On a grey Tuesday in November, the waiting room of a small physical therapy clinic in the suburbs is filled with the same soundtrack: Velcro knee braces, sighs, and the rustle of insurance papers. In the corner, a woman in her fifties rubs her right kneecap nervously. She’s already tried swimming. She’s already tried Pilates. Her GP told her to “stay active but not too much”, which sounded like a joke.
When her name is called, she walks in with a limp and walks out 30 minutes later with a new word in her vocabulary: “heavy loading”. And a warning.
“It will hurt. That’s the point.”
The door closes behind her, and the debate begins.
Why some therapists are now betting on pain, not protection
Across Europe and the US, more and more physical therapists are moving away from the classic advice of “protect the knee, go easy, do gentle exercise”. Instead, they prescribe what sounds almost brutal: loaded squats, split lunges, leg presses, resistance work that actually triggers pain during the session.
For anyone who’s been told for years to avoid stairs and deep bends, the shock is real. This new approach sounds like punishment.
Yet these therapists swear by it.
Take Marc, 47, office worker, former weekend runner. Chronic knee pain for four years, a familiar scan report: “early osteoarthritis”, and a depressing recommendation: “low-impact activities only”. He moved to swimming, did some Pilates videos online, lost a bit of muscle and a lot of confidence. The pain stayed.
When his new physio asked him to squat with a barbell on his back, his first reaction was “Are you insane?”. The first session, he rated the pain a 6 out of 10. By the fourth week, he could sit down and stand up from a low chair without grabbing the armrests like a 90‑year‑old.
He still felt pain, but the fear had shifted.
Behind this provocative strategy, there’s a simple, uncomfortable idea: joints don’t get better by being wrapped in cotton. Muscles around the knee, tendons, ligaments, even cartilage respond to mechanical stress. Moderate, controlled, repeated stress.
Swimming and Pilates can be great, yet they often don’t load the knee enough to rebuild true strength where it counts: standing, walking, climbing, carrying your own body weight. *A lot of patients discover that their knee doesn’t just hurt; it’s weak, under-trained, and overprotected.*
So therapists push, gently at first, into that zone where it stings. Not to be cruel, but to talk directly to the tissues.
The controversial protocol: “painful, but safe”?
The method that divides professionals rests on a clear rule: pain is allowed, as long as it stays in a specific window. Many protocols use a 0–10 scale: you’re allowed to go up to 4, 5, sometimes 6 during an exercise, and the pain should calm down within the next 24 hours without a flare-up.
Sessions mix squats holding onto a support, slow step-downs from a low step, leg presses, and isometric holds where you push without moving. It looks more like strength training than gentle rehab.
The therapist stands nearby, watching the face, the breathing, the trembling thigh.
Imagine Anna, 62, former nurse, with medial knee osteoarthritis. She used to love gardening, now she avoids crouching because “once I go down, I’m not sure I’ll get back up.” After yet another round of painkillers and pool exercises, her physio offers a different deal: eight weeks of progressive heavy loading.
First session: just sitting and standing from a low bench, arms crossed. Pain 5/10, she swears under her breath. Second week: small weights in her hands. Fourth week: slow, controlled step-downs from a 15 cm step. By week eight, she’s back kneeling in the garden bed, still sore sometimes, but far less afraid.
Her MRI hasn’t changed. Her life has.
From a biological standpoint, this approach makes sense. Knee pain, especially in osteoarthritis and patellofemoral pain, is linked not only to “wear and tear” but to how strong and coordinated the muscles are, how confident the brain is, how the joint tolerates load. Light movements in water soothe the system, which is useful. But they don’t always send a strong enough signal to build real capacity.
The heavy-loading camp argues that **the best protection for a painful knee is not rest, it’s strength**. The body adapts to what you regularly ask from it. If all you ask is walking slowly on flat ground and a few gentle stretches on a mat, that’s all it will be ready for.
And the day you need to sprint for a bus or carry a suitcase up the stairs, the bill arrives.
How to “load” a painful knee without wrecking it
For those tempted to try this route, the first step is not grabbing the heaviest dumbbells in the gym. The first step is testing what your knee can tolerate today. One simple entry point: the sit-to-stand test.
Take a chair, ideally a bit lower than your usual one. Cross your arms against your chest. Stand up and sit down slowly 10 times. Notice your pain level from 0 to 10 during the movement and two hours later. If you’re below 5/10 and the pain goes back to baseline the same evening, this is your starting exercise.
Do it every other day, 3 sets of 8–10 repetitions, with controlled tempo.
Common trap: wanting to go too fast, too soon. You feel a small improvement, you get excited, and suddenly you double the weight or add stairs and lunges on the same day. Two days later, your knee is hotter, swollen, angry, and you curse the whole “painful loading” trend.
Let’s be honest: nobody really does this every single day as prescribed on the paper handout. Life happens, sleep is bad, motivation drops. A realistic plan tolerates missed sessions and slow progress.
The key is progression, not perfection. Add difficulty only when the current level feels doable with pain under control and no 48‑hour flare.
Many therapists now explain the rule like this: “Pain is a noise, not a fire alarm.” They invite patients to listen, not panic. That demands trust, and clear limits.
“People hear ‘you need to load the knee’ and translate it as ‘no pain, no gain’,” says Laura, a sports physio in Lyon. “That’s not what we’re saying. We’re saying: some pain is acceptable, but we negotiate the dose. If your pain stays high for two days, we’ve crossed the line.”
- Pain window: Aim for discomfort around 3–5/10 during exercise, not screaming pain.
- 24-hour rule: if pain spikes persist beyond the next day, your session was too intense or too long.
- One change at a time: adjust either the weight, or the number of repetitions, or the depth of the movement, not all three.
- Support allowed: holding onto a table, railing, or wall is not “cheating”, it’s strategy.
- Rest is part of training: your tissues rebuild on off days, not during the effort.
Between fear and progress: finding your own line in the sand
This shift toward loaded, sometimes painful rehab confronts us with a tricky question: what scares us more, the sensation of pain or the idea of losing our freedom to move? Many patients say they’re “afraid of making it worse”, yet they’re already giving up stairs, walks, hobbies. The line between protection and self-sabotage is thin.
Some people embrace this new approach and feel powerful again, others feel betrayed, as if their suffering is being dismissed. Both reactions are valid. There is a real risk: badly supervised loading, without clear rules and follow-up, can worsen symptoms, and the body does have limits.
At the same time, wrapping the knee in bubble wrap rarely brings back the joy of spontaneous movement.
So the question may not be “Is this method good or bad?” but “What dose of discomfort am I ready to try, with what support, for what potential gain?”. For some, the answer is a firm no, and that’s fine. For others, curiosity wins: they prefer six weeks of structured effort over ten more years of avoiding hills.
A balanced path sits somewhere between the old “just rest and swim” recipe and the macho “push through everything” mantra. **The body is not a fragile object, and it’s not a machine either.** It’s a living system that negotiates with stress, adapts, and sometimes protests loudly.
Each of us ends up designing our own contract with our knees, rep after rep.
| Key point | Detail | Value for the reader |
|---|---|---|
| Loading can be helpful | Controlled, progressive strength work around the knee can reduce pain and improve function | Opens a new option if “gentle” exercise hasn’t changed daily life |
| Pain has a safe window | Discomfort up to 4–5/10 is often acceptable if it settles within 24 hours | Gives a concrete rule to judge whether an exercise is harming or helping |
| Progress must be gradual | Change one variable at a time and respect rest days | Reduces the risk of flare-ups and keeps motivation alive over weeks |
FAQ:
- Isn’t any pain during exercise a sign that I’m damaging my knee?
Not always. For many chronic knee conditions, mild to moderate pain during exercise is expected and can be safe if it doesn’t worsen in the following 24 hours. Ongoing increasing pain, swelling, or loss of function is a red flag that needs professional review.- Is swimming or Pilates useless for knee pain?
They’re not useless at all. They can help with mobility, circulation, general fitness, and confidence. The issue is that they often don’t provide enough loading to rebuild strength for real-life tasks like stairs, hills, or carrying weight, so they may need to be combined with targeted strength work.- Can I start heavy loading on my own at the gym?
You can start with bodyweight moves like sit-to-stand, shallow squats holding onto a support, or step-ups on a low step. For heavier work (leg press, weighted squats, lunges), it’s safer to get at least a few sessions of guidance from a physio or experienced trainer who understands painful knees.- What if my knee is very swollen or locks sometimes?
Swelling, locking, or giving way can signal structural problems such as meniscus tears or significant arthritis flares. In those cases, loading needs to be adapted carefully, and a medical assessment is necessary before starting any “painful” protocol.- How long before I notice real changes in my knee?
Most structured programs run for 6 to 12 weeks, with 2 to 3 sessions per week. Some people feel differences in confidence and movement control after two weeks, but changes in strength and pain levels usually become clearer after a month or more. Patience and consistency count more than intensity.
