Returning to Exercise With Back, Knee or Shoulder Pain

Hurt is not the same as harm

A systematic review and meta-analysis found that exercise performed into moderate, tolerable pain produced outcomes at least as good as pain-free exercise for chronic musculoskeletal conditions [18]. Pain during movement — especially with common issues like low back pain or knee osteoarthritis — often reflects a sensitised or protective nervous system rather than ongoing tissue damage [20].

What guidelines actually say

Low back pain

The UK NICE guideline (NG59) and the 2018 Lancet Low Back Pain Series both recommend exercise, staying active and reassurance as first-line care for non-specific low back pain — and advise against routine imaging, prolonged rest and passive-only treatment [15,20]. A Cochrane review found that advice to stay active leads to equal or better outcomes than advice to rest.

Knee and hip osteoarthritis

The OARSI 2019 guidelines strongly recommend exercise (land- or water-based) as core treatment for knee, hip and polyarticular osteoarthritis, regardless of age, comorbidity or pain severity [16]. A Cochrane review of therapeutic exercise for knee osteoarthritis found high-quality evidence for reduced pain and improved physical function [17].

Tendinopathy

Tendon pain generally responds to progressive loading — not to complete rest. Landmark research on heavy-load eccentric training for Achilles tendinopathy showed that patients could return to full activity through structured loading [19], and later trials confirmed that heavy slow resistance produces comparable outcomes with better adherence.

A simple traffic-light framework

Green light — usually reasonable to continue or modify

• Mild, familiar discomfort
• Symptoms that remain stable during and after the session
• Symptoms that settle within about 24 hours
• No meaningful deterioration in function

Yellow light — reduce, modify and monitor

• Discomfort increasing with each set
• Symptoms lasting much longer than usual
• Significant technique changes to accommodate pain
• Reduced confidence
• Noticeable next-day worsening that hasn't settled by the following session

Ways to modify almost any exercise

• Reduce load
• Reduce range
• Change the exercise
• Use more external support
• Slow the movement down
• Reduce volume (sets/reps)
• Increase rest between sets
• Train a different movement pattern instead

Common myths worth retiring

• "Rest until it's pain-free" — prolonged rest usually delays recovery for common back and joint pain [15].
• "Squats or lifting will wear my knees out" — strengthening is protective for knee osteoarthritis, not destructive [16,17].
• "My scan shows a disc bulge / tear, so I must stop exercising" — imaging findings are common in people with no pain and don't reliably predict who hurts [15,20].
• "Any pain during exercise means I'm damaging something" — moderate, settling pain is often acceptable and can accompany improvement [18].

Evidence and references

1. [15]Low back pain and sciatica in over 16s: assessment and management (NG59) — National Institute for Health and Care Excellence (NICE), 2020.
2. [16]OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis — Bannuru RR et al. Osteoarthritis and Cartilage, 2019.
3. [17]Exercise for osteoarthritis of the knee — Fransen M et al. Cochrane Database of Systematic Reviews, 2015.
4. [18]Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis — Smith BE et al. British Journal of Sports Medicine, 2017.
5. [19]Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis — Alfredson H et al. American Journal of Sports Medicine, 1998.
6. [20]Prevention and treatment of low back pain: evidence, challenges, and promising directions — Foster NE et al. The Lancet, 2018.

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