury and/or illness. Since some functional over-reaching is required for physiological adaptation, some fatigue is unavoidable.2 However, the ability of athletes to perform (and tolerate) high training loads, and cope with fatigue, may be influenced more by the central nervous system (CNS) than the cardiovascular and musculoskeletal systems.3 Similarly, while local biological processes (eg, inflammation, tissue damage) are important components of pain, the CNS plays a large role in determining a person’s pain experience.4 In both situations, interpretation of these sensations can be influenced by social, cultural, psychological and environmental factors.

A key challenge is accurately interpreting these sensations. Athletes should first be triaged to identify any pathological causes of these sensations, to reduce the risk of further injury or systemic illness. However, to assume these sensations indicate injury or illness risks consistently under-loading athletes,5 and might lead athletes to believe these sensations indicate that their ‘vulnerable’ body might break down.

Interpreting and managing pain and fatigue: practical considerations

Listen carefully to the athlete’s story

For many athletes, pain develops insidiously and is not associated with an identifiable injury mechanism. A detailed history should establish whether the pain coincides with other sensitising factors (eg, stress, poor sleep).6 Similarly, athlete responses to training load are highly individual, such that fatigue may be reported despite their training being similar to other athletes. In some cases, fatigue may have less to do with the training programme, and more to do with other contextual stressors. For both pain and fatigue, evaluating athlete responses to such sensations and identifying anxious thought processes can be valuable.

Educate and reassure through behavioural learning

If pain is always explained as tissue damage, and blamed on presumed biomechanical or structural flaws, fear about the ability to train and compete will lead to load avoidance. Similarly fatigue, especially among inexperienced athletes, can create fear about the safety of training. Alternatively, ignoring these sensations without considering other contributing factors can lead to symptom exacerbation (figure 1).

By identifying the contributing factors to these sensations, and developing strategies to control them, activity can be maintained while building physical and psychological resilience (figure 1). Positive and reflective communication can help athletes reconceptualise their symptoms, and realise why activity avoidance is a major barrier to achieving goals. Central to this is athletes realising that both pain and fatigue are multifactorial and modifiable, and do not necessarily imply injury, illness or weakness. Identifying discrepancies between an athlete’s predicted response to a threatening situation (eg, increased pain) and the actual outcome (eg, pain same) can assist in this process.7

Team environment

Medical and coaching staff need to understand each other’s perspectives, and share a common understanding of athletic resilience, to achieve athlete-centred goals. We recommend that clinicians and coaches develop good relationships with their athletes so they can identify the breadth of factors that make athletes vulnerable to reporting these sensations.

In conclusion, monitoring perceived training load, pain and fatigue can be useful. However, once serious pathology has been excluded, athletes reporting these sensations should not panic. Instead, this information should be used within a decision-making framework7 8 to understand why an athlete is struggling, allowing for identification and management of the relevant modifiable factors underlying these sensations. In this manner, athletes can continue at least some training, without unnecessarily avoiding activity or provoking symptoms.


Thanks to Athol Thomson and Sean McAuliffe for comments on the draft manuscript, and to Ivan Stankovic for assistance with the figure.



  • Contributors All authors contributed equally to the design and writing of this manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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