Resistance Training

The treatment nobody wants to hear about

If I could prescribe one thing to almost every patient who walks through my door, it would not be an injection. It would not be a manipulation, and I say that as someone who does osteopathic manipulation at every single visit. It would be progressive resistance training.

This is not the answer most people want. An injection is something done to you and it takes fifteen minutes. Strength training is something you have to do, repeatedly, for months, and it is uncomfortable at first. But when you look at what actually changes long-term outcomes across the musculoskeletal conditions I treat, loading tissue deliberately and progressively is at or near the top of the list nearly every time.

Everything else I offer is designed to get you to the point where you can do this, or to remove an obstacle that is stopping you.

Why loading tissue is the mechanism

Muscle, tendon, bone, and cartilage are all mechanosensitive tissues. They read the mechanical demand placed on them and remodel to meet it. Take the demand away and they quietly downgrade. Add demand gradually and they build.

That is not a metaphor. It is the actual biology:

Tendon responds to load by increasing collagen synthesis and organizing fibers along lines of stress. Unloaded tendon becomes disorganized and less tolerant of force, which is why complete rest so reliably fails for chronic tendon pain.

Bone remodels in response to strain. Mechanical loading, particularly the kind produced by resistance training and impact, is one of the few interventions that meaningfully improves bone mineral density in adults.

Cartilage depends on cyclic loading to move fluid and nutrients in and out, since it has no blood supply of its own. Joints that stop moving under load do not stay preserved. They deteriorate.

Muscle is the most responsive tissue of all, and it is also the one that protects everything else. A muscle that can absorb force is a joint that does not have to.

What the evidence actually supports

I want to be specific here, because "exercise is good for you" is a useless statement.

Knee osteoarthritis. Strengthening the quadriceps and hip musculature produces pain and function improvements comparable to what we see with many pharmacologic and procedural interventions, and it is one of the few things that changes the long-term trajectory rather than the symptom. If you have knee arthritis and you do nothing else, do this.

Chronic low back pain. Exercise therapy, including resistance training, is among the most consistently supported treatments in the literature. Notably, no single "correct" program has beaten the others. What matters is progressive loading and consistency, not the specific exercise.

Tendinopathy. Progressive loading is the primary treatment. Shockwave and PRP are adjuncts that help a tendon respond to loading, not replacements for it.

Sarcopenia and falls. Resistance training is the only intervention that reliably rebuilds lost muscle in older adults, and it reduces fall risk. Given that a hip fracture after 65 carries a genuinely frightening mortality rate, this is not a cosmetic concern.

Bone density. Progressive resistance training with meaningful load is one of the only non-pharmacologic interventions with real effects on bone.

The part where people go wrong

Most patients who tell me strength training did not work for them made one of a few predictable mistakes.

They never actually progressed. Doing the same three-pound dumbbell routine for two years is not resistance training. It is a habit. The tissue adapted in the first six weeks and then had no further reason to change. Load has to increase over time.

They went too hard, too early. The opposite failure. An irritated tendon or an angry joint will not tolerate a sudden jump in volume, and the resulting flare convinces people that loading is the enemy. It is the rate of change that hurt them, not the loading.

They stopped when it got uncomfortable. Some discomfort during loading of a painful tissue is expected and acceptable — roughly a 3 or 4 out of 10, settling within 24 hours. That is not damage. Sharp pain, pain that escalates, or soreness that lingers for days is a different signal.

They treated it as a temporary prescription. Tissue that adapted to load will de-adapt when the load stops. This is maintenance, not a course of antibiotics.

How this fits with what I do

I am not sending you away with a photocopied exercise sheet. The reason I treat with my hands first is that a joint that cannot move through its range, or a segment that is locked down and shifting stress somewhere else, cannot be loaded productively. Manual treatment opens the door. Loading is what walks through it.

The same logic applies to everything on the procedure menu. A corticosteroid injection that quiets a joint enough to begin strengthening is a good use of a corticosteroid injection. One that simply lets you avoid the underlying problem for another three months is not. Shockwave for a stubborn tendon works best paired with a loading program. When I use motion analysis, part of what I am looking for is whether you can actually perform a movement well enough to load it safely.

The tools are there to make the training possible. The training is what changes the outcome.

Where to start

You do not need a gym membership, a barbell, or a program off the internet designed for somebody else's body.

Pick compound movements. Something that pushes, something that pulls, something that loads the legs, something that loads the hips. Squats or sit-to-stands, a row, a press, a hinge. These cover most of what a body needs.

Two to three sessions a week. More is not better early on. Tissue adapts during recovery, not during the session.

Work hard enough that the last two repetitions are genuinely difficult. If you could have done ten more, the stimulus was not there. This is the single most common thing I correct.

Increase something every week or two. Weight, repetitions, or sets. Small increments. This is the entire game.

Expect it to take months. Muscle responds within weeks. Tendon and bone are on a much slower schedule — think three months minimum for meaningful tendon remodeling, and longer for bone.

When to check in first

Come see me before starting if you have pain that wakes you at night, unexplained weight loss, a history of cancer, progressive numbness or weakness, or any loss of bowel or bladder control. Those are not strength training problems.

Otherwise, come in if you have tried and keep flaring, if you do not know where to start given the specific thing that hurts, or if you want the movement screened before you load it. That last one is worth doing. Loading a compensation pattern just makes the compensation stronger.