Strength Training in Physiotherapy: Why They Work Better Together

Most people think of physiotherapy and strength training as two different worlds: one is what you do when something hurts, and the other is what you do at the gym. In practice, strength training is often part of physiotherapy itself. It helps move rehabilitation beyond short-term symptom improvement by rebuilding the capacity needed for work, sport and everyday life.

That last part is the bit that usually gets skipped, and it is often why the same niggle keeps coming back a few months later. Here is how the two fit together, and how to load your body in a way that builds it up rather than flaring it up.

Used well, strength training can help people rebuild strength, improve function and prepare for the demands of work, sport and everyday life.

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The Short Answer: Strength Training Is Part of Physiotherapy

Strength training is not something you graduate to once physiotherapy is finished. It is one of the main tools inside it, and for most people it starts a lot earlier than they expect.

What changes between a gym and a clinic is not the principle but the starting point. In a gym you generally start from what you can already do, whereas after pain, injury or surgery the exercises, the starting weight and the speed you build up all have to be matched to what your body can handle right now, which may be well below what you managed six weeks ago.

Both settings run on the same three rules:

• Start where the tissue is now, and build up a little at a time.
• Make the plan fit you, your history and what you are trying to get back to.
• Train the muscles and movement patterns that matter for the activity you want to return to, because squatting, hinging, pushing, pulling and carrying are what you actually use.

General gym training can be valuable, but pain or injury may require the exercises, starting loads and progression to be adjusted to what you can currently tolerate.

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Load and Capacity

Almost everything else in this article follows from one idea, so it is worth a minute of your time.

Picture two lines. The first is load, which is everything you put through a body part, and that includes your training, work, commute, stairs at home and unplanned physical activity. The second is capacity, which is how much that body part is ready to handle at the moment.

Pain tends to show up when load climbs above capacity, and that can happen from either direction, which is the part most people miss. Load can go up, as it does with a sudden jump in weekly running distance, a heavy weekend after a quiet month, or a new sport your body has not been prepared for. Capacity can also drop, quietly, through a stretch of illness, a busy patch with no training, poor sleep, or time in a boot after an injury. The load that felt easy in March is not the same load in July if your capacity has fallen in between.

That leaves you with two levers rather than one.

• Lower the load. Do less, spread it out, or move it around while things are sore. This is what usually settles symptoms quickly.
• Raise the capacity. Use strength work to lift the ceiling, so that ordinary life stops hitting it.

Lowering the load works, and it works fast, which is exactly why it is so easy to stop there. But if your capacity has not moved, you have simply put the ceiling and the demand back on course to meet again, and normal life will walk you into it sooner or later. Raising capacity is the slower lever, and it is the one that changes what happens three months from now. Most people who get a lasting result use both.

It also explains why the same problem behaves so differently in two people. Two runners can both turn up with a sore Achilles, but the one running 20km a week off ten years of training and the one who went from nothing to 20km in a month have very different gaps between load and capacity, and they need very different plans, even though the label on the problem is the same.

How Strength Training Builds Capacity

When people hear the words strength training they picture bigger muscles, and that is part of it, but in recovery the changes that matter most are happening in tissues you cannot see in the mirror.

The idea behind it is simple. You ask a body part to handle a bit more than it is used to, you give it time to recover, and it adapts by becoming more capable. Do that over and over, sensibly, and its capacity goes up, which means more room before anything starts complaining.

Many of the persistent musculoskeletal problems I see are not simply about ongoing tissue damage. They often involve a mismatch between what the person is asking their body to do and what it is currently prepared to tolerate. A tendon that grumbles on your third run of the week, a knee that aches going down stairs, a back that tightens after a day at a desk: these are often signs that the demand has moved ahead of what the body is currently ready for.

Not everything changes at the same speed, and knowing that stops people rushing. Muscles can begin producing more force relatively quickly, partly because the nervous system becomes better at recruiting them. Tendons and bones generally change more slowly, which is why building capacity requires consistent loading rather than a few hard sessions.

That gap in speed is the useful part. It is why feeling stronger after a fortnight is not the same as being ready for the thing that caused the problem in the first place, and it is why resting until it feels better and then going hard again fails so reliably: the symptoms improve on the fast timeline while the slower tissues are still catching up.

So when I use strength work in rehab, I am not chasing soreness or numbers on a bar. I am lifting the ceiling on what your body handles comfortably, so that the thing which used to flare has more room before it does. That makes progressive strengthening one of the tools I rely on most to support long-term function and physical capacity.

When Strengthening Starts

The question I get asked most is when the weights are allowed to start, and the honest answer is that some form of loading usually starts earlier than people expect, because the real question is not whether to load but how much and in what form.

It helps to think of it as four stages that overlap rather than four separate boxes. In practice they blur into each other, you will often be in two at once, and it is completely normal to drop back a stage during a flare-up and pick up where you left off.

1. Settle it down. Take the pressure off whatever is winding it up, keep moving in the ways that feel alright, and get your confidence back in the movements that currently feel risky. Even here there is nearly always something you can load, and it is often somewhere else in the body.
2. Get the control back. Balance, range and slow steady movement, so that the weight you add next goes where you actually want it instead of being taken up by whatever takes over first.
3. Build strength. This is the stage that looks like real training: step-ups, bridges, rows, squats, hinges and carries, going up in small steps over weeks.
4. Get back to the demand. For an athlete that might mean heavy gym work and sport-specific loading, while for most people it means carrying kids, handling luggage, a full day on their feet, or getting through a normal training week without paying for it the next day.

What moves you on is not the calendar, it is how the body answered the last increase: whether the symptoms stayed inside the range you expected, settled in the time you expected, and left you the same or better the next morning. When that is true week after week, you add a little. When it is not, you hold where you are.

A Traffic-Light Guide to Loading

I often use the following traffic-light framework as a starting point. The appropriate response can differ depending on the injury, stage of recovery and exercise being performed.

Judge it on how the body part answers during the session, in the hours afterwards, and the next morning, rather than on how it feels in the moment.

The goal is not to avoid all discomfort, because a body part that is adapting will talk back now and again. The goal is to stay honest about which colour you are actually in, and to respond to it. You are not trying to be tough; you are trying to be accurate.

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What This Looks Like in Practice

Theory is easy. Here is how load and capacity play out in the cases I see most often.

The runner with a grumbly Achilles

A recreational runner comes in with an Achilles that aches at the start of every run, eases off a few kilometres in, and is at its worst on the first few steps out of bed the next morning. That morning pattern is often the most useful thing they tell me, because it says far more about how the tendon coped with yesterday than the pain during the run does.

Rest may temporarily settle symptoms, but restoring tendon capacity usually requires progressive loading rather than rest alone.

In practice that means calf work the tendon can handle, built up steadily over weeks, while the running is adjusted rather than stopped altogether. Distance, frequency, pace and hills can all be adjusted depending on which part of the running load is provoking the tendon most, and I judge progress on the next morning rather than on the session itself.

The strength work is what lifts the tendon’s tolerance so that running stops crossing the line. For midportion Achilles tendinopathy, a review of 29 randomised trials found that active treatment generally looked better than waiting it out at three months, and that because a calf-muscle exercise programme is easy to prescribe, low in cost and carries few harms, it is a reasonable place to start, although the authors were clear that the certainty of the evidence is low.¹

Tendons reward patience more than most tissues. The people who do best are rarely the ones who did the most in week one, they are the ones still doing it in week twelve.

The knee that aches on the stairs

Someone in their fifties notices their knee complaining on the way down stairs, and again after they have been sitting for a while. It is usually worse going down than going up, and it is often the point at which they start avoiding stairs altogether, which quietly lowers capacity even further.

Stair pain does not necessarily mean something has torn. Progressive strengthening can improve the knee’s ability to tolerate the forces involved in stairs, sitting and daily activity.

Building up the thigh, glute and hip muscles changes both how the joint is loaded and how much it handles comfortably. That usually starts in the positions the knee accepts today, then works gradually back towards the ranges and speeds that currently set it off, rather than avoiding them for good. For knee osteoarthritis in particular, resistance training has good evidence behind it for improving pain, strength and day-to-day function.²

The back that tightens at a desk

A desk worker gets a low back that stiffens up by mid-afternoon, loosens off on the walk to the car, and is fine at the weekend. That pattern often suggests that prolonged sitting and the demands of the working day are contributing, rather than proving that the back is damaged.

The back is rarely as fragile as it feels. Strength work, regular movement and gradually building tolerance can help people manage the demands of prolonged sitting and everyday loading.

Alongside strengthening the trunk and hips, the change that tends to make the biggest difference is simply breaking up the sitting more often, well before the point where it normally starts to complain. Exercise is one of the better-supported options for long-term musculoskeletal pain, with reported benefits across pain, function, sleep and quality of life.³

In all three cases the pattern is the same: find a load the body accepts, stay in the green-to-amber zone, and add more as capacity grows. That is physiotherapy and strength training doing the same job from two directions.

Frequently Asked Questions

Do I have to wait until the pain is gone before I start strengthening?

Usually not. Loading can often begin while symptoms are still there, as long as the response stays in the green-to-amber range and settles when you expect it to. Waiting for pain to disappear completely often means capacity has dropped further still by the time you get going.

Is some pain during exercise alright?

Low-level discomfort that settles within a couple of hours and leaves you the same or better the next morning is generally fine. Sharp pain, being clearly worse the next day, or swelling, giving way, numbness or weakness is not, and should be looked at.

How long before I notice a difference?

People often feel stronger fairly early on, because the nervous system adapts quickly, whereas tendons and bones change more slowly. That means being able to handle the activity that caused the problem usually lags behind the feeling of being stronger, and that gap is normal and worth planning around.

Can I just train at a gym instead of seeing a physiotherapist?

Plenty of people train perfectly well on their own. An assessment earns its keep when pain, injury, surgery or plain uncertainty makes it hard to know what the starting load should be, or when the same problem keeps coming back despite sensible training.

How often do I need to train for this to work?

Being consistent over months matters far more than any single session. Two sensible sessions a week that you actually keep repeating will build more capacity than one heavy week followed by a fortnight off.

Conclusion

Physiotherapy and strength training are not competing approaches. Progressive strengthening is often what allows rehabilitation to move from short-term symptom improvement toward greater capacity, confidence and performance.

The right starting point depends on your symptoms, current ability and goals. The aim is not to push through everything or avoid all discomfort. It is to find a level your body can tolerate, then build from there.

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About the author

Daniel da Cruz (BPhysT, PN-SSR1) is an HPCSA-registered physiotherapist based in Sandton, South Africa, with a clinical interest in strength training, load management, tendon and joint rehabilitation, and return to sport and work. He often works with people who are not completely stuck, but who keep running into the same flare-up at the same point in their week.

This article reflects Daniel’s practical approach: many recurring musculoskeletal problems involve a gap between what someone is asking their body to do and what it is currently prepared to handle, rather than something simply being broken. The aim is to find a level the body accepts, then build the capacity to handle more.

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References

1. van der Vlist AC, Winters M, Weir A, Ardern CL, Welton NJ, Caldwell DM, Verhaar JAN, de Vos RJ. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. British Journal of Sports Medicine. 2021;55(5):249–256. https://doi.org/10.1136/bjsports-2019-101872 ^↩
2. Lim J, Choi A, Kim B. The Effects of Resistance Training on Pain, Strength, and Function in Osteoarthritis: Systematic Review and Meta-Analysis. Journal of Personalized Medicine. 2024;14(12):1130. https://doi.org/10.3390/jpm14121130 ^↩
3. De la Corte-Rodriguez H, Roman-Belmonte JM, Resino-Luis C, Madrid-Gonzalez J, Rodriguez-Merchan EC. The Role of Physical Exercise in Chronic Musculoskeletal Pain: Best Medicine—A Narrative Review. Healthcare (Basel). 2024;12(2):242. https://doi.org/10.3390/healthcare12020242 ^↩

This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. If your symptoms are severe or getting worse, or if you have swelling, giving way, numbness, weakness or loss of function, please seek an individual assessment.