Strength Training for Pain & Injury Rehab

Exercise is the closest thing there is to a miracle drug,12 and strength training is one of the best kinds of exercise. It’s practically like magic, both healthier and more efficient than most people know. It’s a valuable component of fitness and injury rehabilitation for a wide range of people — not just for gym lovers, and not only for the reasons most patients and professionals think about. It is one of the best anti-aging tools we have, particularly with its ability to prevent falls and fractures later in life.3

Lois Smith is one of many who came to lifting via CrossFit. She started after the birth of her second son, to “rehabilitate my core” and “now it’s a way of life!” Her lifting is often featured on her Instagram @lois_smithy. This article showcases many other real women who lift heavy things.

Strength training includes the gym-o-centric, oomphy style of exercise that mostly guys like to do — pumping as much iron as possible, bodybuilding, powerlifting. Anyone who doesn’t feel like they fit into that scene tends to veer away from resistance training entirely, except during occasional New Year’s resolution phases, or when prescribed and/or supervised by a physical therapist. I hope this article will convince you to take it more seriously, no matter who you are.

I will spell out why building strength truly matters to everyone, and “how” to do it — which is easy, because technique is amazingly unimportant. Simply wearing muscles out by any means is usually good enough for the average person or even the average athlete.

While I hope anyone who’s ever spent time in a gym will find this guide helpful, it’s especially written for people with chronic pain and stubborn injuries who are wondering: Where does strength training fit in to a recovery plan? While it does have a vital role in rehab, it’s rarely a “treatment” per se, because weakness is rarely the reason people are injured or in pain to begin with. But it is a crucial tool for precise, methodical load management, an ideal way to help people take baby steps back to normal function … and then beyond into better-than-ever territory.

People with chronic illness and pain may have the most to gain from resistance training, but also face the strongest headwinds and harms in making the effort. So I will also explore the things that make strength training medically difficult or even dangerous for a few, and how to work around that limitation if possible.

The best (and least advertised) benefits of strength training

Over the years, I have come to love strength training for fitness and rehabilitation, but not for entirely conventional reasons, many of which are problematic. Fortunately, there are some other great reasons to challenge your muscles regularly:

• Strength training is more efficient and easier than most people realize, requiring less of a commitment. This surprising fact is explored in great detail in a separate article. Building strength also has more lasting benefits than most people realize — permanently improved muscle cells!45
• Strength training is much better for general fitness, health, and weight loss than most people realize, and specifically it can substantially replace so-called “cardio” workouts, which are highly repetitive and time-consuming and are a risk for all of the common repetitive strain injuries (RSIs like iliotibial band syndrome, plantar fasciitis, shin splints and several more). For instance, making muscles work hard is “essential” for people with diabetes, because there’s good evidence it controls blood sugar at least as well as aerobic workouts and probably better.6 It’s also anti-inflammatory and good for brain health, just as we have long known about exercise in general.7
• Strength training can be done safely and precisely, particularly aided by machines, so that you can pursue fitness while minimizing the risk of aggravating existing injuries or creating new ones — a major rehabilitation advantage that is under-rated or missed entirely by many professionals. This makes it a great tool for “load management” in injury rehab.
• It’s also likely that resistance training is directly therapeutic for specific tissues, assuming the dose is right. That is, just pulling on stressed tissue — tendinitis, say — may be analgesic and therapeutic through a variety of mechanisms.
• Women can benefit immensely from strength training, with no risks unique to them. The myth of feminine fragility is sexist nonsense from another era. Even powerlifting and bodybuilding are not particularly risky for anyone, and they are definitely not riskier for women than men. Women do not need to fear “bulking up” accidentally. And women have even better reasons to get stronger for the sake of general health: preventing osteoporosis.

Nothing’s perfect, of course. It is possible to hurt yourself or aggravate an existing condition (especially a repetitive strain injuryor bone stress injury), and I will review many caveats below. But most sensible people “can’t go wrong getting strong.” And even getting mildly injured from time to time is probably an acceptable trade-off!

If you think lifting weights is dangerous, try being weak. Being weak is dangerous.

Bret Contreras, PhD, lifter, trainer, researcher, more, via Twitter

The corrective exercise trap: strengthening does not generally prevent or fix injuries by improving biomechanics

Before any more singing of the praises of strengthening … let’s set the record straight: weakness is not a good general explanation for injury, and many kinds of stubborn pain have nothing to do with strength training.

Tedious, specific, “corrective” or “therapeutic” strengthening exercises are a staple and tired cliché of physical therapy. Everyone assumes their rehab montage will involve a lot of disciplined strengthening of specific muscles. “The belief that physiotherapy exercises have to be different from simple strengthening exercises is still common,” writes physiotherapist blogger Adam Meakins. “This is both disappointing and sad.”8

This high-falutin’ use of resistance training is not nearly as sophisticated as it seems. In practice it is mostly powered by the simplistic notion that people are injured or in pain because something is weak and needs to be “toughened up.” And that in turn is routinely exaggerated into the more impressive-sounding assumption that there is something in-correct about patients — fragile, weak, crooked — which can be both identified and corrected by specific, expertly prescribed strengthening exercises (and stretching too). This paradigm was born in the 1950s when Dr. Thomas DeLorme was promoting strengthening for injured soldiers.9 “The consensus behind its use was the assumption that people in pain, and/or injured, were weak.”10

But there is little or no overlap between a strength deficit that isn’t obvious and a clinical problem that is. Healthy people do not suffer from obvious strength deficits, but subtle weakness is rarely clinically significant. And maybe never.

And you can “go wrong getting strong” — mostly by doing it for the wrong reasons. This has been called the “corrective exercise trap.”11 The belief that something needs fixing is the trap, the wrong reason. It’s mostly incorrect, and harmful for both patients12 and pros.13 It leads straight to overzealous coaching and training, doing too much, too soon.

There are many good examples of the mania for “advanced” rehabilitative resistance training. You can’t have technical exercise prescription without technical diagnosis, which is why Functional Movement Screen is so popular, even though it was never intended to be a diagnostic tool. Hip weakness is a fashionable cause of running injuries like iliotibial band syndrome or shin splints, and that is closely related to the more general paranoia about “dead butt syndrome,” which in turn is a more specific manifestation of the even more popular notion that we all need good “core strength” to fend off back pain and other injuries. There’s also the upper and lower “crossed” syndromes, posture bogeymen used to justify both strengthening and stretching.

All of those things are mostly nonsense. I discuss most of them more below or in other articles.

Implying that patients are weak and fragile with unnecessary strengthening prescriptions sends a message that probably does more damage than anything it’s allegedly helping. Fixing a “flaw” is a terrible rationale for resistance training… especially when there are much better, valid reasons to do it!

A replacement for “cardio”

Contrary to the conventional wisdom, strength training is just as good for general fitness and weight loss as aerobic exercise.14 Most people believe — ever since the “aerobics” fad in the 80s — that you have to train the heart to get in shape, and you can only train the heart with cardio, but it’s not true: it is primarily skeletal muscles that adapt to all kinds of exercise, get more metabolically efficient, do more with less oxygen and nutrients, and then demand less from the heart.15

So the condition of muscle substantially defines fitness, and considerable fitness can be achieved with strength training alone — and without the drudgery of relentless cardio workouts, and their injury and re-injury risks. Such workouts — especially running, cycling, and swimming — involve significant risk of repetitive strain injury. Strength training can keep you in shape, while also giving severely fatigued anatomy a badly needed rest — rest which is a hugely important but neglected factor in rehabilitation from many of the world’s most common injuries.

By all means, if you are a serious runner, cyclist or swimmer, resume your sport as soon as you can — for the love of it, and for the fitness, because those sports certainly also are good for muscle! But strength training is a valuable and effective substitute, because sometimes you just have to take a break to heal.

Weightlifting as medicine for pain and injury

You can also apply resistance training directly to a specific problem, like a medicine — that is, you may be able to help muscles, tendons, and some other related tissue simply by using them strongly. For instance, even tissues that are already creaking under the strain of overuse may actually get better by using them even more, with extra weight! Avoiding overdose is critical, but there’s a good chance it will work.

Using muscles in the area of discomfort has some potential to be immediately soothing as well, even when you’re not sure exactly what’s hurting or why. It’s much like rubbing and wiggling it, just with more oomph. You should obviously be cautious, and start with gentle rubbing and wiggling and mobilizing first. But weightlifting probably can be a pain-killer (analgesia), probably through neurological mechanisms. I have a personal rehab story about how I got some substantial pain relief from doing the most painful thing — resistance training for my forearm muscles — something that seemed too daring to recommend to readers, but I was willing to try myself.

But the real prize would be a measurable effect on the progression of healing. Resistance training may also be “good for” tissues in this sense, perhaps by encouraging homeostasis and adaptation. It’s hardly guaranteed. The body may not actually need a “stimulus” to know that it needs to heal, and it isn’t necessarily that case that giving tissue a challenge is going to help much.

But it does seem to. The most straightforward example is that resistance training is a great stimulus for healing bone after a fracture. Whatever load the bone can safely bear will help it heal faster, stronger, better. This is so clearly true that a citation is not needed, but here’s one anyway.16

There are many other examples that do need a citation, however. For instance, if you have Achilles tendinitis, will doing a bunch of heel lifts help you get through it quicker? Will pulling strongly and regularly on a distressed tendon actually help it to stop failing? The evidence we have so far is it generally quite promising,17 but there are still many unanswered questions about the details. Does resistance training meaningfully reduce inflammation? Does the tendon get measurably stronger, reducing rupture risk in the months and years ahead? Is eccentric training more effective for these goals than concentric?

It’s not a magic bullet and there are risks, but there’s enough potential that it’s a tool that should at least be considered for many common painful problems.

This topic is discussed in much more detail, with a lot more citations, in the members-only section of my guide to repetitive strain injuries, section “Exercise is anti-inflammatory medicine for injuries.”

Some definitions

Strength training is the only method of building muscle mass and strength, and it is the final step in a progression of rehabilitative exercise intensity. Rehabilitation is all about breaking recovery down into “baby steps.” For the severely injured, the first step is the easiest of all possible exercises: simply moving. After that, mobilizing and stretching: slow, rhythmic, gentle tissue challenges. Then comes some endurance training (which is really just light strength training): lower load, higher reps, just to get comfortable with loaded movements again. And — when you are almost completely recovered already — proper strength training is an ideal final phase.

Fun fact: for the first few weeks of regular strength training, any strength gains you experience are mostly due to simply learning how to actually contract the muscle you are exercising (“recruitment”). Only after a few weeks of sustained training do your muscle cells start to get bigger (not more numerous), a process called “hypertrophy.”

How to build strength

The physiological changes associated with strength training occur when you exhaust a muscle within a minute or two.18 If you’re not doing this, you might be doing something worthwhile, but it’s not strength training (or not the most efficient strength training).

When you’re training, you can either count repetitions or just go for as long as you can. I prefer the latter for a variety of reasons, but it’s far more common to count reps. I’ve asked for a second big wall clock in my gym, but the management is puzzled by that: I’m the only one timing my sets. Everyone else is just counting reps and doesn’t care how long the set takes.

There’s a never-ending scientific debate about how to optimize the variables for different types of people and different goals by fine tuning the number of sets, the length of the break between sets, the number of workouts per week, and so on — although the last of those, frequency, is quite settled down now. (Hint: less than almost everyone else assumes.)

There are going to be individual differences for everyone, but most people will do well with the dials set like so:

• only a few key exercises per workout
• 1–2 sets per exercise
• sets separated by a couple minutes rest
• each set lifting about as much as you can keep in the air for a couple seconds, or 10–20 slow- to medium-speed repetitions per set
• 4-8 days of rest between workouts (more than most people think, see below)

What’s this about “exhaustion”?

It’s true, you will be tired after strength training — quite whipped! — but “exhaustion” has a more technical meaning in strength training. Exhausting muscle tissue, or taking it to “failure,” is essential for building strength.

Good, consistent exercise form is crucial in strength training not just because it’s safer — it is the simplest, best way of judging both exhaustion and progress. You know you’ve “exhausted” a muscle when you cannot repeat a contraction without losing good form. And exhaustion is exhaustion: it doesn’t matter whether you get there by repeating an easier lift more, or doing a harder one a few times.

If you shake or wobble significantly and can’t stop it, you’ve lost form. If you can’t actually perform the action without squirming into a different position, you’ve lost form. If you can’t do it without bringing in a bunch of other muscles to “pinch hit,” you’ve lost your form.

And, of course, if you start doing fifteen repetitions instead of just twelve before you lose your form … you know you’re getting stronger!

Exhausting muscles requires recovery. How much recovery? How long should you wait before doing the next set?

Giusi Protopapa (Instagram @protopy____) started CrossFit in 2019 “almost by accident” while looking to improve her fitness. Now she’s working out at least four days per week. “That time dedicated solely to myself is sacred; by the end of each workout, I come home more tired, but undeniably happier.” Worried that lifting will make you less feminine? “The essence of being a strong, feminine woman is self-assurance!”

Less is not less: strength training does not have to be as frequent as you thought!

Most people assume that you have to train muscles at least twice a week to make them stronger, and probably three times per week.

Wrong!

Believe it or not, scientists are actually pretty much unanimous in their agreement about this. In the last twenty years of research, there is barely a single dissenting note! Strange, I know. Exercise science is usually more controversial.

A lot of people are skeptical about this, and should be. But I have an entire article devoted to summarizing the research. If you doubt my word, please check for yourself: nine key scientific papers between 1988 and 2007 are cited, all showing clear evidence that most people can probably reduce their training frequency with little or no change in result. See Strength Training Frequency.

Once or twice per week for a given muscle group is adequate for most people, and three times per week definitely has a diminishing returns problem. Depending on the variables, some people could literally triple their gym time and effort, from 1 to 3 workouts per week, and get no additional benefit. Others might get some benefit, but minimal.

Such time savings are not trivial. Particularly for patients doing strength training only because it’s important rehab, the reduced commitment is truly important — it could easily mean the difference between doing it and not doing it. This is a guess, but it may also be even more appropriate — safer — for people with injuries to take more time for recovery between workouts.

Lift faster, function better

Another cliché of strength training that turns off a lot of people: lifting as much weight as you possibly can, groaning and grunting your way through tediously slow repetitions.

If your goal is to age gracefully, you’re probably better off moving lighter weights more quickly. Lifting weights faster makes aging people more functional. A 2022 scientific review is a nice clean win for power training.19

And what does “faster” mean exactly? Just “move the weight as fast as possible in the lifting phase.” Schnell, schnell!

This big new review of the science says that lifting weights faster — power training — results in more functional adults, probably because “muscle power is more highly correlated with physical function than strength or muscle mass.”

And whatever is good for function is probably also a win in a rehab context. To whatever extent strength is helpful in rehab (an endlessly debatable topic), this evidence suggests that a power training style might be optimal.

Naturally there’s some uncertainty. This is science, and science is rarely sure of anything (a feature, not a bug). But it’s a fairly clear result with practical implications for many people, and you are not going to go too far wrong by trying to move your weights quicker.

Jennifer Adams (Instagram @best_life_bits) is a massage therapist who had been lifting casually for years before she kicked it into high gear in 2021. She dove into the deep end at a gym most women would have been wary of: all men, all serious. But she forged ahead, guided by YouTube. What kept her going? “I feel less tired at work. More confidence in moving heavy things. I look better.” She actually tried hard to get bulky, and failed: “My muscles look more ‘toned’ after a few years lifting heavy than all those years of lifting high reps and making cardio a priority.” Interestingly, the male-dominated gum was “freeing” because “there’s no judging if you grunt or strain or fail.” She has many clients that she believes could “improve or cure their aches if they worked out.” And there’s the bone density benefits regardless!

Seriously, hire a trainer

If you are serious about using strength training to bulk up or to complete a rehabilitation process, you should definitely hire a personal trainer and/or a physiotherapist. Not only is it obviously safer to use heavy weights with guidance, you will simply get better results.20

However, do beware of trainers who push too hard and think that you need more than one workout per week.

“Blowing off steam” psychologically is one of the great benefits of strength training

Endurance training is probably the king of exercising as an outlet for frustration, but it’s certainly one of the important side-benefits of strength training too — and lower loads and higher reps and moving briskly from one exercise to the next can easily crank your heart rate well up (which is probably what’s needed for this purpose). Although everyone knows that exercise is good stress management, the interesting explanation for it is not widely known. It’s actually firmly grounded in biology and science: basically, exercise simulates a reaction to a stressful emergency which then also triggers the relaxation and recovery mode that follows. Robert Sapolsky:

The stress-response is about preparing your body for an explosive burst of energy consumption right now; psychological stress is about doing all the same things to your body for no physical reason whatsoever. Exercise finally provides your body with the outlet that it was preparing for.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 255

I think this is one of those really great little “user’s manual” things to understand about our own nature. The biology of stress is all about mobilizing biological resources for intense, life-saving activity, like running like hell from a predator, or (eek) fighting one. The curse of being human is that the same emergency biology can be triggered by abstract concerns, no predators required. But stress and anxiety are still preparing us for an emergency. So go with it — act like there’s an emergency!

The practical problems with “corrective” strength training

Strength training probably can aid rehabilitation in a few cases. For instance, two papers have shown that strength training was effective for treating neck pain,2122 which probably proves at least this much: almost any activity is probably better than no activity. Another pair of studies showed that painful shoulder muscles respond well to strength training, getting both stronger and less painful.2324

However, these benefits are probably the benefits of exercise in general rather than the benefits of strengthening anything in particular.

Strength training as therapy often fails. Why? Three main reasons:

It’s barking up the wrong tree, because of the corrective exercise trap (discussed above). The problem isn’t that people are weak and just need to be toughened up. While I appreciate a certain amount of “use it or lose it,” it’s also kind of like the cause of a headache is not the absence of Aspirin. Strength training probably isn’t the magical missing ingredient when someone is in chronic pain. Almost no one gets into much painful trouble in the first place because they were weak. Weakness is not, by and large, the cause of pain and injury.

It’s too tedious! In my experience the huge majority of people simply cannot stick to a no-end-in-sight regimen of fiddly little strength training exercises. When physiotherapists prescribe large batches of these things, they are simply not coming to terms with the realities of human psychology. In medical science, this is the difference between “efficacy” and “effectiveness”: how things work in theory versus practice.25

Too much, too soon. It tends to lead to poor load management, especially with overuse injuries. There are some ways that strength training can backfire, some that are inevitable, but most are easily avoided by staying in the Goldilocks zone … and encountered regularly when you don’t, which happens all too often, especially due to overzealous coaching and encouragement from personal trainers and physical therapists. I will review many of the specific ways that things can go wrong below, but the point here is just that it can go wrong, and it may not be an overt backfire: often it just subtly sabotages progress, prevents it from doing any real good.

Mariana Molinari decided to get stronger after two years of chronic post-pregnancy back pain, and because she was “leaner than recommended for health.” She knew next to nothing about lifting, and got going mostly with the help of a book, and started to get stronger … and the back pain disappeared! “It was a little weird to see my body change but feeling so strong and so good.” She fell in love with lifting, and especially of “being able to do things I never thought possible.” After many years, she became a trainer so she could help others discover the same thing. “It’s like the prescription that I feel we all need to keep up with life. I can do things at 56 that I couldn’t do in my 20s.” You can do online training with Mariana at Strength Sisters 101.

Strengthening headwinds and handicaps

Getting stronger mostly seems like something almost anyone can do, and it really is more efficient than most people realize … but not for everyone. The playing field of biology is not level. Some people will struggle to improve muscles for reasons that are totally out of their control. For instance, evidence strongly suggests that some people, are literally genetically incapable of strength training.26

And people with chronic lung trouble — which may not be obvious or diagnosed — are about 25% weaker across the board. They just cannot build muscle like people with healthier lungs. Yikes!

Garcia et al. tested the muscle strength in 112 people with interstitial lung disease (ILD),27 a large category of disorders that mess with lung function in dozens of ways.28 The subjects were compared to 48 healthy adults, finding that they were about 25% weaker on average. For instance, the quadriceps muscles were 58–87% as strong as they were without ILD, with an average of 72%. Lower body muscles were generally weaker, and the triceps was the least affected muscle at 84%. Only a handful of subjects with ILD matched the strength of the healthy controls in any muscle.

“Adults with ILD present a generalized reduction in peripheral muscle strength,” the authors concluded.

How does that work? I find it morbidly fascinating that muscles might wilt when they are chronically deprived of O2, but it could also just be an exercise headwind. Maybe ILD just saps energy and makes it 25% harder to exercise on average! Is it a limitation that could be overcome with enough oomph, like a cyclist working 25% harder to maintain speed in a headwind? Or are they doomed to weaker muscles? Or both? Unknown by me.

Disturbingly, there a probably lot more people in this boat out there these days than there used to be — thanks to Covid, of course. Covid definitely aggravates existing interstitial lung disease, and it almost certainly can also fire up a fresh new case of ILD. There are likely millions of people out there right now who have new or aggravated ILD since their last covid infection.29

So that’s one good example of a non-rare problem that makes it hard for people to get stronger, if not impossible. It gets worse, though! Some people actually face nasty consequences if they try to build strength …

Jesse Robson started lifting when she began training to be physiotherapist (clinic in Bridgewater, Nova Scotia, Instagram @live.well.physio). “I never wanted tell someone else they ‘should’ be doing something (e.g. regular resistance exercise) if I wasn’t willing to put the time and effort into doing it myself.” She’d had chronic pain for about five years before that, and thinks lifting played a significant role in her recovery. “After deadlifting 200 lbs, it seemed far fetched that my body might be damaged, broken, or unstable.” If you’re wary, she’d love you to just try it out. “I have the impression that many women are proud to have overcome sexist stereotypes related to heavy lifting (“let me get that for you honey”) and enjoy showing that they can lift heavy things!” But it also might “dramatically improve the last 10 years of your life. And best of all, you look cool doing it.”

Strength training harms: “You can’t go wrong getting strong” … or can you?

Many independent, motivated people in pain will go to the gym hoping to train their pain away, only to discover that it isn’t quite that easy. Some succeed, others fail… and some who fail actually make it worse.

Maybe they heard that “you can’t go wrong getting strong.” The idea that strengthening is almost perfectly risk free is a surprisingly popular concept in rehab and chronic pain treatment, but it’s naive. There’s certainly truth in it, probably more than just a kernel, but it’s wrong a little too often for comfort. That clever rhyme may not be a great thing to tell a lot of patients.

Most risks of strength training go away if you just add one simple caveat: “You can’t go wrong getting strong … with good load management.” Keep the intensity in the Goldilocks zone, no big spikes in intensity, don’t rush it, and most of what might go wrong probably won’t.

There are some pathologies that are deal-breakers for resistance training, but those are mostly irrelevant in the context of typical musculoskeletal medicine. When it comes to working with garden variety aches ‘n’ pains, there is almost no such thing as “going wrong” with strength training if you don’t go too far, too fast. But if you do? With poor load management, you can easily go wrong strength training. And of course a lot of people do overdo it, for many reasons, but chiefly because of that no-pain-no-gain attitude, so extremely prevalent in amateur fitness culture.

We have a theory versus practice problem here that probably accounts for a wide range of opinions on this:30 if you assume sensible dosing and competent coaching, then it really is hard to go wrong getting strong. But, if you focus on the prevalence of amateurish and reckless training “in the wild,” then going wrong is all too likely.

Nine specific ways strength training can go wrong

This is a list of examples of how strengthening can go significantly wrong. The first one is the only one that is obvious.

1. Direct, simple injury, of course. It has to be at the top of this list. It’s not as common as people fear — powerlifting is amazingly safe for backs, for instance — but it’s not exactly rare either. Bad things can happen when you are moving around heavy things, primarily muscle strains (tearing muscle), but also sprains, contusions, overuse injuries, and a long list of miscellaneous and straightforward accidental damage.
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Misdiagnosis is a big subcategory of ways that strength training can go wrong. Some problems that appear to be “simple” musculoskeletal problems, like back pain, actually have medical causes, some of them ominous, such as pain caused by a tumour, or a drug side effect. The failure to diagnose such things correctly can lead to prescriptions of completely ineffective or harmful strength training. Here’s just a few key examples, and there are probably dozens more (because there are so many surprising ways to hurt):

• While training to look the part of Spartacus, actor Andy Whitfield pushed through a lot of back pain, assuming it was a normal reation to the intense training, but it was actually a cancer that killed him a few months later. Such scary causes of back pain (and other pain) are rare, but not rare enough — the possibility should not be ignored. A benign back tumour tormented a personal friend of mine, pressing on a nerve, for about five years before it was diagnosed. During that time, he tried strength training a couple times, with predictable, miserable results … and then he was decisively cured by surgery.
• Another “tumour”: One of my readers had runner’s knee (iliotibial band syndrome) caused by a benign cyst stuck under his IT band like a rock in a shoe: good luck treating that with strength! All you’re going to do is piss it off.
• Hypermobility (hypermobility spectrum disorders and Ehlers–Danlos syndrome) is usually caused by complex genetic defects that have poorly understood effects on muscle and connective tissue. Patients are often chronically sore and suffer from a parade of miscellaneous “unrelated” musculoskeletal problems that can go undiagnosed for years, even a lifetime. It’s possible that strength training is doomed to backfire with these patients. Or perhaps they need strength training more than anyone? But only with much greater caution than average, and probably much more than they are likely to suspect the need for.
• Chronic fatigue syndrome (unexplained fatigue, also often overlapping with chronic pain, which is why I’m including it here): these patients may seem like ideal candidates for exercise therapy, but if the cause of the fatigue is myalgic encephalomyelitis — a non-rare neurological disease that routinely evades diagnosis — exercising can backfire,31 maybe even making things worse permanently.32
• Facioscapulohumeral muscular dystrophy (FSHD) is a common and mild form of muscular dystrophy that can cause only minor symptoms for decades, including and especially weakness, soreness, and chronic musculoskeletal complaints … exactly the kind of trouble for which strengthening is often prescribed! And it might help mitigate the problem, but patients will certainly be much more vulnerable to exercise overdose, and of course their problems cannot actually be solved by strength training.

Aggravating RSIs. You can certainly go wrong getting strong if you have one of the common overuse injuries like shin splints or plantar fasciitis and you start doing too much training, too soon. Overloading cannot fix overloading! Strengthening is a risky activity before the tissue has calmed down enough to tolerate new challenges. And yet this an extremely common mistake. The belief that the injury was caused by a weakness and therefore can be fixed by “toughening up” — that’s the corrective exercise trap at work there — often leads to over-training in the early stages of rehab from these injuries.

It’s also worth noting that they are often driven by natural vulnerability to relatively normal loading — not “overuse” per se — and so anything less than extraordinary caution with dosing can easily make them worse. Patellofemoral pain is the canonical example: that joint is naturally biomechanically extreme, and can get overloaded even with normal use.

Frozen shoulder can get severely exacerbated by any attempt at strength training, no matter how careful. This condition can even flare up badly even just with range of motion exercises.

Neuropathies — pain caused by trouble with nerve tissue — can be seriously exacerbated by resistance training. These conditions are often surprisingly subtle and undiagnosed, but misdiagnosis probably isn’t the main problem: it’s the underestimation of their vulnerability to exercise therapy in general and strength training in particular.

Chronic achilles tendinopathy is prone to rupture, and can be triggered by rehabilitative strength training, especially rapid loading (eg plyometrics). While carefully managed eccentric loading might be therapeutic, it’s not totally clear, and exactly how much load these tendons can handle without breaking is largely unknowable.

Sensitization often involves greatly reduced load tolerance … so much so that even cautious resistance training is ineffective at least, hazardous at worst. Since sensitization is probably a factor in most stubborn injuries, this is highly relevant to a lot of rehab, especially for the worst cases. Chronic widespread pain is related to sensitization (lots of overlap), may eventually benefit from building their strength, but often have such poor load tolerance that they just can’t handle resistance training — at first for sure, maybe never.

Anxiety and hypervigilance. Some people are indoctrinated to believe that the point of strength training is to fix weakness (especially “core” weakness) that makes them vulnerable to injury. Belief in fragility can become a major factor in future episodes of pain, especially back pain, which is notoriously sensitive to such anxieties.33 It can also lead to a great deal of wasting time if people focus on training obscure muscles far beyond their functional needs.

Trigger point exacerbation. The sore spots that most of us often develop in soft tissue are poorly understood,34 but they probably involve some vulnerability to physical stress, but anecdotally it seems like physical stress often does bother them, and it makes a certain amount of sense.35 They may flare up if you’re not careful, even if they respond well to cautious progressive training. I think quite a few “injuries” at the gym are not muscle strains (tears) but simply aggravated trigger points, which can be so acute that they feel like injuries.36

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Escaping the corrective exercise trap: strength training as a load management tool

Yes, there is good news! Strength training can be extremely valuable in rehab, and it can be done safely. In fact, the whole point is that it’s the ideal way to control how much tissues are challenged — to make sure it’s a “challenge” you can adapt to, rather than a harmful stress you cannot.

Although overloading cannot fix overloading, when you’re ready for it strength training can and should become a valuable component of rehab from nearly any kind of injury or chronic pain problem. It is your most important load management tool. It is extremely flexible and can be performed in a wide range of intensities, and easily customized to stimulate only what you want to stimulate.

You should do strength training when you have already paid your dues doing easier work first. You should do it to cover that last, crucial step from “recovered” to “better than ever.” You should do it to test your tissues, to reveal remaining vulnerability, to demonstrate to yourself that you really are better. It is a powerful way of demanding the highest possible function from your tissues, the most potent way of “using it” instead of “losing it.” The physiological effects are significant and numerous:

• blood flow is increased far more than any massage could ever do, capillaries open up wide, the entire system mobilizes resources to supply hungry muscles with oxygen and nutrients
• metabolic waste products are produced and washed away at a prodigious rate, probably including old stale ones still lingering in the dregs of trigger points that you mostly (but not entirely) got rid of in earlier stages of recovery
• coordination and neurological function improves with every workout as you “learn” how to actually recruit a respectable number of muscle fibres, which is responsible for most early strength gains
• rusty inhibitory and excitatory reflexes are exercised, normalized, balanced, which probably provides an injury prevention benefit

Tara Hawkin (Instagram @taraatthebar) has been lifting for about a decade, and says she’s an exception to the rule that it’s hard to get “too bulky”: she “looks at a weight and puts on more muscle!” She’s dodged any significant injury, but her back gets “cranky for a few days” after a lot of snatches or deadlifts. “Lifting with your ego is usually a pretty quick way to get injured,” she says, and recommends “gradual progressive overload with some weeks off thrown in.” Like seemingly every woman who lifts, she loves “the empowerment angle” and feeling “I walk through the world with a confidence that I may not have if I didn’t have these boulder shoulders. They’re great for carrying my child and also for making only one trip up from the car with all the groceries!”

Strength training does not just happen in gyms

Some people don’t like gyms. I’m one of them, actually — or used to be, anyway. I have gotten comfortable in them over the last decade.

You should consider trying to overcome gym shyness because (a) the people there are probably nicer than you think, (b) strength training is fairly efficient and you probably don’t need to spend as much time there as you fear, and (c) the precision and control of universal gym equipment has many advantages.

Nevertheless, there are some excellent, creative alternatives to gym training. Your own body weight can be more than adequate for strength training many large muscle groups. Slow deep knee bends, push ups, chin ups, and abdominal roll-ups are all good examples of body-weight-only exercises that many people cannot do many of — good places to start strength training without gym equipment.

However, it must be said that a thorough strength training program simply cannot be done without at least some apparatus. A small investment in a few barbells and exercise bands or tubing (large, colourful elastic bands or tubes) allows for an almost infinite number of strength training options.

Can strength training prevent/treat athletic injuries like runner’s knee?

Early in the article, I questioned the major role of strength training in injury prevention and rehab, but that was a general discussion about the problems with the “corrective exercise trap.” In this section, I’ll go over a few specific examples. What does rehab research have to say about the role of strengthening in preventing injury?

On the bright side, strength training probably can reduce the risk of tearing a muscle, an extremely common sports injury (muscle strain). It makes more sense, and there’s some evidence supporting that.37 But that’s probably the only prominent example.

Repetitive strain injuries in particular — like plantar fasciitis and patellofemoral syndrome — are often seen as a price that active people pay for being weak in some way. Although this has always been a popular view, it’s been given new life since the early 2000s by a lot of hype about hip weakness specifically, which supposedly makes athletes vulnerable to running injuries. This idea started with IT band syndrome, and has spread to virtually every common repetitive strain injury in the knees and ankles and feet.

I have written a detailed analysis of the evidence about ITBS and hip weakness, and the bottom line is clear: there’s no clear link.38

How about shin splints, for contrast? There are now three recent studies looking for the hip strength link. The weakest of them is only technically positive.39 The other two found nothing at all.4041

And so it goes. Unfortunately, hip weakness is just a pet theory that got out of hand.

A 2014 meta-analysis is the best reference available to support a more general claim that resistance training will prevent/treat overuse injuries.42 Unfortunately, “the best” is not very good: the authors’ conclusion about injury prevention is based on data from just four studies of questionable/limited relevance …43 and there is definitely some contrary evidence as well.44

Strengthening might ward off some overuse injuries, but that’s an untested hypothesis, and Lauersen et al. simply does not provide meaningful support for it—not even remotely. There are all kinds of other reasons to train your muscles. Use those reasons. You don’t need this one.

Supplementing for muscle health and growth

I cover this topic at length on my supplements page, with some attention given to what helps strength training, plus links to plenty more detailed information (especially on Examine.com).

Note that vitamin D supplementation — very widely used to support muscle health as we age — is not clearly beneficial for preventing sarcopenia (the muscle equivalent of osteopenia), and it may even be counter-productive!45

About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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More women who lift heavy things

I couldn’t fit them all into the body of the article! Here are a few more … and I will add more over time, and you’re very welcome to nominate yourself. If you are a woman with a photo of yourself lifting something heavy (and not necessarily barbells), I’d be happy to add you to the gallery. Contact me.

Annemarie, a Brazilian physiotherapist, giving us the only example of non-athletic lifting in this collection. We need to be strong for all kinds of practical reasons, of course, and most “women who lift heavy things” are just … women who lift heavy things that aren’t barbells, like 20 gallons of water. Annemarie tells me she has “no training AT ALL” and is “just being functional through daily routine and not shying away from lifting. After I did a course on human movement evolution/anthropology with a colleague here in Brazil, this became even more logical. Your daily routine should be your training. ‘Move more, train less’ is one of their mottos. The more generalist you become, the more you will improve at specialist tasks. I think of hunter-gatherers as a biological norm, and then apply that to day-to-day life — just on a waaaaay smaller scale.”

Kelly Lobgeier started lifting quite young, but dropped it for many years when she started a family — the reverse of several other stories here. But she missed the lifting! “I’ve always been a huge fan of weight training, and boxing.” When she returned to the sport at age 42, there was no stopping her: she quickly ramped up from three days a week to five, then found a coach, and then went on to compete in four bodybuilding shows in three years. “That process taught me how important diet is for body composition, and the importance of pushing your body to certain limits.” She has been a personal trainer since 2019.

Rachel Moore has been lifting for about six years, and considers it "a form of mental therapy, getting into my body and out of my head." Her advice to beginners is to find the right gym or even community to guide them at their own pace. “I’m group oriented in my exercising so I like having a coach and people around me doing the workouts together, it helps me stay motivated!”

Stephanie Fraser (Instagram @stephanie.fraser) started her “fitness journey” after having her first son in 2008, but it wasn’t until she started training and coaching that she started to “lift to get strong” and “fell in love with powerlifting and the training involved.” Now she trains in Olympic lifting and coaches powerlifting. “As with any sport,” she’s had some injuries. “That taught me a lot about patience, my own mortality.” Her advice for women is “always this: lifting can help you feel powerful which will give you a mental boost like nothing else. Plus it can provide a healthy outlet to constructively cope with the emotional labour we typically struggle with as women. It will help you with the much-needed bone strengthening and mitigate muscle loss we face as we age, allowing us to keep our independence more effectively.”

Terri Rowan was aiming to deadlift her bodyweight when this photo was taken. “I don’t know why I chose that number, it just seemed like a good number,” she says. “I got to my goal pretty quickly.” Why does she do it? “I legitimately get enjoyment out of lifting heavy things. That enjoyment is probably a swirling mass of lots of things: chemical (endorphins), a sense of achievement, etc.” But also the big reason that seems to be shared by most women weightlifters: “as female identifying I think it is also just badass to be able to lift heavy shit.” s Her advice for beginners is “Don’t let perfection be the enemy of progress. We won’t talk about how long I debated with myself about what combination of plates to buy when I set up my home gym. But I finally just bought some, and guess what, they’re still the same ones I use! Don’t complicate things.”

Related Reading

• Strength Training Frequency — Less is more than enough: go to the gym less frequently but still gain strength fast enough for anyone but a bodybuilder
• Endurance Training for Pain & Rehab — Why endurance training might be a wise alternative to strength training (especially when healing from an injury)
• Mobilize! — Dynamic joint mobility drills are an alternative to stretching, a way to “massage with movement”
• The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain
• Micro Muscles and the Dance of the Sarcomeres — A mental picture of muscle knot physiology helps to explain four familiar features of muscle pain

Some good strength training resources around the web (mostly for readers who are pretty serious about their strength training):

• The Strength Athlete (thestrengthathlete.com). Good quality evidence-based blog, coaching, and other resources for powerlifters. A couple of articles of potential interest to PainScience.com readers:
  • Potential roadblocks for AI coaching for powerlifting
  • The importance of external cues
  And I was interviewed on their podcast in late 2019.
• Strength and Conditioning Research (strengthandconditioningresearch.com). Detailed analysis of exercise science, biomechanics, and applied strength and conditioning.
• The Glute Guy (bretcontreras.com). Great writing and critical analysis of strength science… with a butt focus. 🍑

Notes

1. Academy of Medical Royal Colleges. Exercise: The miracle cure and the role of the doctor in promoting it. AOMRC.org.uk. 2015 Feb. PainSci Bibliography 53672 ❐

   This citation is the primary authoritative source of the quote “exercise is the closest thing there is to a miracle cure” (although there are no doubt many variations on it from other sources over the years).

2. Gopinath B, Kifley A, Flood VM, Mitchell P. Physical Activity as a Determinant of Successful Aging over Ten Years. Sci Rep. 2018 Jul;8(1):10522. PubMed 30002462 ❐ PainSci Bibliography 53004 ❐

   If you want to age well, move around a lot!

   We already know that physical activity reduces the risk of several of the major chronic diseases and increases lifespan. “Successful aging” is a broader concept, harder to measure, which encompasses not only a reduced risk of disease but also the absence of “depressive symptoms, disability, cognitive impairment, respiratory symptoms and systemic conditions.” (No doubt disability from pain is part of that equation.)

   In this study of 1584 older Australians, 249 “aged successfully” over ten years. The most active Aussies, “well above the current recommended level,” were twice as likely to be in that group. Imagine how much better they’ll do over 20 years …

3. Hong AR, Kim SW. Effects of Resistance Exercise on Bone Health. Endocrinol Metab (Seoul). 2018 Dec;33(4):435–444. PubMed 30513557 ❐ PainSci Bibliography 49683 ❐
4. Schwartz LM. Skeletal Muscles Do Not Undergo Apoptosis During Either Atrophy or Programmed Cell Death-Revisiting the Myonuclear Domain Hypothesis. Front Physiol. 2018;9:1887. PubMed 30740060 ❐ PainSci Bibliography 52684 ❐

   Why is it easier to get back in shape than it is to get into shape in the first place? Some adaptations to muscle training are temporary and vanish quickly if you don't keep working out. But others, like the addition of extra muscle nuclei, appear to be more or less permanent. Nuclei are added as you train so that they can build and manage more proteins in a plumper muscle cell. When you stop training, the cell slowly deflates — atrophies — but the nuclei helpfully remain, dormant, waiting until you are ready to exercise again. See Alex Hutchinson’s more detailed analysis of the study.

5. Moberg M, Lindholm ME, Reitzner SM, et al. Exercise Induces Different Molecular Responses in Trained and Untrained Human Muscle. Med Sci Sports Exerc. 2020 Aug;52(8):1679–1690. PubMed 32079914 ❐

   Muscles “remember“ strength: when you train, “key regulatory genes and proteins… are influenced by previous training history.” See also Schwartz.

6. Codella R, Ialacqua M, Terruzzi I, Luzi L. May the force be with you: why resistance training is essential for subjects with type 2 diabetes mellitus without complications. Endocrine. 2018 May. PubMed 29730785 ❐

   Dr. Brad Schoenfeld‘s comment on the study: “The title says it all. Many modalities of exercise are beneficial, but resistance training is the most important activity you can do for overall health and wellness. 💪🏻”

   From the abstract:

   Anaerobic, intense physical activity, such as that of strength or power sports disciplines, is not univocally recognized as safe and simple to realize, however, it is important in stimulating energy and glucose metabolism. According to recent evidence, high-intensity training may be prescribed even in the face of cardiovascular diseases, peripheral vascular disease, or osteoarthritis. Some studies have shown resistance training to be more efficient than aerobic exercise in improving glycemic control. This review explores the most up-to-date indications emerging from literature in support of the beneficial effects of strength stimulation and resistance training in patients with type 2 diabetes without complications.

7. Liu Y, Chu JMT, Yan T, et al. Short-term resistance exercise inhibits neuroinflammation and attenuates neuropathological changes in 3xTg Alzheimer's disease mice. Journal of neuroinflammation. 2020 01;17(1):4––4. PubMed 31900170 ❐ PainSci Bibliography 52495 ❐

   Lifting weights: good for Alzheimer’s? Good chance. This study clearly showed a neuroprotective effect from resistance training in mice. Compared to mice who were not given cute little barbells! Specifically, they found:

   “improved cognitive performance and reduced neuropathological and neuroinflammatory changes in the frontal cortex and hippocampus of mice… [and] inhibition of pro-inflammatory intracellular pathways.”

   Obviously a human study would be more persuasive (always), but it’s still early days for studying neuroinflammation. Lots of what we now know about exercise physiology we learned from mice initially. It’s likely (or at least highly plausible) that the effect will be confirmed in humans as well, despite the fact that “mice lie and monkeys exaggerate” in research.

   It has been clear for many years now that exercise in general is neuroprotective — that is, it has an anti-inflammatory effect in the brain and slows down Alzheimer’s disease progression — but that insight mostly comes from studies of aerobic exercise. This study extends that effect to resistance training, which is why the conclusion isn't much of a reach: we already know that another kind of exercise does this, and we already know that resistance training is an excellent way to exercise.

   And now, just for fun… how exactly do you strength train mice? A ladder with a treat at the top, and teensy weights attached to their tails! I am not even joking: that really is how they did this. “The mice were motivated to climb up the ladder to a total of 15 times, with progressively heavier weights attached to their tails and a 2-minute rest in between each climb.” Sounds like more fun than my gym visits.

   There are many other studies I could have chosen to support the general claim that resistance training has broad health benefits. This is a good example of a particularly valuable effect that is still being illuminated by research.

8. The whole post made by physiotherapist blogger Adam Meakins:

   The belief that physiotherapy exercises have to be different from simple strengthening exercises is still common.

   Physios love to give over complicated, under loaded, corrective exercises in a belief they are superior and more effective.

   Then there is the argument that physio exercises are more functional as they are focused on ideal alignment and motor control!

   But in my experience these corrective functional exercises are anything but corrective or functional.

   Instead these exercises are better described as subversive distraction exercises.

   These exercises tend to occupy patients usually just long enough for natural history to kick in and make physios look effective.

   The idea that physio exercises have to be different from standard strengthening exercises is due to physios desire to appear different and highly specialised.

   This is both disappointing and sad!

9. Todd JS, Shurley JP, Todd TC. Thomas L. DeLorme and the science of progressive resistance exercise. J Strength Cond Res. 2012 Nov;26(11):2913–23. PubMed 22592167 ❐
10. Lagerman P. Reasoning exercise dosage for people with persistent pain. In Touch. 2018 Autumn;(164):30–35. PainSci Bibliography 52992 ❐

    Lagerman paraphrasing The End of Physiotherapy and Eriksen et al.:

    Exercise is a key component of the physiotherapist’s management repertoire, and physiotherapy has, historically, neglected a broader holistic view of the patient in favor of a reductive perspective of the body which has resulted in treatment exercise being focused on pathology. While this view is the mainstay in the treatment of most acute musculoskeletal conditions, it is ineffective in the management of those patients with persistent pain where causal links to pathology cannot be substantiated.

11. Tumminello N, Silvernail J, Cormack B. The Corrective Exercise Trap. Personal Training Quarterly. 2017 Mar;4(1). PainSci Bibliography 52905 ❐

    Tumminello, Silvernail, and Cormack decisively but gently and diplomatically tip over this most sacred cow of personal training and therapy:

    In order to spot a physical flaw that needs to be corrected, one must begin by having a reliable measure of whether or not it is actually problematic in the first place.

    Spoiler alert: there is no such reliable measure! Corrective exercise is built on wishful thinking. Screening for movement dysfunctions has been failing one fair scientific test after another. The importance of posture has been wildly exaggerated. The importance of anatomical variation has been virtually ignored.

    These authors all have excellent credentials and top notch clinical reasoning skills. These are smart guys tackling several thorny sub-topics like postural dysfunction, movement dysfunction, core stability, and — most important of all, I think — the “nocebo concerns” with corrective exercise: “when clients are told such things about themselves from an authority figure (as they might be during some corrective exercise evaluations), that this potentially makes one’s clients less resilient and more prone to injury and pain.”

12. Exaggerating the importance of defect-correction is actually dangerous for the patient (nocebic). Tumminello et al. again: “When clients are told such things about themselves from an authority figure (as they might be during some corrective exercise evaluations), that this potentially makes one’s clients less resilient and more prone to injury and pain.” Translation sans diplomacy: stop #%&^ telling patients they are fragile and weak!
13. Tumminello et al.: “The danger here is that many fitness professionals might end up making their training process more about a formalized evaluation procedure and less about good personal training.” In other words, the professional gets stuck in the self-serving belief that this “technical” approach is inherently superior to basics like exercise in general and good load management during rehab. And so they waste their time (and the patient’s) focusing on the wrong thing, cooking up “expert” exercise prescriptions.
14. Clark JE. Diet, exercise or diet with exercise: comparing the effectiveness of treatment options for weight-loss and changes in fitness for adults (18-65 years old) who are overfat, or obese; systematic review and meta-analysis. J Diabetes Metab Disord. 2015;14:31. PubMed 25973403 ❐ PainSci Bibliography 54044 ❐

    Resistance training is an excellent method of improving body composition (ratio of muscle to fat) and markers of health (risk of cardiovascular disease). This meta-analyis concluded that weight-loss methods “utilizing exercise were more effective than those that employed just a hypocaloric diet,” and that combining diet with resistance training (weight lifting) was specifically more effective than combining it with endurance (aerobic) exercise. This flies in the face of the popular belief that endurance training is “heart exercise.”

15. Your heart and blood vessels themselves do not significantly adapt to any kind of training, but your muscles most definitely do. This critical point has been proven in various ways, but my favourite is the experiment that trained only one leg in cyclists, leaving the other leg out of shape and weak. Their aerobic fitness was great when using the trained leg, but lousy with the untrained leg: clearly, it wasn’t their hearts that changed! (Citation needed. I’m not sure why there isn’t one here. I remember the study, but cannot find it!)
16. Suljevic O, Schwarze UY, Okutan B, et al. Does early post-operative exercise influence bone healing kinetics? Preclinical evaluation of non-critical sized femur defect healing. Bone. 2023 Nov;176:116869. PubMed 37562662 ❐ This is just a rat study, but I selected it anyway. While rats are not humans, it seems likely that they are a good model for this purpose. And although we have a great deal of positive but indirect evidence of the effect of resistance training on human bone health in a broad way (e.g. see Hong for the epidemiological perspective), the scientific interest in bone strength and quality is weirdly limited, and even more so in the specific case of resistance training while healing from a fracture. To the best of my knowledge, the effect of resistance training on post-fracture bone health in humans just hasn’t been studied … and so this is just the next best thing. And it concluded that “post-operative exercise increases the bone healing kinetics and stimulates the new bone formation during and after the training protocol has ended.”
17. Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015 Jul;43(7):1704–11. PubMed 26018970 ❐

    Trials have shown promise for eccentric training (contracting while elongating) for Achilles tendinitis (and other tendinitises), but … does it really have to be “eccentric”? Maybe any resistance training will do the job. This trial was designed to test that by comparing eccentric training to a more conventional weightlifting style of heavy slow resistance training.

    They tested both approaches for three months in a few dozen people with chronic midportion Achilles tendinitis. The tendons changed! “Significant reduction in tendon thickness and neovascularization”! But …

    None of these robust clinical and structural improvements differed between the ECC and HSR groups.

    Eccentric wasn’t better. It was actually a little worse in one way: amusingly, people were more satisfied doing the regular exercises — probably because they’re less tedious!

18. Kisner C, Colby LA. Therapeutic exercises: foundations and techniques. 3rd ed. FA Davis Company; 1996.
19. Balachandran AT, Steele J, Angielczyk D, et al. Comparison of Power Training vs Traditional Strength Training on Physical Function in Older Adults: A Systematic Review and Meta-analysis.. JAMA Netw Open. 2022 May;5(5):e2211623. PubMed 35544136 ❐ PainSci Bibliography 52092 ❐
20. Mazzetti SA, Kraemer WJ, Volek JS, et al. The influence of direct supervision of resistance training on strength performance. Med Sci Sports Exerc. 2000 Jun;32(6):1175–1184. PubMed 10862549 ❐

    From the abstract: “Directly supervised, heavy-resistance training in moderately trained men resulted in ... greater maximal strength gains compared with unsupervised training.”

21. Nikander R, Mälkiä E, Parkkari J, et al. Dose-Response Relationship of Specific Training to Reduce Chronic Neck Pain and Disability. Med Sci Sports Exerc. 2006 Dec;38(12):2068–2074. PubMed 17146312 ❐

    Similar to Ylinen, researchers divided 180 female office workers with chronic neck pain into three groups: one group did strength training, another did endurance training, and a third did nothing. They found that “both strength and endurance training decreased perceived neck pain and disability.”

22. Ylinen J, Häkkinen A, Nykänen M, Kautiainen H, Takala EP. Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study. Europa Medicophysica. 2007 Jun;43(2):161–9. PubMed 17525699 ❐

    There are only a handful of studies of long-term strength training for neck pain: two by this research group (Ylinen 2003, Ylinen 2006), plus their three-year follow-up to the first. They found that a year of regular neck strength or endurance training meaningfully reduced pain and disability. These benefits were sustained for three years in over a hundred women, even though many people didn’t continue training after the first year.

    There are only a handful of other studies of exercise for neck pain, which have all failed to detect any of lasting benefit to exercise for neck pain. The results of these studies suggest that “most training studies seem to have been too short-term producing notable physiological changes.” But duration is the key, not intensity: “a relatively small training load is high enough to produce these changes, as there was no significant difference between the strength and endurance training groups with regard to the primary outcomes,” pain and disability.

    Although these results are certainly good news, it’s important to keep in mind that not all patients improved completely, and even those who did achieve lasting results had to exercise diligently for a year (although six months might have done the trick, we can’t tell from this data). So strengthening is not a reliable or easy fix for neck pain (the efficacy vs. effectiveness problem strongly applies, see Beedie).

23. Andersen LL, Andersen CH, Zebis MK, et al. Effect of physical training on function of chronically painful muscles: a randomized controlled trial. J Appl Physiol. 2008 Dec;105(6):1796–801. PubMed 18948442 ❐ PainSci Bibliography 54962 ❐

    This simple test of strength training as therapy for shoulder pain had positive results in 42 women with shoulder pain, researchers found that “specific strength training relieved pain and increases maximal activity.” Indeed, their pain was reduced 42–49%, and this result was less than 5% likely to be due to random chance.

24. Nielsen PK, Andersen LL, Olsen HB, et al. Effect of physical training on pain sensitivity and trapezius muscle morphology. Muscle & Nerve. 2010 Jun;41(6):836–44. PubMed 20513105 ❐

    In this experiment, 62 women (40 with shoulder pain, 20 without) participated in either a general exercise program or specific strength training for their shoulders. Pain tolerance and strength increased response to strength training in the women who started out with pain. In those who had no pain to begin with, both general exercise and specific exercise training were beneficial.

25. “Efficacy” is how well a treatment works in ideal circumstances, such as in a carefully contrived scientic test. Unfortunately, real life is rarely ideal! (You may have noticed.) “Effectiveness” is how well the same thing works in typical clinical settings and patients’ lives. Which is what matters to most patients. For example, a 2015 editorial in the British Journal of Sports Medicine explains that exercise (in a physical therapy context) is well-known to be efficacious, but often is not effective. That is, it works well when tested "in the lab," but not so much for real patients. Again, effectiveness is what matters to patients! If effectiveness is low, only a few lucky and/or disciplined people can realistically expect to benefit.
26. Hubal MJ, Gordish-Dressman H, Thompson PD, et al. Variability in muscle size and strength gain after unilateral resistance training. Med Sci Sports Exerc. 2005 Jun;37(6):964–972. PubMed 15947721 ❐

    This 2005 paper presents good evidence that there may be genetic differences between people that account for a surprisingly wide range of responses to strength training.

27. Garcia T, Mantoani LC, Silva H, et al. Characteristics of skeletal muscle strength in subjects with interstitial lung disease. Arch Phys Med Rehabil. 2024 Jan. PubMed 38272247 ❐
28. “Interstitial” usually refers just to the spaces between cells (like the mortar between bricks). But with ILD, “the term interstitial is a misnomer because the pathologic processes are not restricted to the interstitium” (Goldman and Cecil’s Internal Medicine, 25th edition, chapter 92, “Interstitial Lung Disease”). It also includes the empty spaces in the lung, the air-filled tubs and sacs, their walls, the tiny blood vessels and lymphatics. All of that is “involved in the pathogenesis and manifestations of ILD.” Lungs are all about being hollow, so that you can fill them with air. In other words, the lung is full of spaces, and ILD is about anything that limits out ability to fill and use those spaces. This is most obviously caused by things like pollutants and genetic diseases, and, of course infections like covid.
29. Fukihara J, Kondoh Y. COVID-19 and interstitial lung diseases: A multifaceted look at the relationship between the two diseases. Respir Investig. 2023 Sep;61(5):601–617. PubMed 37429073 ❐ PainSci Bibliography 49911 ❐

    Covid probably definitely aggravates interstitial lung disease, and may even cause it in people who went in without ILD, but much of the existing data on this is from early in the pandemic, when Covid was less well controlled. Covid today is probably much less to cause ILD, along with all other complications, thanks to vaccinated patients, antivirals, and steroid therapy at the right time to blunt a cytokine storm.

    But even well-managed Covid continues to be nastier than influenza. So the potential to cause ILD clearly remains. And even mild ILD is very bad news. For instance, we know that it makes people significant weaker (see Garcia).

    It’s worth noting that this paper also discussed some evidence of Covid vaccine-induced ILD — which is fully expected if Covid itself causes ILD. Vaccines, by nature, always cause the same problems that infections cause — but less often, and less severely! In this context, any evidence that vaccination can cause some ILD simply backs up the evidence that Covid also does — and more often, and more severely.

30. I conducted informal polls on both Facebook and Twitter, and responses were quite diverse. As expected, at least some pros clearly truly believe that you literally “can’t go wrong.”
31. The infamous “PACE” trial was a big British study that concluded that graded exercise therapy was helpful for myalgic encephalomyelitis (AKA “chronic fatigue syndrome”). But the PACE trial has been tainted by scandal, and harshly criticized as “uninterpretable” at best. There are good reasons to believe that PACE got it disastrously wrong, and exercise actually hurts ME patients. See Shepherd, Rehmeyer, Tuller, Coyne.
32. “We hypothesize that these crashes, or episodes of heightened fatigue, may have a cumulative effect on a patient’s health, and may compromise the patient’s potential for a full recovery.” From: Instructions for Stanford Chronic Fatigue Syndrome Patients.
33. Ingraham. The Mind Game in Low Back Pain: How back pain is powered by fear and loathing, and greatly helped by rational confidence. PainScience.com. 1446 words.
34. Ingraham. The Trigger Point Identity Crisis: The biological evidence that a trigger point is a lesion in muscle tissue. PainScience.com. 3775 words.
35. The “integrated hypothesis” of trigger point formation, while controversial, describes a tissue state that might very well impair strength and make the muscle more vulnerable to mechanical strain. Even more specifically, the metabolic state of a trigger point, and the idea that it’s a micro-cramp, are both plausible specific reasons why trigger points might not combine happily with strength training.
36. Even if you discard the idea of trigger points entirely, you can easily just cite the more generic idea or “functional” muscle injury or “fatigue-induced muscle disorder,” which is basically something between normal post-exercise soreness and outright trauma. Certainly not all muscle injuries are as pathologically straightforward as you might think. See Mueller-Wohlfahrt et al., and I discuss this in detail in my muscle strain book.
37. Tyler TF, Schmitt BM, Nicholas SJ, McHugh MP. Rehabilitation After Hamstring-Strain Injury Emphasizing Eccentric Strengthening at Long Muscle Lengths: Results of Long-Term Follow-Up. J Sport Rehabil. 2017 Apr;26(2):131–140. PubMed 27632842 ❐
38. Ingraham. Does Hip Strengthening Work for IT Band Syndrome? The popular “weak hips” theory is itself weak. PainScience.com. 4703 words.
39. Becker J, Nakajima M, Wu WFW. Factors Contributing to Medial Tibial Stress Syndrome in Runners: A Prospective Study. Med Sci Sports Exerc. 2018 Oct;50(10):2092–2100. PubMed 29787473 ❐

    The researchers measured hip strength in a couple of dozen athletes and then waited (two years) to see who would develop medial tibial stress syndrome (a prospective study, which is the right way to do it). The runners who developed medial tibial stress syndrome originally had weaker hip abductors (that’s the muscles on the sides of the hips). It wasn’t a dramatic difference, but it was detectable and clinically significant… if it’s real.

40. Yagi S, Muneta T, Sekiya I. Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc. 2013 Mar;21(3):556–63. PubMed 22875369 ❐ Although hip strength was studied, it wasn’t even mentioned in the summary of results: no detectable link.
41. Luedke LE, Heiderscheit BC, Williams DSB, Rauh MJ. Association of Isometric Strength of Hip and Knee Muscles With Injury Risk in High School Cross Country Runners. Int J Sports Phys Ther. 2015 11;10(6):868–76. PubMed 26618066 ❐ PainSci Bibliography 52536 ❐ “Hip and knee muscle strength was not significantly associated with shin injury.”
42. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med. 2014 Jun;48(11):871–7. PubMed 24100287 ❐ PainSci Bibliography 53226 ❐
43. All the 4 studies are of the lower limb, two of them about hamstrings and eccentric training, both of which have limited applicability to the question of preventing overuse injuries (most injuries of the hamstrings are not overuse injuries, and eccentric training is not typical resistance training). The third was a study of ACL injuries, which are traumatic, not overuse, so that doesn’t contribute to the case for preventing overuse injuries. And the final one was for patellofemoral pain, which does count, but its results are hardly decisive (see Coppack et al.).
44. Brushøj C, Larsen K, Albrecht-Beste E, et al. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008 Apr;36(4):663–670. PubMed 18337359 ❐
45. Bislev LS, Grove-Laugesen D, Rejnmark L. Vitamin D and Muscle Health: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials. J Bone Miner Res. 2021 09;36(9):1651–1660. PubMed 34405916 ❐