It is not all about strength: rethinking mechanistic assumptions in exercise-based rehabilitation for musculoskeletal pain relief

Exercise is considered requisite in the management of most musculoskeletal (MSK) pain conditions.1 It is the foremost treatment recommendation for conditions including rotator cuff-related shoulder pain, Achilles and patellar tendinopathy, MSK low back pain and osteoarthritis (OA).2 3 Driven by its intuitive logic and communicative simplicity, the hypothesis that ‘pain diminishes because strength increases’ remains a prominent explanation for the effectiveness of exercise. In this editorial, we challenge the premise that strength gains mediate pain reduction and highlight alternative mechanisms with stronger empirical support.