I Don’t Treat Pain First. I Treat the Load Decision First.
This statement is often misunderstood as ideological or dismissive of pain.
It is neither.
It is a clinical sequencing rule—one based on causality, testability, and reversibility.
Pain matters.
But pain is not where durable change begins.
Pain is the signal, not the decision
Pain is an output of the system under stress.
It tells us that the system is struggling, not why.
Treating pain first assumes that:
- the system is otherwise ready,
- the original stressor has resolved,
- and relief will generalise to real life.
In recurrent musculoskeletal pain, these assumptions routinely fail.
That failure is not theoretical—it is clinical.
Load decisions determine whether pain appears at all
A load decision is any factor that determines:
- how force enters the body,
- how that force accumulates over time,
- and how the system is prepared to tolerate it.
These decisions occur long before pain appears:
- in gait strategy,
- in movement habits,
- in training volume,
- in recovery behaviour,
- and in environmental constraints.
Pain emerges when these decisions exceed the system’s tolerance.
If the decisions remain unchanged, pain recurrence is predictable—regardless of how well pain is treated.
Why load decision comes first (not only, but first)
Load decisions have three properties that pain does not:
- They are upstreamLoad decisions shape stress distribution before tissues or the nervous system fail.
- They are testableAltering load entry or exposure often produces immediate, observable changes in effort, control, or symptom behaviour.
- They are reversibleUnlike age, genetics, or disease, load decisions can be modified quickly and safely.
This makes them the most rational first hypothesis in clinical reasoning.
Treating pain first hides the real error
Pain-first care often works—temporarily.
Manual therapy, modalities, reassurance, and local strengthening can reduce symptoms by:
- altering sensory input,
- reducing tone,
- changing expectation.
What they rarely change is:
- how force enters the system,
- how often it accumulates,
- or whether capacity has improved.
When life resumes, the same load decisions reassert themselves—and pain returns.
Relief without load correction is borrowed time.
Load decision does not mean load ideology
Saying “load decision first” does not mean:
- all pain is mechanical,
- biology is irrelevant,
- psychology is secondary,
- or pain should be ignored.
It means sequencing matters.
Biology and neuroregulation constrain adaptation.
Pain can reshape movement.
Systemic disease can dominate the picture.
In these cases, pain modulation or medical management may lead.
But even then, load decisions do not disappear.
They simply stop being primary.
When pain must be treated first
A load-decision–first approach has clear boundaries.
Pain is treated first when:
- acute trauma or fracture is present,
- active inflammation dominates,
- pain prevents safe movement or learning,
- systemic pathology is primary.
In these situations, pain control restores the capacity to make better load decisions later.
Pain treatment becomes a means, not a philosophy.
The real goal is not pain relief
The goal is tolerance.
A system that can:
- walk,
- work,
- train,
- and recover,
without triggering protection.
Pain reduction is expected—but only as a consequence of better decisions under load.
The position, clearly stated
I don’t treat pain first because pain is not the problem to solve.
I treat the load decision first because that is where failure begins.
When load decisions are corrected, pain often resolves.
When they are not, pain inevitably returns.
This is not denial of complexity.
It is respect for causality.
Final word
Pain tells you where the system failed.
Load decisions tell you why.
If you want durable outcomes,
you don’t chase the alarm.
You fix the decision that set it off.
Disclaimer:
This content is for informational purposes only and does not replace professional advice, diagnosis, or treatment. Use it at your own discretion. If you wish to share your opinion, use the link below:
https://yeswanthyarlagadda.com/constructive-critique/
Published on: 01 February 2026, 16:08 IST