The pain monitoring model for exercise rehab: how to use it in a home program

The pain monitoring model lets a patient keep exercising, and often keep up some sport, with a set amount of pain instead of stopping at the first twinge. The patient rates pain from 0 to 10. Up to 5 during and just after the activity counts as acceptable, provided it has settled by the next morning and is not creeping up from one week to the next. It grew out of Swedish work on patellofemoral pain and Achilles tendinopathy, and many physical therapists use it to guide loading in tendon rehab and other painful conditions.

Below you will find where the model came from and how it is used in tendinopathy, knee osteoarthritis and low back pain. After that: how to explain it to a patient, how to build it into the cues of a home exercise program (HEP), which pain no number makes acceptable, and where the evidence runs out.

What is the pain monitoring model?

The model gives the patient a number and a timeline instead of a vague "let pain be your guide". Pain is rated on a numeric scale where 0 is no pain and 10 is the worst pain imaginable (Silbernagel and colleagues, 2020). Thomeé's original system used a visual analog scale. Ullern and colleagues describe its zones this way, on the condition that the pain has subsided by the next morning:

Zone	Pain, 0 to 10	Common clinical reading (not a tested rule)
Safe	Below 2	Carry on
Acceptable	2 to 5	Carry on, and check the response the next morning
High risk	Above 5	Reduce the activity or the load

The zones and limits are from the original system. The last column is how clinicians commonly read them. Three checks then decide whether the load was right (Sprague and colleagues, 2021; Rosen and colleagues, 2022):

1. During the activity, pain stays at 5 out of 10 or below.
2. Straight after the activity, pain may reach 5, but by the next morning it is back to its usual level.
3. From week to week, pain is not creeping up. If it is, the activity is reduced.

The next-morning check matters because a session that felt fine at the time can still turn out to have been too much. Our pain scales tool explains the numeric rating scale if your patient has not used one before.

Where the pain monitoring model comes from

Thomeé used a pain monitoring system in a 12-week program for young women with patellofemoral pain, published in Physical Therapy in 1997. The 40 women trained with either isometric or eccentric muscle work, and both groups improved in pain, strength, jumping and activity level. Later papers credit this as the origin of the model (Sprague and colleagues, 2021; Ullern and colleagues, 2025).

The best-known trial came 10 years later. Silbernagel and colleagues randomized 38 people with Achilles tendinopathy to the same tendon-loading program. One group kept running and jumping, guided by the pain monitoring model. The other group stopped those activities for 6 weeks. Both groups improved over 12 months, by similar amounts, and the authors found no negative effects from carrying on with activity.

A 5-year follow-up by the same team looked at 34 patients treated with exercise alone for Achilles tendinopathy. Of these, 27 (80%) had fully recovered. More fear of movement went with poorer recovery of calf endurance, and on that basis the authors recommended using a pain monitoring model when patients are treated with exercise (Silbernagel and colleagues, 2011). That was a case series of treated patients, not a comparison with another rule, so it supports exercise more than it supports the model itself.

How it is used in Achilles and patellar tendinopathy

Tendinopathy is where the model has the most use and the most data. In their clinical guide to Achilles tendinopathy, Silbernagel and colleagues (2020) say the priority is to avoid moderate and severe pain and symptoms that get worse over time. They describe the model as a guide to tendon loading. For the return to sport, they classify activities as light, medium or high level from the athlete's pain ratings during and after activity and how hard the tendon felt it had worked. Our Achilles tendinopathy program uses the same next-morning check to decide when to move up a stage.

For patellar tendinopathy, Rosen and colleagues (2022) suggest the Achilles model may be used for all tendinopathies. Pain of 5 out of 10 during and after exercise is acceptable, but the tendon pain has to be below 5 the following day, and pain that rises from week to week means the activity should be reduced. Sprague and colleagues (2021) tested the idea in a pilot trial of 15 people. For the first 6 weeks, one group carried on with their usual recreational activities using the model, while the other avoided running, jumping and anything that provoked the tendon outside treatment.

The pilot found the pain-guided approach feasible. With 9 and 6 people in the two groups, it was never meant to show which approach works better. The patellar tendinopathy program keeps the pain during its strength work lower, at about 3 out of 10, which is a reminder that the ceiling of 5 is not fixed.

Shoulder trials set their limits in different places too. A scoping review found 86 randomized trials of resistance exercise for rotator cuff related shoulder pain, published from 2018 to 2023, and 58 of them gave no pain rule at all. Of the 28 that did, 12 allowed pain during exercise, 6 discouraged it and 10 were unclear. Where a limit was given, 3 out of 10 and 4 out of 10 were the most common, ahead of 5 (Ullern and colleagues, 2025).

Using it for knee osteoarthritis

The model has been borrowed for knee osteoarthritis, though with less testing. Thorstensson and colleagues (2005) ran a 6-week, twice-weekly high-intensity program for 61 people aged 36 to 65 with knee osteoarthritis. Pain during exercise was not treated as an obstacle if the patient found it acceptable and no increase in symptoms lasted beyond 24 hours, a rule based on Thomeé's work. The program itself had no effect on pain or function compared with the control group, with some gain in quality of life.

That result is a useful caution. A pain rule tells the patient how hard to push, but it does not make a program work on its own, and the trial cannot tell you why this one did not help. The knee osteoarthritis program starts gently and builds up over weeks.

For a joint, many physios also start with a lower ceiling, such as 3 out of 10, and add a swelling check: a knee that is more swollen the next day means the load was too much. This is common practice rather than a tested rule. The knee example in the FITT guide uses the same numbers.

Knee patients can also be told that the flare after early sessions tends to shrink. In a group of adults with knee or hip pain doing supervised neuromuscular exercise twice a week for 8 weeks, average joint pain fell from 3.6 to 2.6 out of 10. The acute pain flares after exercise also got clearly smaller as the sessions went on (Sandal and colleagues, 2016). The authors suggest using this to set patients' expectations before they start.

Does it work for low back pain?

The evidence here is thin. The two sources below are a suggestion and a review of progression methods, not trials of the model in back pain.

Smitheman and colleagues (2023) compared fear of movement in people with chronic low back pain and people with Achilles tendinopathy and found it common in both. In their discussion they suggest that the pain monitoring model and training diaries may be a useful addition to treatment for chronic low back pain. That is an idea borrowed from tendon care, not a trial result.

A 2025 systematic review of exercise progression in nonspecific low back pain adds a caution (Tuninetti and colleagues). It notes the lack of a clearly defined pain threshold or standard pain response to exercise. From the studies they reviewed, the authors put together a first draft of a decision guide, which has not been tested. Where back pain is only loosely linked to load, for example nociplastic pain that is more influenced by psychosocial factors, they suggest progressing on a planned schedule (time-contingent) may suit better than waiting for pain to allow it (pain-contingent). Where the pain is mainly load-related and easily stirred up, they suggest a hybrid pain monitoring model: small steps, a check 24 to 48 hours after exercise for soreness, stiffness, night pain and the effect on daily activities, and a step back if a flare is out of proportion or lasts too long.

A looser version is common practice for backs. Some ache or stiffness during and after exercise is expected, the check is the next day, and the program moves forward on a plan rather than waiting for pain to reach zero. Our low back pain program uses similar wording for patients: some discomfort is usually fine if it has settled within a day and is not getting worse week on week. Pain spreading into the leg, new numbness or tingling, or a back that is clearly worse the next day means the load was too much for now, and the patient should stop and tell their physio.

How to explain the pain monitoring model to patients

Patients often arrive with one of two beliefs: any pain means harm, or no pain means no gain. The model sits between the two, and it is easier to follow as a picture. A traffic light is a common way to teach it: green is below 2, amber is 2 to 5, red is above 5. Green and amber are fine, and red means ease off.

Then give them the timeline. A common way to say it, using the stricter next-morning rule:

"Some pain while you do these is OK, up to about 5 out of 10, unless your physio sets a lower limit. It might ache a bit afterwards too. What matters most is tomorrow morning: if it is back to normal for you, the amount was right. If it is not back to normal, or it keeps getting worse week by week, we did too much and we drop back a step."

Give the patient one test to use each morning, the same one every time. For an Achilles tendon that is often the first steps out of bed, for a patellar tendon a single leg squat, and for a knee with osteoarthritis getting up from a chair or going down stairs. A short log of the during, after and next-morning numbers, even on the back of the exercise sheet, gives you something concrete to review. The traffic light, the script, the morning test and the log are common practice, not tested methods.

Be clear about what the model does not cover. It is for the familiar pain of the problem you are treating. New kinds of pain, pain in a new place, or the warning signs further down this page are not "amber", and the patient should stop and get help.

How to write it into exercise cues

A pain rule only works if it travels with the exercise. Put a short version in the cue for each exercise that is likely to hurt, in the patient's words, not yours. Here are four examples. If you are a patient reading this, treat the numbers as broad ranges and not as your prescription. Your physio will adjust this.

Exercise	A cue with the pain rule built in
Calf raises for Achilles tendinopathy	"Tendon pain up to 5 out of 10 is OK, but sharp pain is not. Check your first steps out of bed tomorrow. If they are not back to normal, do 1 set fewer next time, and tell your physio if the tendon is clearly worse."
Isometric calf raise hold on a sore day	"Mild tendon pain is OK if it does not build as you hold. If it builds, put your other foot down and hold for less time next go. It should be back to normal by the next morning. If it is worse, ease off and tell your physio."
Sit to stand for knee osteoarthritis	"Some knee ache is OK if it stays at about 3 out of 10 or less, is back to normal by the next morning and the knee is no more swollen. Sharp pain or a knee that gives way means stop and tell your physio."
Bird dog for low back pain	"Some stiffness is expected. If your back is not back to normal by the next morning, go back to the last level, and tell your physio if it is clearly worse. If pain runs down your leg, or you get numbness or tingling, stop and tell your physio."

Link the rule to your progression and regression too. One way to do it: move one thing forward, such as load, reps or hopping height, once the three checks have been met for a week or two, and drop back one step when a check is broken. It is common practice rather than a tested protocol. Changing one variable at a time also tells you what caused a flare, and the FITT guide covers how to write the dose around it.

Write the same rule in your clinical note, so the next clinician knows what "acceptable" meant for this patient. For everything else, from picking the exercises to planning the follow-up visit, read how to write a home exercise program. If a patient is not doing their exercises because they hurt, the adherence guide covers what else to look at.

PocketPhysio has room for your own cue on every exercise, so the pain rule can go there in your words, next to the movement it applies to. Each exercise also has a video and a voice guide. The program goes out by SMS, email or link, or straight to the Pocket Physio Care app, and WhatsApp is an option too.

When pain is not acceptable

The model only covers the expected, familiar pain of the condition being treated. Teach every patient that these signs override any number on the scale. They should stop and get help:

1. Chest pain or pressure, dizziness or feeling faint, a racing or irregular heartbeat, or being far more out of breath than the effort should cause.
2. Your calf or thigh becomes swollen, warm, tender, red or darker than usual, or has a throbbing or cramping pain that feels different from normal muscle ache. Stop and get medical advice the same day, as this can be a blood clot. If you are also short of breath or have chest pain, call emergency services.
3. A sudden pop or snap at the back of your ankle or heel, a feeling that someone kicked you there, or sudden pain there after which you cannot push off or rise onto your toes on that leg. Stop, take the weight off that leg carefully and go to an urgent care center or emergency department the same day, even if you can still walk, as this can be a torn Achilles tendon.
4. Pins and needles, numbness or weakness in an arm or leg that does not go away after you stop. Get medical advice the same day. If one side of your face or body suddenly goes numb or weak, or your speech becomes slurred or muddled, call emergency services, even if it goes away.
5. Numbness around your genitals or bottom, new trouble with your bladder or bowels, pain, tingling, numbness or weakness in both legs, or loss of feeling in one leg. Call emergency services or go to an emergency department straight away.
6. Your leg or foot gets weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
7. Sharp pain during an exercise, a joint that gives way, new swelling, or pain that is still worse a few days after you drop back a step. Stop that exercise and check with your physio before you do it again.

If chest pain, pressure or tightness does not ease quickly when you rest, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, feeling sick, feeling light-headed or being short of breath, call emergency services straight away, as this can be a heart attack. If it eases quickly and none of these happen, get medical advice the same day, and do not exercise again until you have been checked. If you faint while exercising, call emergency services, even if you feel fine again quickly.

Pain at night or at rest is not exercise pain and has its own timings. For a tendon or joint problem such as the knee or the Achilles:

Pain is there at night or at rest and keeps getting worse. See your doctor within a few days. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse. If you are being treated for cancer now, contact your cancer team the same day.

For back pain the timings are shorter:

Pain that is worse at night, or does not ease at all when you rest. See your doctor within a few days. If you have had cancer, now or in the past, or you have lost weight without trying, get medical advice the same day. If you are being treated for cancer now, contact your cancer team the same day.

New back pain and you have had cancer, now or in the past. Get medical advice the same day and mention your cancer history. If you are being treated for cancer now, contact your cancer team the same day.

Emergency: you have had cancer, now or in the past, and your back or neck pain feels like a tight band around your body, or comes with pain spreading down an arm or leg, weakness, numbness or pins and needles in your arms or legs, trouble walking, or trouble controlling your bladder or bowels. Call your cancer team's emergency number straight away, or go to an emergency department if you do not have one or cannot get through. This can be cancer pressing on the spinal cord (metastatic spinal cord compression), which needs treatment straight away.

After surgery, the surgeon's instructions or the local protocol set how much pain is acceptable, not a model built for tendon pain. The same goes for heart and lung conditions, where the medical team sets the limits. See a physio or doctor if pain keeps breaking the rules for more than a week or two despite dropping the load, or if you are unsure whether a pain is the familiar one.

Limits of the evidence

The model is widely used. The evidence behind it is narrow. Thomeé chose the limits from clinical experience, and Ullern and colleagues (2025) knew of no study that has compared them with other values or other pain rules. The 2007 trial had 38 people and tested whether carrying on with running and jumping under the model changed the outcome. It did not compare the model with a different pain rule, so it cannot tell you that 5 is better than 3 or 4.

The numbers also vary between sources. Some describe the next-morning rule as pain back to its usual level (Sprague and colleagues, 2021), others as tendon pain below 5 the next day (Rosen and colleagues, 2022), and trials in shoulder pain most often used 3 or 4 out of 10 (Ullern and colleagues, 2025). In a 2025 Delphi study on Achilles tendinopathy, international experts ranked pain highly among exercise parameters but did not reach consensus that it has a major influence (Demangeot and colleagues). They did note that pain should be checked during the session, straight after it and on the following day.

Two reviews have looked at the wider question of whether exercise should hurt at all. Smith and colleagues (2017) pooled 7 trials with 385 people with chronic musculoskeletal pain. They found a small short-term benefit for pain in favor of painful exercise, with no difference in the medium or long term, or in function.

An update by Tran and colleagues (2025), with 16 randomized trials, found no clear difference between painful and nonpainful exercise in pain or disability at any time point. The confidence intervals were wide and the certainty very low to low, so the effect is unclear. The authors concluded that pain during exercise may not need to be avoided for patients to improve.

Pain ratings are also personal. A 5 from one patient is not a 5 from another, so compare each patient with their own baseline rather than with a fixed number. For knee osteoarthritis and back pain, most of the model's support is borrowed from tendon work.

The short version

The pain monitoring model lets patients exercise with some pain, inside clear limits. Pain can reach about 5 out of 10 during and after activity, but it should be back to normal by the next morning and not rising over the weeks. It has the most support in Achilles and patellar tendinopathy and has been borrowed for knee osteoarthritis. In back pain there is little direct evidence, and a planned, schedule-based progression may suit some people better. Put the rule in each exercise cue in plain words, give the patient one morning test, and teach the warning signs that no number on the scale can cover.

References

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2. Thomeé R. A comprehensive treatment approach for patellofemoral pain syndrome in young women. Physical Therapy. 1997;77(12):1690-1703. doi:10.1093/ptj/77.12.1690
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10. Smitheman HP, Lundberg M, Härnesand M, Gelfgren S, Grävare Silbernagel K. Putting the fear-avoidance model into practice: what can patients with chronic low back pain learn from patients with Achilles tendinopathy and vice versa? Brazilian Journal of Physical Therapy. 2023;27(5):100557. doi:10.1016/j.bjpt.2023.100557
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Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.