Training with a shoulder or knee injury: what to adapt and when to stop
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In a 2007 trial, continuing to train within a pain limit gave results similar to rest. With shoulder or knee pain, the usual answer is not to quit the gym but to adapt it. Which exercises to change, how much pain is acceptable and which signs mean you should see a doctor.
This article is for overuse aches you already know, not for a knock or a new, intense pain. If the pain came on suddenly, after a fall or a pop, or there is swelling, locking, weakness, tingling or night pain that does not ease, check with a healthcare professional first.
That said, most gym-related shoulder and knee aches do not call for complete rest. In 2007, Silbernagel and colleagues compared two groups of people with Achilles tendinopathy: one stopped running and jumping for six weeks, and the other kept going, but within a pain limit. After a year, both had improved a lot with no significant difference between them. Training sensibly did not slow recovery.
Gym injuries: fewer than you might think
The review by Keogh and Winwood (2017) on weight-training sports found low injury rates compared with team sports. The most affected areas were the shoulder, lower back and knee, and the most common problems were muscle strains and tendinopathies. In other words, the typical case is not breaking something but piling on more load than the tissue can take.
That is why the answer is usually to adjust the load, not remove it completely. An irritated tendon or joint needs less stimulus for a while, but not none.
How much pain is acceptable: the pain-monitoring model
The Silbernagel study used a simple rule that many physiotherapists apply to other areas too:
| When | Acceptable | Sign to reduce the load |
|---|---|---|
| During exercise | Pain up to 5 out of 10 | It goes above 5 or changes the way you move |
| After training | Back to your usual level by the next morning | Still higher the next day |
| Week to week | Stable or improving | Pain or stiffness increases every week |
If one session goes over the limit, it is not a failure: next time lower the weight, the sets or the range of motion, and try again.
Knee: what the evidence says
For pain around the kneecap (patellofemoral pain), the international consensus by Collins and colleagues (2018) recommends exercise as treatment, especially combining hip and knee exercises. In knee osteoarthritis, the Cochrane review by Fransen and colleagues (2015), with 44 trials, found that exercise reduces pain by about 12 points out of 100 and improves function.
What about deep squats? The review by Hartmann and colleagues (2013) concluded that they are not more dangerous for a healthy knee than partial ones: pressure behind the kneecap peaks around 90° of flexion and is spread better as you go lower. If it hurts at 90°, you may tolerate another range better. What matters is finding the range that does not hurt, not banning the squat.
| If this bothers you… | Try… |
|---|---|
| Barbell squat | Box squat at a height that does not hurt, or a lighter goblet squat |
| Walking lunges | Static split squat or a low step-up |
| Leg extension | Partial range or less weight with more reps |
| Jumping and running | Drop them for a few weeks and work the hips: glute bridge, abductions, Romanian deadlift |
You will find the technique in barbell squat and a very adjustable single-leg option in Bulgarian split squat.
Shoulder: what the evidence says
For the shoulder the evidence is weaker. For rotator cuff related pain, the review by Naunton and colleagues (2020) found that loaded, progressive exercise is the most studied option, though its benefit over no treatment is uncertain. Exercise without load or progression showed no benefit.
The GRASP trial by Hopewell and colleagues (2021), with 708 patients, adds a nuance: six sessions of progressive exercise were no better than a single advice session with a physiotherapist, which included home exercises. And the corticosteroid injection gave no long-term benefit. The practical takeaway is to keep moving the shoulder with loads you tolerate; you do not need a sophisticated program.
| If this bothers you… | Try… |
|---|---|
| Barbell bench press | Dumbbells with a neutral grip, or a floor press (less range) |
| Overhead press | Incline press, or a dumbbell press with the elbow slightly in front of the body |
| Parallel bar dips | Drop them for a while; push-ups with hands elevated |
| Wide-grip pull-ups | Neutral or underhand grip, or lat pulldown |
More options by muscle in shoulder exercises. A progressive warm-up helps the shoulder arrive ready for heavy sets: RAMP warm-up.
How to organise your week in the meantime
- Train everything that does not hurt as usual: an irritated knee does not stop you training your upper body, nor a shoulder your legs.
- Keep the area moving with the adapted exercises and the pain rule.
- Increase the load slowly once pain stays stable for two weeks: reps first, then weight, and full range last.
- Watch your overall fatigue: poor sleep or back-to-back hard weeks also lower tolerance (see fatigue management).
In the Progrevia generator you can mark the area to protect —shoulder, knee or lower back— and the engine removes or adapts the exercises that load it most. It does not replace a professional assessment, but it gives you a routine to keep training while you recover.
- Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The American Journal of Sports Medicine. 2007;35(6):897-906.
- Keogh JW, Winwood PW. The epidemiology of injuries across the weight-training sports. Sports Medicine. 2017;47(3):479-501.
- Collins NJ, Barton CJ, van Middelkoop M, Callaghan MJ, Rathleff MS, Vicenzino BT, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain. British Journal of Sports Medicine. 2018;52(18):1170-1178.
- Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2015;1:CD004376.
- Hartmann H, Wirth K, Klusemann M. Analysis of the load on the knee joint and vertebral column with changes in squatting depth and weight load. Sports Medicine. 2013;43(10):993-1008.
- Naunton J, Street G, Littlewood C, Haines T, Malliaras P. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2020;34(9):1198-1216.
- Hopewell S, Keene DJ, Marian IR, Dritsaki M, Heine P, Cureton L, et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. The Lancet. 2021;398(10298):416-428.
Progrevia · · How we write our guides
Frequently asked questions
Can I train with knee pain?
If it is a familiar overuse ache, usually yes, adapting the exercises and staying within a pain limit: up to 5 out of 10 during exercise, and back to your usual level by the next morning. If there is swelling, locking, the knee giving way, or the pain started after a knock, get it checked first.
Are deep squats bad for your knees?
Not for a healthy knee. The review by Hartmann (2013) concluded that pressure behind the kneecap peaks around 90° and is spread better as you go lower. With pain, look for the range you tolerate instead of dropping the squat.
Which exercises should I avoid with shoulder pain?
The ones that cause more pain than is acceptable, usually heavy overhead presses, dips and wide-grip barbell bench presses. Try neutral-grip dumbbells, incline presses and neutral-grip lat pulldowns.
Is complete rest best for tendinitis?
In most cases, no. In the trial by Silbernagel (2007), continuing activity within a pain limit gave results at one year similar to stopping for six weeks. The tendon needs less load for a while, but not none.
When should I see a doctor about gym pain?
If the pain came on suddenly, after a fall or a pop, or there is swelling, locking, loss of strength, tingling, night pain that does not ease, or it does not improve within a few weeks despite adapting your training.
Informational content based on the available scientific evidence: it does not replace advice from a healthcare professional. If you have an injury or a medical condition, or are pregnant, check with one before changing your training or diet.
