Getting Out of Pain Isn’t the Same as Being Game-Ready

Your shoulder feels better, you’ve been doing your exercises, and you’ve even gotten stronger. So why aren’t you automatically ready to throw now following an injury? While these are definite improvements as part of the rehab process, there is still a bit of a gap between this and being prepared for the in-game demands of baseball and softball. This is because throwing a baseball (along with other movements in baseball) is a highly specific, high-speed movement that places substantial demands on the entire body. Eventually, though, rehab has to cross the line from preparing you to throw to actually throwing.

Rehab Has to Start Somewhere

In the early stages of rehab for most injuries, the goals are fairly straightforward: reducing aggravating loads, restoring movement, rebuilding strength, regaining confidence, and gradually increasing load and activity. This is important because it sets us up for success in the later stages of rehab, but people often mistake the improvements seen during this phase as meaning they are ready to return to sports.

Getting Stronger Doesn’t Automatically Mean You’re Ready to Throw

You can get stronger, restore your range of motion, and have less pain while still lacking the specific capacity required for throwing and other baseball-related activities. This is because after a period of inactivity, you lose some of your tolerance to throwing. Even if you are able to maintain some throwing, it still isn’t at the intensity or volume that you’re used to, and you still decondition to some degree. But gym exercises and throwing are not interchangeable; banded external rotation, heavy rows, and medicine ball slams aren’t throwing. They’re all useful pieces of the rehab process in preparation for throwing to bridge that gap, but they don’t instantly have you ready to throw 100% again. Eventually, throwing itself has to become part of the rehab process, because there is no substitute for exposing the arm to the demands of throwing.

Baseball Doesn’t Just Ask Your Shoulder to Work

Another thing to consider is that baseball is a full-body sport, and throwing involves the legs, hips, and trunk through to the shoulder, elbow, and hand. A good rehab plan will have you continuing to work on these areas as permitted by your injury, but it is easy to focus on just the injured shoulder or elbow. So just like throwing, there needs to be a gradual progression and reintroduction of these movements while accounting for your injury before you’re ready to return to games. Plus, baseball isn’t just one throw. Baseball asks you to repeat these movements, sometimes under fatigue, sometimes after some inactivity, sometimes at high intensity and sometimes with relatively little recovery between plays. So when considering if you’re ready to return to play, it isn’t just “does your shoulder hurt?”, but “can you tolerate what baseball is going to ask you to do?”

The Gym Prepares You. Throwing Finishes the Job

Strength and conditioning are important, but so are training the skills. Eventually, we do need to go from general capacity to specific capacity and throw. But there’s a distinction between throwing in a controlled session and in-game situations. We want to continue to build strength in the gym, but we need to start rebuilding throwing strength with a progressive throwing program. General conditioning needs to transition to look like game play. Exercises start off controlled and basic, but should add more movement and speed. Drills are controlled and basic to start, but build in complexity and speed to mimic in-game plays. We go from high tension eccentrics and powerful medicine ball slams to then adding in throwing, starting at a lower intensity and volume, and building from there to bullpens, live at-bats, and finally competition. How we progress this though depends on the individual athlete.

So What Does Good Baseball Rehab Look Like?

Good rehab isn’t “do these five magic exercises.” Good rehab involves assessing the injury, understanding the demands the athlete faces, calming down any sensitivity and pain, rebuilding physically and mentally, gradually exposing the athlete to the demands, and adjusting according to how they respond. This is why I am excited about my new partnership with Baseball Ireland. My role isn’t simply to tell players whether they should rest and do some banded exercises. It’s to help athletes understand their injury, determine how they can safely work around their injury, find their entry point to rehab for their injury, and work through the process of returning to what they actually want to do.

Rehab isn’t just about getting you pain-free; it’s to help you tolerate the demands of the sport you want to return to.

When the Season Catches Up With You

As the summer sports season comes to an end, you may begin to notice you feel a little bit different after games compared to at the start of the season. You might be a little more sore, sleep a bit longer, need more time to warm up, or be managing some nagging injuries. This isn’t because you’re becoming less fit, but rather because you’re accumulating more and more fatigue throughout the season. As a result, your strategies for training and recovery may need to change in order to ensure you’re well enough to perform right to the end of the season.

This fatigue you experience towards the end of the season isn’t about a single training session or game that you overdid it in, or even a busy week. It is the accumulation of everything that comes with your sport over the past several months. While multi-hour training sessions and games are a big factor, think about your additional strength training, other physical activity, repetitive sports demands, life stress, the extra time for travel and its associated logistics around nutrition, hydration, and sleep, and work on top of everything else. All of these things, over the course of an entire season, can add up, even if you do have good recovery habits. This is why an off-season is really important, because it gives you an actual break from your sport and everything associated with it.

This end-of-season fatigue is a continuum of signs and symptoms that athletes should be aware of. We’re all used to the typical soreness or tiredness we feel after a game. At the start of the season, these symptoms typically improve with rest and don’t worsen, affect performance, or persist. As the season progresses and fatigue accumulates, you might be a little more sore or stiff, need a bit more time to get going, or need more time to recover. But if this trend continues to worsen without any changes, we can start to see more persistent fatigue and, in some cases, symptoms associated with overtraining and burnout. You may start to feel persistent fatigue even with your usual recovery methods, sleep may be affected, and there is usually a decline in performance. Irritability, changes in motivation, or even apathy towards your sport can be signs that you’re moving beyond normal end-of-season fatigue.

Ideally, we’re not reaching that overtraining and burnout phase towards the end of the season, but it can happen. The key to mitigating this, though, isn’t necessarily to take extended breaks from your sport or to stop when you do start to creep into this excess fatigue. Rather, we want to be proactive and change the dose of activity. This could be any combination of reducing volume (e.g. swings, throws, running distance, etc.), reducing intensity when appropriate, eliminating unnecessary accessory work, and taking inventory of your recovery methods to see if something is lacking. That being said, you want to maintain the qualities, attributes, or skills that you actually need for your sport. You’re not doing less of everything, but instead being more selective about what you do - prioritize the activities that are most important for your sport and reduce or eliminate the things that provide less value. For example, if a baseball player is their team’s primary pitcher, they may place less emphasis on their hitting while also reducing the number of throws in their bullpen sessions.  Here, the “less is more” approach best summarizes how to manage fatigue at the end of the season.

During the off-season, you have the time and energy to build your strength, conditioning, attributes, and sports skills. Once the season begins, especially with a regular weekly schedule, it becomes nearly impossible to continue building everything at the same rate. That’s when your training should shift to focus on maintaining what you have built and recovering from games. If fatigue towards the end of the season sets in, that’s when more of an adjustment is needed to ensure your health and performance for the last little push.

Training and games are a stress. Recovery is what allows you to adapt to those stressors. At the beginning of the season, you may be able to tolerate training and game loads because you’re relatively fresh. But several months later, that exact same training load can be a different stimulus because you’re carrying more fatigue. A way to tackle this accumulating fatigue isn’t necessarily doing less of everything, but rather being more selective about what you do.

Your Slow is Too Fast, and Your Fast is Too Slow

When I started training for my 10km race almost a year ago, I decided to add some speed sessions to my training and really start to vary my sessions. This included long, slow distance (LSD), easy, tempo, interval, and recovery runs. I had dabbled in these different runs a bit when I ran cross country in high school, but last year it took a little bit of time to get a handle on them and truly appreciate their purpose. If you don’t, you end up in this weird middle ground where every run is tiring without the intended benefits.

Not every run you do as part of your running training has the same purpose. Easy and LSD runs are done at a lower intensity in order to help develop your aerobic base, accumulate mileage, and increase your tolerance to running, all while allowing you to recover relatively easily. Tempo runs are generally shorter but require a sustained higher effort, meant to develop your ability to maintain a faster pace for longer. Intervals are higher intensity, used for developing speed and for repeatedly producing high efforts. Recovery runs are your slowest, meant to be very low intensity while keeping you moving (I find recovery runs to be a misnomer, because anytime you are running, regardless of the pace, you are still accumulating effort, load, and mileage. However, this is a common term and so we’ll save that discussion for another day).

When we don’t follow these training zones, we end up in this grey zone. Easy runs that are done too quickly, and fast runs that aren’t fast enough put us in this middle effort area that misses the point of these different runs. If your easy runs end up being moderately hard, you’re no longer getting the same aerobic-endurance stimulus, and you’re accumulating greater fatigue than intended without the ability to increase distance. If all of your fast runs are only moderately hard, you’re not getting the stimulus you’re looking for from your faster training either. Essentially, all of your runs end up looking around the same pace, which defeats the purpose of the different workouts.

If you’re running purely for enjoyment or general fitness, you don’t necessarily need to worry about training zones or carefully structuring every run. But even then, there’s still a useful lesson here: not every run needs to be hard to be worthwhile. Easy running still provides a training stimulus and health benefits, while being less fatiguing to help you stay active. Sometimes the best thing you can do is slow down and enjoy the miles.

If your slow is too fast and your fast is too slow, you may need to check the ego when it’s time to go slow, and turn it up a gear when it’s time to go fast. Your fast should be fast enough to provide the stimulus you’re looking for. Your slow should be slow enough to build your aerobic base and let you recover. Not every run needs to be hard to be productive.

Pain is Part of the Picture, But Not the Whole Picture

Pain is real, but pain is weird. This past week in my baseball game, I had to dive back to first base for three pick-off attempts, and then I stole second base, and I came out of it with a scrape on my right knee. The rest of the day and into the next, it was throbbing and painful, with a tearing sensation while bending my knee. But it got me thinking, “this is just a scrape to the outer layer of my skin, why does this hurt so much?” That is because pain tells us something has happened, but it doesn't necessarily tell us what has happened.

Pain is very abstract, and it can be difficult to describe and quantify, yet it is usually the central theme during injury assessment and rehab. The textbook definition of pain is an unpleasant sensory and emotional experience linked to actual or potential damage; the keyword being ‘linked’ and not ‘the result of’. It’s why a paper cut can be quite painful. But it’s also why diagnostic imaging can reveal rotator cuff tears or knee osteoarthritis in people without pain or other symptoms. Two people can have similar degrees of degeneration (or as I prefer, age-related changes), yet one has very minimal symptoms and one has debilitating symptoms. Pain reflects your experience, but not necessarily how much harm has occurred. A 1/10 pain doesn’t mean a 10% tear and an 8/10 doesn’t mean an 80% tear.

So why is pain so variable among people? Pain is influenced by numerous factors. One of those factors is, of course, what is happening at the tissue level. But also think about your previous experiences with pain, your current level of stress, your sleep quality, your level of concern about the injury, your expectations about your pain, and what you think your pain means, just to name a few. All of these factors can change your experience of pain, either turning up or down the volume knob on your injury.

Pain is useful because it usually forces us to change something. If there’s a stone in our shoe, we stop and take it out. If I scraped my knee, I’m probably not going to kneel down on it. Pain after an acute injury can help us protect the area while it heals, but that doesn’t mean we have to stop everything we’re doing. Though the individual nature of the injury and pain matters, we can still generally do some activity as long as the pain is tolerable. At the same time, no pain doesn’t mean everything is fully healed and you’re ready to go. My knee could be pain-free, but the scab is still forming and therefore highly susceptible to re-injury.

When it comes to assessing an injury and developing a rehab plan, there is more to it than just, “how much does it hurt?” I ask a lot of questions that paint a more complete picture of your injury beyond just pain. Was this a traumatic injury or something that slowly developed? What can you currently do? What is your pain preventing you from doing? What impact is your pain having on you day-to-day? What impact is it having on your physical activity? Is your pain getting worse or changing at all? Does your pain make sense to you? Can you control your pain? How confident are you that this will improve? These questions give me WAY more information than simply describing your pain. They tell me about the impact it is having on you, as well as your views and outlook on your pain. This paints more of a complete picture than a 5/10 dull aching pain.

My scraped knee reminds me that pain is weird, but it doesn’t accurately reflect what’s going on. This scraped knee made running feel really weird, but I’ve previously been able to play baseball with a full-thickness rotator cuff tear. It may help to think of pain, not as an indicator of what we’ve done to ourselves, but as a volume knob that gets turned up and down to reflect our experience.

Why Baseball Players Should Do More than Just Play Baseball

As the baseball and softball season starts to wind down across Ireland, many teams and players may already be looking towards next season. The weather is still great for getting outside, but as we transition to the fall and winter, teams will start to move inside to continue with their training. However, even though we all love baseball, variety in activity is important for athletic performance, and the off-season is a great time to play something different.

One thing that makes baseball and softball different from other sports is the repetition of the same explosive movements. We throw and hit from the same side; we sprint in straight lines counter-clockwise; and we stick to fielding specific positions. This isn’t bad within the context of developing baseball-specific skills - specificity and repetition are important for performance. But that also doesn’t mean that’s all we have to do to be good at baseball. Giving your body different things to do can be valuable in developing your athleticism.

A great example of this within our own bodies is how our bones respond to loading. Bones adapt to mechanical loading by increasing their density, but repeated loading in the same way, such as during distance running, provides less of a stimulus over time. But when we add new and varied loading, such as change of direction and deceleration, we provide new stimuli for the bone to adapt to. That is to say, different activities can be beneficial for our bodies, and this can carry over to a variety of activities.

This is especially important for kids, as there has been much debate over whether kids need to specialize early in order to go far in their sport, or if a multi-sport approach is better. While the relationship between sport specialization and performance is complicated, early single-sport specialization is associated with an increased risk of overuse injuries. Plus, playing multiple sports exposes kids to different movement demands, skills, environments, and physical loads.

For the average recreational adult, though, variety is still valuable. Variety is the spice of life, and this is especially true when it comes to the physical and mental demands of sports. Even if baseball or softball is your primary sport, participating in other sports can expose you to movements, speeds, positions, and physical demands that baseball doesn’t. You might sprint differently, change direction more often, jump, react to unpredictable movements, or use your body in ways that baseball doesn’t require. Those experiences can help you become a more adaptable athlete, even if they don’t directly make you a better hitter or pitcher.

None of this replaces throwing, hitting, or baseball-specific training when those things need to be trained. But doing something different doesn’t take away from being a baseball player. It can help you become a more adaptable athlete - and a better athlete can ultimately become a better baseball player.

Understanding Your Injury Shouldn’t Require a Medical Degree

Have you ever left a therapy appointment knowing your diagnosis, but still not really understanding what it meant? Research consistently supports patient education as a key part of the assessment and rehab process. But a good explanation of your injury should leave you with less confusion, not more information.

Why More Information Isn’t Always Better

The trap many clinicians fall into (myself included early in my career) is assuming that more anatomy or physiology information leads to better understanding, and therefore better outcomes. In reality, most patients don’t need a detailed session in anatomy. They need an explanation that helps them understand their situation. This often boils down to: what is going on, how serious is this, how long will it take, and what will it take to get it better? All of that can be answered without a deep dive into biology.

The Real Problem is Clarity, Not Information

We live in a time where information is everywhere. Within seconds you can search your symptoms or ask AI what might be going on. The problem patients face isn't a lack of information—it's that medical information isn't always easy to interpret or apply to your own situation. This can leave patients feeling more confused, uncertain, or stressed, even though they have the information. The key to patient education isn’t providing more information - it’s providing clarity and showing how that information relates to the patient specifically.

Tailoring Education to the Patient

How do you know what explanation someone actually needs? I usually ask my patients during an assessment, “What do you think is going on with your injury?” Not because I’m testing them, but because it gives me valuable information about their level of understanding, and how to best approach them with education. Their answer determines how I respond—if someone gives me a detailed explanation, then I can usually be a little more detailed or use some specific terms. If they really don’t know or can’t quite put a finger on their words, then I take a wider, general approach first.

Throughout the assessment, I’m listening for what they’ve been told by others, what they’ve learned on their own, the beliefs they hold around their injury, what they feel they can and can’t do, what they’ve been doing to get better, what they think needs to be done to get better, and so on… What the patient tells me guides what kind of education I provide. Almost always, patient education leans towards the previously mentioned wants of the patient—what is going on, how serious is this, how long will it take, and what can be done for it.

When Anatomy Actually Matters

That doesn’t mean anatomy and physiology aren’t important. They absolutely have their place, particularly when helping answer the why—“why did this happen?” and “why are we doing this?” The anatomy and physiology is why youth baseball players experience Little League Elbow and not UCL tears leading to Tommy John surgery, and why non-throwing is recommended for 4-6 weeks but other exercises can be performed. But that same explanation can be translated into language that’s much easier for the patient to understand.

The goal of an assessment and patient education isn't to overwhelm you with anatomy or impress you with medical terminology. A good explanation should leave you with less confusion, not more information. You should leave knowing what is likely happening, why it's happening, and what your next step is, in terms that you understand and feel confident moving forwards with.

Arm Care is About More Than Just the Arm

What comes to mind when you hear “arm care”? Most baseball and softball players probably think about rotator cuff exercises using resistance bands and light dumbbells, external rotations, the Thrower’s 10, or shoulder mobility. But throwing isn’t just a movement of the shoulder; it involves the entire body.

I like to think about throwing like cracking a whip. The crack doesn’t come from the very end of the whip alone - it comes from energy being transferred from the handle, through the entire length of the whip. Throwing works much in the same way. Throwing starts with the legs pushing off the ground and driving the body forward, then turns into rotation with the hips and torso transferring energy up through the body. The shoulder and arm are the last links with the arm unwinding and the wrist providing the last flick.

While most of the attention when it comes to throwers is on the shoulder and elbow due to the tremendous forces on these joints (and rightfully so), we should also think about arm care in a more global sense as well. Arm care isn’t just about strengthening the shoulder - it’s about building a body that’s prepared to tolerate the demands of throwing.

• Build a stronger athlete: Throwing starts from the ground up, so arm care shouldn’t stop at the shoulder. Developing strength through the legs, hips, and trunk helps create and transfer force through the body. We also shouldn’t overlook general upper body strength. Compound exercises like rows, presses, and pull-ups don’t just strengthen the larger muscles - they also challenge the rotator cuff while allowing us to use heavier loads than isolated exercises alone. Isolation exercises still have an important place, but they should complement, not replace, a well-rounded strength program.

• Build work capacity: Arm care is about maintaining the quality of your throws throughout a practice, game, or tournament. As fatigue builds, movement quality can change, and recovery between innings or games becomes more important. Good aerobic fitness won’t make you throw harder, but it helps you recover between bouts of high-intensity effort so you can continue performing throughout the day.

• Build throwing capacity: As mentioned in last week’s blog, throwing is a skill of its own and a unique demand on the body. Therefore, it needs to be developed and progressed on its own. Being a strong athlete with good conditioning provides the foundation, but it doesn’t automatically prepare your arm for throwing. Having a progressive throwing program that manages your workload is just as important to arm care as the strengthening exercises. Nothing can replace throwing.

• Recovery: I’ve talked about recovery before, but it is an often overlooked aspect. We tend to focus on all of the things we add to get better (e.g. resistance training, long toss, weighted balls), while overlooking the things that actually allow our body to adapt to training; and even then, we tend to focus on fancy gadgets rather than the low-hanging fruit of sleep, nutrition, hydration, and managing stress.

As a baseball and softball player, you are more than just an arm, shoulder, or elbow. You are an athlete, and while the arm is the bread and butter, you need to remember that the rest of your body is just as important to throwing. If you want a more resilient throwing arm, stop thinking only about your arm and start preparing your whole body.

The Gym Prepares You to Throw. It Doesn't Replace Throwing.

Many baseball players spend the off-season getting stronger in the gym, hoping it will improve their throwing performance and prepare their arm for baseball season. But when the first few throwing sessions arrive, it’s common for their arm to feel sore, heavy, or just not ready at the start. It’s easy to wonder, “I’ve been training all winter - why doesn’t my arm feel ready?” The answer is simple: the gym prepares you to throw, but it doesn’t replace throwing.

Why Strength Isn’t Enough

Don’t get me wrong, the gym is fantastic when it comes to training for baseball players. The gym builds muscular strength and power, muscle mass, and even improves the strength of tendons and bones. These adaptations raise your physical capacity and prepare your body to better tolerate the demands of baseball. Overall, this increases your ability to produce force and perform.

‍ ‍But throwing isn’t just about strength - its a skill with physical demands that can only be developed by throwing.

Why Throwing Is Different

Throwing a baseball is a very unique and specific skill. It involves the fastest rotational speeds in sport and enormous eccentric forces as the body rapidly decelerates the arm after ball release. This involves not just strength, but efficient mechanics with proper timing, coordination, and sequencing of the entire body. No gym exercise reproduces all of those simultaneously. I love using medicine ball throws, explosive movements, plyometrics, and heavy eccentrics as part of my rehab programming for baseball players. These exercises help bridge the gap because they expose the body to high forces and fast movements. But they still don’t reproduce the unique demands of throwing.

‍ ‍No exercise recreates throwing as well as throwing itself. Think of the gym and throwing as two separate forms of training. The gym develops the physical qualities that support throwing, while throwing develops the specific movement patterns and tissue adaptations required to throw. They’re complementary, but neither replaces the other.

Our bodies adapt specifically to the stresses we place on them. If we squat regularly, our lower body will certainly get stronger, but we’ll also get really good and efficient at squatting. If you train for 100m sprints, you’re going to get really good at short-distance sprinting, but this won’t translate to being able to run a marathon. So when you throw consistently, your arm gradually adapts to tolerate the unique speeds and forces experienced with throwing. These adaptations cannot be fully developed any other way.

This is the reason players often feel sore when they first begin throwing after an off-season despite working out in the gym. You may be physically stronger coming into the season, but your arm hasn’t experienced the unique forces of throwing for months. Even players who continue throwing during the off-season often see a rapid increase in throwing volume and intensity once preseason begins. Your arm simply needs time to adapt to the demands of throwing.

The Gym and Throwing Work Together

By all means, continue to work out in the gym. Lift heavy weights, build strength, build power, and incorporate your lower body and core to really get the most out of your throwing. But don’t expect the gym to completely prepare your arm for game demands. A gradual throwing progression is what teaches your arm to tolerate the unique demands of throwing.

‍ ‍The gym builds the qualities that support throwing. Throwing builds the specific adaptations required to throw.

What Should a Healthy Throwing Arm Feel Like?

We often assume that a healthy throwing arm should feel perfect. No soreness, tightness, or stiffness. So when our shoulder or elbow starts to ache after throwing, it’s easy to wonder if something is wrong. But that expectation isn’t realistic. A healthy throwing arm isn’t always a pain-free throwing arm.

First, it is important to realize that throwing a baseball, especially when pitching, is stressful on the arm. Humans evolved to throw, but not necessarily to throw a 5oz baseball at nearly 100 mph, 100 times every few days. Every throw places tremendous forces on the shoulder and elbow that are unique to throwing, making it hard to adapt to this outside of actual throwing.

Think about Usain Bolt and sprinting. We can’t expect someone trying to run as fast as humanly possible to finish every training session feeling completely fresh. Pitching is no different. Pitching places enormous stress on the arm, so some soreness is a normal consequence of asking your body to perform at such a high level.

The key question then becomes, is this behaving like normal throwing soreness? I touched upon this before but a general feeling of soreness or fatigue without a clear onset that settles within a day or two is what we’re looking for. This soreness is thought to come from fatigue in the muscles that repeatedly absorb and produce the high forces required for throwing. Once you’re done throwing and given the opportunity to rest, the soreness subsides as you recover. Your arm can be entirely healthy and prepared for the demands of throwing and still have some degree of soreness.

There is going to be some variability in how our arm feels game-to-game due to the many factors that can affect performance. Healthy throwing arms are going to have good days where everything feels smooth and effortless, and healthy throwing arms are going to have bad days. Healthy throwing arms can get sore or feel tight and stiff.

‍ ‍Healthy throwing arms recover.

Setting the right expectations is one of the best ways to avoid unnecessary worry. A healthy throwing arm isn’t one that never gets sore - it’s one that tolerates throwing, recovers well, and is ready to do it again. Don’t judge your arm by how it feels immediately after one outing. Judge it by how it responds over the next day or two, and by the overall trend across weeks of throwing. If your arm isn’t recovering the way you’d expect - or you’re unsure whether what you’re feeling is normal - then that’s a good time to book an assessment. The goal isn’t just to diagnose an injury, but to help you understand what’s normal, what’s not, and how to keep throwing with confidence.

What I’ve Changed My Mind About: Strength and Pain

          Muscular strength is one of the biggest themes in rehab. Weak muscles are often blamed for pain - weak glutes or core for low back pain, and weak shoulder muscles for neck pain or poor posture. The logic seems straightforward: if weakness causes pain, then getting stronger should fix it.

          That’s certainly what I believed early in my career. I assumed strength was the main driver of recovery. But over time, and after reading more research, I changed my mind. People often improve while doing strengthening exercises, but those improvements aren’t consistently explained by increases in strength. If it isn’t strength that’s making people feel better, what else is changing?

          Strengthening exercises are prescribed for many painful conditions, and they often work. But the literature has repeatedly found that improvements in pain don’t always line up with improvements in strength. For example, tendinopathies of the Achilles, knee, and shoulder often see improvements without meaningful changes in tendon structure or strength. Those with either general knee pain or knee osteoarthritis can see improvements in their pain and function without the surrounding muscles drastically improving. This growing body of evidence has led me to change my wording around the use of strengthening exercises - often people get better with strengthening, but it’s not necessary in order to get better.

          Exercise changes much more than muscle strength. It can reduce tissue sensitivity, improve confidence in movement, reduce fear around pain, improve cardiovascular fitness, improve sleep and overall health, and gradually expose the body to the demands you’re returning to. Strength is just one adaptation among many.

          It’s important though to make the distinction between rehab for pain and rehab for physical performance and return to sport. Strength still matters in injury rehab. Following ACL reconstruction, the research suggests that quadriceps strength needs to be at least 90% compared to the unaffected side; otherwise, the risk of re-tear increases. For baseball players, there are a couple of different metrics in shoulder strength to aim for in order to maintain a healthy arm. Strength is important in this context, but rehab for pain is not the same as rehab for performance; pain cannot be reduced to just, “get stronger.”

          I still want my patients to get stronger. I just no longer assume that getting stronger is the reason they improve, or even needed to improve. I used to present exercise as the way to get stronger in order to get out of pain. Now I present exercise in a much broader sense. Exercise is a way to stay active despite injury and pain, increase activity tolerance, reduce fears around movement and pain, and restore confidence to return to sport and activity. This doesn’t mean strength doesn’t matter. It just means that pain is more complicated than strength alone. Strength gains are often one of the outcomes of good rehab, but not necessarily the reason it worked.

Reference:
Powell J, Wood L, Cashin AG, Lewis JS. It is not all about strength: rethinking mechanistic assumptions in exercise-based rehabilitation for musculoskeletal pain relief. Br J Sports Med. 2026 Mar 17;60(6):407-409.