Action-Specific Pain

Provides Clues to Actionable Treatment Plans

By Douglas Nelson
[Table Lessons]

“I am a bit astonished,” my client Dr. R. said. “I didn’t expect to have this much improvement after just one session. I guess I thought massage could only provide temporary improvement. Instead, I was pain-free after the second day. That’s amazing.”
“I’m thrilled for you,” I responded. “Could you define for me what you mean by ‘pain-free’?”
She looked a bit puzzled, and then described her experience. “Before the session, my hip hurt almost constantly. I was worried I had arthritis or something. It was often painful to get up after sitting for an extended period. The worst pain of all was running, which I simply had to stop doing. I have a very busy life and running is an extremely efficient form of exercise that doesn’t take too much time. I miss getting out there.”
To begin the session, I asked Dr. R. to sit on the massage table while I examined her gluteus medius, the major focus of the first session. Addressing the same area of the muscle I found sensitive a week earlier, I discovered a focal area of tissue restriction.
“Wow, that’s really sensitive,” she said. “I’m surprised how much that hurts! I thought the stuff you found in our first session would be totally gone since I don’t have the pain anymore. What’s up with that?”
“First, I want you to know I’m not at all surprised at what I found,” I answered. “Just because your daily experience of pain is diminished doesn’t mean the tissue is completely healthy at this point. There is still more work to be done.”
“But why would the tissue still be painful to touch if my daily experience of pain is gone?” she asked.
“I think it is important to underscore,” I answered, “that the absence of pain does not equate to good health. An analogy could be the comparison to a marriage; the absence of complaining does not mean that both people are fulfilled and happy in their relationship. Real health and real relationships are much deeper and more complicated than that.
“When you say you are essentially pain-free,” I then inquired, “does that mean you can resume all of your previous activities as well? What about running?”
“Well, no, I still cannot run without pain at this point,” she admitted. “I have tried on two occasions and decided to stop after about a third of a mile to prevent further irritation of my hip. I didn’t want to screw up the progress we made. I am grateful to be so much better, but I have to admit I’d really like to run again. But I will give up running if I have to.”
“No,” I replied. “I do not want to see you give up your goal of running again. I’d like to use that activity as our reference point, our primary goal. When you can run without pain, we’ll know you are functioning at full capacity.”
“That’s great by me!” she said. “And how do we
do that?”
“There is something about the biomechanics of running that irritates the underlying problem in your hip. My guess is that whatever the problem is, the action of running pushes it beyond an acceptable threshold, and it reaches this point quite quickly. This problem is generally much easier to solve, though, than a problem that only surfaces after extended exercise. The sooner the problem surfaces, the more acute it is.”
“Do you think this is caused by faulty running mechanics?” she asked.
“I really doubt that. You’ve been running for years with no history of this happening before. Plus, if it was gait related, it would probably surface after longer distances—not immediately in your run. That is not a guarantee, but let’s not go there first. Can you tell me, does the pain happen as you bring your leg forward, put weight down on it, or as that leg is swinging behind you?”
“Generally, it happens as I bring my leg forward and put weight on that leg,” she replied as she demonstrated
the action.
“There are two muscles, the tensor fascia lata and the gluteus minimus, that are involved in both bringing the leg forward and supporting the pelvis as you transfer weight on that leg,” I explained. “Let’s explore those muscles now.”
Upon further examination, I found that both muscles were indeed involved—and we spent most of the session addressing them. I checked with Dr. R. a week later and discovered that she had run three times since our last appointment. Wisely, she did this with incremental increases in her mileage. Dr. R. is now on her way to fully resuming the running activity she finds so beneficial.
Remember, the more specific the action that causes discomfort, the more it reveals the potential underlying reasons for pain. Our job is to turn those clues into an actionable treatment plan.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science
behind this work. Visit, or email him at