A 2025 editorial published in the British Journal of Sports Medicine argued that increasing muscular strength is not the main driver for reducing pain. Instead, they wrote that strength training is one component among several factors that contribute to pain reduction, based on the biopsychosocial framework of pain.
These other factors include improved self-efficacy, changed pain beliefs, reduced fear of movement, and reductions in inflammatory biomarkers.
Powell et al. wrote that research shows that improvements in pain and function typically do not result from increased muscle strength or musculoskeletal changes. Instead, exercise appears to help through other mechanisms that are not well explained by strength gains alone.
For example, they cited:
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A 2023 systematic review on Achilles tendinopathy found no association between improvements in pain and disability and changes in muscle-tendon structure or strength.
- A 2025 randomized controlled trial (RCT) of 76 adults with patellar tendinopathy found strength training benefits did not change the physical properties, tendon thickness or degree of new blood vessel formation.
- A 2022 RCT of 60 adults with shoulder pain and disability found that the scapular position and shoulder muscle strength “did not mediate the effect of scapular stabilization exercises on shoulder pain and disability.”
“For patellofemoral pain, improvements in hip muscle strength do not explain the beneficial effect of hip resistance exercises,” Powell et al. wrote, adding that knee extension strength mediated about 2% of the treatment effect.
“Across conditions, the conclusion is similar: Exercise therapy is modestly effective, but rarely because people get stronger. The chasm between belief and data warrants attention,” they wrote.
Powell told Massage & Fitness Journal that he and his colleagues have been “brewing” about this issue for about eight years. “I started noticing a disconnect between what we tell patients, ‘You need to get stronger’ and what the evidence shows about how exercise reduces pain,” he said.
As the evidence piled up over the years, Powell said the data became harder to ignore. “The editorial felt timely because we now have enough converging evidence across conditions to make a credible case that strength gains are unlikely to be the primary driver of pain relief from exercise,” he said.
Powell said an alternative to saying “You need to get stronger” would be something like “Exercise can help you adapt in ways that build confidence, reduce pain and improve function. The key is finding the type that works for you.”
The shift is from a single-mechanism promise, like increased strength leads to less pain, to a “broader, more honest message that acknowledges uncertainty while still championing exercise,” he said.
“It also gives clinicians more room to tailor exercise to patient preferences and goals rather than defaulting to a one-size-fits-all loading programme,” Powell added.
Applying to practice
To help clinicians better understand and apply the biopsychosocial approach to exercise and pain management, Powell suggested sharing the evidence on pain reduction mechanisms that many may not have yet seen in the mediation literature. “Beyond that, it’s about reframing what ‘good exercise prescription’ looks like, not just sets, reps and load, but attending to self-efficacy, fear of movement, patient goals and the therapeutic relationship,” he said.
Powell said this process doesn’t mean clinicians should abandon biomechanics, which requires context within the broader biopsychosocial framework. “Practically, mentorship, case-based learning and critically appraising the assumptions behind our clinical reasoning are more effective than didactic lectures about the biopsychosocial model in the abstract,” he said.
On the research side, Powell et al. suggested that future researchers should design trials that test mechanisms, not just effects.
Powell said a standard RCT tells whether an intervention works or not, such as does exercise reduce pain more than no exercise? Mediation analysis asks how or why it works, like what’s on the causal pathway between the intervention and the outcome? he said.
“For example, an RCT might show that a resistance exercise programme reduces shoulder pain at 12 weeks,” Powell continued. “A mediation analysis within that same trial could test whether the improvement was explained by gains in strength, reductions in kinesiophobia, changes in self-efficacy, or some combination. It requires measuring candidate mediators at appropriate time points and using statistical methods to estimate indirect effects. The key difference is that RCTs test the total effect; mediation analyses decompose it.”
Nick Ng, BA
Nick Ng is the editor of Massage & Fitness Jounal and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s degree in graphic communications, Nick had completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate’s degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
