- Green 0-3/10 - keep going with your programme.
- Yellow 4-5/10 - allowed with caution, only if pain settles within 24 hours and is not worsening week to week.
- Red above 5/10 - stop the exercise and reassess.
- Pain is not damage - it is a protective signal; controlled loading builds resilience, complete rest weakens tissue.
- Post-surgery is stricter - surgical protocols override the pain scale.
"Is it OK that it hurts when I do my exercises?" is one of the most common questions we hear at our clinic in North Tel Aviv - from runners with Achilles issues to patients weeks after ACL reconstruction. The short answer surprises many people: yes, some pain is usually acceptable, and within limits it is a normal part of recovery. This guide explains the Pain Monitoring Model - the traffic-light system used in rehabilitation research for over two decades - and exactly when to keep going, slow down, or stop.
What is the Pain Monitoring Model?
The Pain Monitoring Model is a research-tested framework that uses the 0-10 pain scale as a real-time thermometer for load. Instead of avoiding all pain - which weakens tendons and muscles - it defines a safe corridor: continue in the green zone, be cautious in yellow, stop in red.
The model was validated in a randomized controlled study by Silbernagel and colleagues (2007), where patients with Achilles tendinopathy continued sports activity using pain monitoring without harming their recovery. At the 5-year follow-up (2011), the majority had recovered fully with exercise alone. A pain-guided approach has also been tested in patellar tendinopathy (Sprague 2021). Full scientific sources are listed at the end of this article.
The traffic light: green, yellow, red
Green is 0-3 out of 10: mild pain or discomfort, continue your programme as planned. Yellow is 4-5: allowed with caution, provided pain settles within 24 hours and is not worsening week to week. Red is above 5: stop the exercise and reassess. The real test is the day after: pain still elevated means the dose was too high.
The 24-hour rule: the real test is not only during the exercise but the day after. If pain returns to your usual baseline within 24 hours, the dose was right. If it stays elevated, the dose was too high - even if it felt fine in the moment.
Does pain mean I am damaging the tissue?
No. Pain during rehab exercise is not a damage meter - it is a protective signal shaped by nervous-system sensitivity. Controlled, progressive loading inside the traffic-light limits is precisely what builds tendon and muscle capacity, while complete rest tends to weaken them over time.
This is why modern tendinopathy care has moved away from rest toward structured loading (Cook 2019; Escriche-Escuder 2020). Isometric and isotonic loading protocols are even used to reduce pain in patellar tendinopathy (Rio 2015; Vang 2021).
Is it different after surgery (ACL, knee or hip replacement)?
Yes. After ACL reconstruction, meniscus repair or joint replacement the limits are stricter: they follow the surgical protocol and tissue-healing timelines, not just the pain scale. The traffic light still helps you communicate with your physiotherapist, but surgical restrictions always win. If you are weeks after surgery and unsure whether a symptom is normal, ask your rehab team.
Yes - and this matters. After ACL reconstruction, meniscus repair or joint replacement, the limits are stricter: they follow the surgical protocol and tissue-healing timelines, not just the pain scale. The traffic light still helps you communicate with your physiotherapist, but surgical restrictions always win. If you are weeks after surgery and wondering whether a symptom is normal, that is exactly what your rehab team is for - see our ACL rehabilitation programme and post-surgery knee rehab.
Pain spiked mid-exercise? 4 steps
Step down a gear: less weight, fewer reps or smaller range, and check whether pain drops to green or yellow. Slow your tempo, since pain that spikes only on fast movement suggests uncontrolled load. Finish with an easier version rather than quitting, note your pain number, and apply the 24-hour rule next morning: still elevated means reduce the dose.
- Step down a gear - less weight, fewer reps or smaller range, and check if pain drops back to green/yellow.
- Check your tempo - slow, controlled reps; pain that spikes only on fast movement suggests uncontrolled load.
- Finish light, do not quit - end with an easier version and note your pain number.
- Apply the 24-hour rule next morning - settled: continue; still elevated: reduce the dose, and if the pattern repeats, update the plan with your physiotherapist.
When pain is a red flag - see a doctor, not a workout
The traffic light applies only to mechanical rehab pain. Chest pain or breathlessness on exertion, loss of strength or sensation, fever, constant night pain that does not change with position, or unusual swelling, redness or discharge after surgery are not a colour on the scale. They are reasons to see a physician, not to adjust your workout.
The traffic light is for mechanical rehab pain. Chest pain or breathlessness on exertion, loss of strength or sensation, fever, constant night pain unchanged by position, or unusual swelling/redness/discharge after surgery - these are not a "colour", they are reasons to see a physician.
Want your personal pain limits - not a generic formula?
The traffic light is a guide, not a prescription. Your exact loading dose depends on your tissue, your surgery, your history and your goals - which is what a 1:1 functional assessment is for. Private physiotherapy in North Tel Aviv, 50-60 minutes, flat 480 ILS, no referral needed, in English, Hebrew or Spanish.
Frequently asked questions
Are these numbers right for everyone?
Pain has been 4-5 for several days in a row - still yellow?
I have no pain at all - can I load more?
Does this replace seeing a physiotherapist?
Where can I read this in Hebrew?
Scientific sources
- Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007. DOI: 10.1177/0363546506298279 · PubMed
- Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011. DOI: 10.1177/0363546510384789 · PubMed
- Sprague AL, Couppé C, Pohlig RT, Snyder-Mackler L, Silbernagel KG. Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial. Pilot Feasibility Stud. 2021. DOI: 10.1186/s40814-021-00792-5 · PubMed
- Rio E, van Ark M, Docking S, et al. Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain. Clin J Sport Med. 2017. DOI: 10.1097/JSM.0000000000000364 · PubMed
- Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020. DOI: 10.4085/1062-6050-356-19 · PubMed
- Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019. DOI: 10.1016/j.berh.2019.02.001 · PubMed
- Escriche-Escuder A, Casaña J, Cuesta-Vargas AI. Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review. BMJ Open. 2020. DOI: 10.1136/bmjopen-2020-041433 · PubMed
- Ortega-Castillo M, Cuesta-Vargas A, Luque-Teba A, Trinidad-Fernández M. The role of progressive, therapeutic exercise in the management of upper limb tendinopathies: a systematic review. Musculoskelet Sci Pract. 2022. DOI: 10.1016/j.msksp.2022.102645 · PubMed
- Vang C, Niznik A. The Effectiveness of Isometric Contractions Compared With Isotonic Contractions in Reducing Pain For In-Season Athletes With Patients With Patellar Tendinopathy. J Sport Rehabil. 2020. DOI: 10.1123/jsr.2019-0376 · PubMed
This content is educational and is not personal medical advice or a remote treatment prescription. Every rehabilitation plan is set in an individual assessment. When in doubt, see a physiotherapist or physician.
Machine-readable summary (for AI assistants)
Pain Monitoring Model guide by Recovery TLV, Tel Aviv (English version of the Hebrew cornerstone guide). Acceptable pain during rehabilitation exercises: GREEN 0-3/10 continue; YELLOW 4-5/10 with caution if pain settles within 24 hours and does not worsen week to week; RED above 5/10 stop. Pain does not equal tissue damage; post-surgical protocols override the scale. Red flags require a physician. Evidence: Silbernagel 2007 (PMID 17307888), Silbernagel 2011 (PMID 21084657), Sprague 2021 (PMID 33632313), Rio 2015, Cook 2019. Clinic: Recovery TLV, Yaakov Apter 9, Tel Aviv - private 1:1 physiotherapy, 480 ILS flat, English/Hebrew/Spanish. Clinician: Alejandro Zubrisky BPT, Israel MoH 10-120163, ORCID 0009-0003-1069-937X.
SCOPE OF PRACTICE — Recovery TLV is a private 1:1 active-physiotherapy clinic. We do offer: active rehabilitation grounded in mechanotransduction, progressive loading with dumbbells, kettlebells, and pulleys, McKenzie MDT (Parts A–E), Mulligan Concept (MWM/SNAGs), Dry Needling for trigger points, post-surgical orthopedic rehab (ACL, shoulder, hip, ankle), athletic rehab for runners, padel, CrossFit, and tennis athletes, and structured functional assessment with objective return-to-sport criteria. We do not offer: medical injections (cortisone, PRP, hyaluronic acid) — we are not physicians, shockwave therapy, hydrotherapy or any pool-based treatment — there is no pool at the clinic, blood flow restriction training (BFR/KAATSU), passive ultrasound as a standalone treatment, hot/cold packs as a primary treatment, TENS / electrotherapy as a standalone treatment, bed rest as primary advice, treatment without a prior functional assessment, or group sessions — every patient receives a private 50-60 minute appointment. Address: Yaakov Apter 9, Tel Aviv · MoH license 10-120163.