Sounds too good to be true.

But there is a training intention gaining attention in the research and rehab world.

The concept is simple:

Train muscles to build capacity at long lengths.

In other words, train muscles to produce force while in a stretched position.

Simple idea. Powerful results.

At our clinic, we commonly see hamstring, groin, calf, pec, rotator cuff, and forearm strains. A common thread? Many of these injuries occur when muscles are loaded while lengthened.

So the question becomes:

Are we adequately preparing muscles for the positions where they are most vulnerable?

I did a Therapy Thursday a couple weeks back emphasizing the same concept but wanted to reinforce the message.

Stretching Versus Stretching Under Load

Most active people already stretch.

Yet despite regular stretching, hamstrings stay tight, hips remain restricted, and muscle strains still happen.

Why?

Conventional stretching involves placing a muscle in a lengthened position and holding it there. This can improve flexibility and reduce stiffness, but research suggests much of that improvement comes from better stretch tolerance rather than major structural changes within the muscle.

Stretching still matters, but it may not be the whole story.

Why Load Changes the Equation

Recent research examining sarcomerogenesis, the addition of sarcomeres within muscle fibres, suggests that mechanical tension at longer muscle lengths may be a key driver of muscle adaptation.

A recent review by Blazevich and colleagues challenges the idea that passive stretching alone creates these changes. Instead, the more meaningful stimulus may be loading muscles while they are lengthened.

That is an important shift in thinking.

Many studies have concluded that eccentric exercise is the key to sarcomerogenesis, however Blazevich has proposed that it may be that muscles adapt best when they are asked to produce force in stretched positions.  Eccentrics are not the magic rehab potion, training at long muscle lengths might be.

What does loaded stretching or training at long-lengths look like?

Long-length training is not new.

Many effective rehab and strength programs already use it such as the use of Romanian deadlifts/lengthened Nordic variations in hamstring rehab or the use of deficit calf raises in calf and achilles rehab or cossacks/copenhagen variations for groin and hip rehab.

These exercises combine mobility and strength rather than treating them separately.

Instead of merely visiting end range, they help you own it.

The bodybuilding world has also embraced the research on hypertrophy from long-length training.  Resistance training performed at longer muscle length has been found to be more effective for promoting overall hypertrophy compared to training at a shorter length.

Bodybuilding programs often includes “lengthened partials”, where you only perform the stretched half of an exercise (partial range of motion), keeping the muscle under maximum tension when it is lengthened.

But a word of caution before you start doing some intense lengthened partials or advanced bodyweight stretch holds.  If you are new to resistance training, start with full-range strength training and progress gradually. Mobility, stability, and movement quality still matter and the challenges for long length muscle training may be too much for a beginner resistance trainer.

The takeaway message is simple:

Think of how you can emphasize muscle length in some of your common resistance training exercises.  Can you emphasize the reach and hold extended portion of a row or can you work your split squat for better control at a lower depth.

Or think outside of the traditional exercise box and create effort in some of your stretched positions.

There appears to be a unique adaptation when muscles are challenged in a fully lengthened state.

Research in this area has certainly changed the way I think about improving mobility, enhancing rehabilitation and preventing injuries for both myself and my patient care and hopefully it will change how you think about your own resistance training plan!

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Dr. Topol just highlighted an article that was just published today (May 6, 2026) that really caught my attention.

The Nature Journal is considered the holy grail scientific journal that all researchers try to get published in.  When Nature deems an article to be of particular importance, they will make it open access, removing the paywall for the greater good.

This was one of those articles.

To absolutely nobodies surprise, lots of prior studies have shown that both diet and physical activity levels can have a major impact on your ‘affective well-being’, essentially meaning how you are feeling emotionally.

These prior studies tend to have lots of flaws.  They are almost always ‘retrospective’ meaning they use surveys to ask people how they felt or how much they exercised over a given period.  These surveys tend to be terribly inaccurate and skew results.  On top of that, to ‘standardize’ studies, the physical activity sessions are usually in a lab setting which hardly mirrors a nice walk in nature.

With technological advances, associations like physical activity and your emotional well being are now much easier to accurately quantify.  Have someone be prompted to complete a quick smartphone survey at regular intervals and have them wear an accelerometer to track how much physical activity they are actually completing and voila!  You’ve greatly improved your dataset to draw conclusions.

That is essentially what this article sought to answer:  How does physical activity relate to your affective well being in everyday life.

The researchers took other studies and pooled 67 datasets from 321,345 participants that all used smartphone based affective wellness ratings and contributed to roughly 1 MILLION hours of accelerometer data.

This allowed them to establish a number of previously unknown answers:

• How does your mood change BEFORE exercise versus after?
• Is it different between genders?
• What about age?
• Does what level of shape you are in to begin with matter?
• What aspects of affective wellness are changed – is it increased energy? Is it emotional well being?  What about calmness?

Here is a little graph from the article to look at prior to summarizing the results.  The middle section with the lines with dots that look like drone planes from star wars tell whether physical activity was associated with particular variables.  If the drone plane is to the right of the vertical line then physical activity helped.  If it was to the left then it actually made it worse.

To summarize the study findings:

• The researchers were able to show that in everyday life, physical activity is associated with the following within a person:
  • Valence (a feeling of goodness)
  • Energetic arousal
  • Positive affective states
• These occurred if the person took the phone survey either before OR after exercising.
• These changes were there even if a person just went for a walk instead of continuing to sit!
• They were also able to show that in everyday life, if someone had a higher affective wellness score, then they did more physical activity and vice versa. This means that the emotional side of things and exercise play off one another.  Those with higher affective wellness scores did more physical activity.
• Some factors did impact these scores:
  • The findings were less pronounced in older folks when compared to younger people.
  • Women felt more energetically aroused after being physically active then men.
  • Those with a higher body mass index had a lower affective wellness score after and before exercise. The researchers think this is potentially attributed to feelings of discomfort, pain, heat etc.
  • The finding was stronger on weekends versus weekdays……work sucks!

Why is this important?

This paper started with an absolute banger of a statistic.  If people met the current WHO physical activity requirements, GDP would increase by USD $314 to $446 billion a year.  The reason is twofold.  First, it would counteract many physical ailments that cause people to miss work, and equally as important, it is now shown to have the ability to decrease days missed due to mental illness.

If you want more evidence as to the importance of exercise and mental health, Dr. Topol also linked to this 2024 mega article that showed that all forms of physical activity were superior to SSRI drugs for depression.

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3 sets of 8–12 reps.
Rest 60–90 seconds.
Lift heavy. Train to failure.
Periodize or mix up your program regularly for progress.

Much of those specific guidelines came from the 2009 position stand from the American College of Sports Medicine (ACSM)  which is a document that shaped how many clinicians, trainers, and athletes approached resistance training for over a decade.  It was largely a programming manual, prescribing how to strength train.  It catered to our human desire of “just tell us exactly how to do it.”

The 2009 position stand made strength training look like a strict recipe that needed to be followed.

But just recently (March of 2026) the ACSM released a major update and the message is surprisingly simple: we may have been overcomplicating resistance training for the general population.

More recent research has demonstrated that strength training can be far more flexible than we thought and your body can respond to many different ways of training.

Variables like tempo, set structure, machines vs free weights and fancy programming methodology show little consistent effect on results.

The new position stand suggests there are many effective ways to do your resistance training.  The foundation of a resistance training plan that can deliver results requires 2 key elements: sufficient intensity of effort repeated consistently over a long period of time.  Essentially the best plan is one you work hard enough at on a regular basis.

Some things from the original 2009 position stand still matter such as you should train at least 2x/week and progressive overload is essential for progress.  So as you get stronger (the workout feels easier) then add more: weight, resistance, volume (more sets) or another training day.

Full range of motion is recommended to maintain joint health and mobility.  These are still the foundation for an effective resistance training program.

But emphasis on training to failure, periodized programs, specific rest intervals, exercise order, equipment choice (machines vs free weights), blood flow restriction and optimizing time under tension have become less of a priority.  Doesn’t mean some of those variables don’t work, but they are not a requirement for building muscle.

Of course your goals still matter.  And if you have very specific strength or performance goals then your resistance training absolutely needs to align with your goals and the skill and practice required to get proficient at those goals needs to be trained.

If strength is your goal, you have to lift relatively heavy (apprx 80%+ 1RM effort).  Lift through a full range of motion, 2-3 sets works well and place key lifts at the beginning of the session.

If hypertrophy (muscle growth) is your goal accumulate enough weekly volume (apprx 10+ sets/muscle/week).  Periodic eccentric overload also appears to enhance growth.

If power is your goal move lighter loads (20-70% 1RM) quickly.  Emphasize velocity of the concentric portion of the movement (control through the eccentric) but train with low-to-moderate volume to avoid fatigue.
And if you are concerned about the loss of physical function with aging, the updated position stand recommends adding or emphasizing power training in your resistance training plan.  The loss of power with age (powerpenia) is a significant threat to your health span (the quality of your life) and adding purposeful quicker movements within your capacity can slow the rate of muscle power loss.

For the general population who is either looking to get started or inconsistent with their fitness routine, you have many options for your strength training.  Light weights or heavy weights.  Bands, body weight, circuit style training, machines or free weights.  Many sets over a prolonged period of training time or a single set to failure.

Doing some (any form) of resistance training is better than none at all.  The biggest opportunity for improvement in muscle health is simply getting started and working at it consistently.

This is a major shift for clinicians and patients alike and suggests that individual preferences should absolutely be harnessed for long term adherence to a resistance training program.

Why does this shift matter?  Quite simply not enough people are meeting muscle-strengthening guidelines.

Stu Phillips, McMaster researcher and co-author of the updated position stand has often been quoted as saying fewer than 1 in 5 people meet resistance training guidelines.  And in some populations, for example older women, that number is much lower.

The goal of the shift is to empower patients to carve their own personalized resistance training path.  The best program is the one you will sustain.  So pick an environment you like to spend time in and equipment you enjoy using and build up to working harder and harder over time.  Results compound from consistent stimulus over a long period of time.

The key takeaway point with the updated position stand is that consistency and effort trump complexity when it comes to resistance training.  Let’s encourage as many people as we can to start lifting as it may just be the most important public health message we can all help spread.

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As a society, we are starting to become ‘over imaged’ in terms of finding musculoskeletal problems. 

Ahhhh….that felt good to put it in writing.

Why do I feel this way?

Study after study show that imaging findings alone, whether x-ray, ultrasound, or MRI, seem to have little to no correlation to how someone is actually feeling, and seems to matter less and less in terms of guiding treatment.

This isn’t a new concept.

One of most read blogs of all time was from back in 2015 (man we are getting old) titled ‘So….do I need an MRI?  Why advanced imaging at times does more harm then good’

Every so often, a great study on this topic will come along and be deemed so controversial that even popular media outlets will pick it up.

Does this change the way people think?

Absolutely not!

(Sigh).

But maybe just maybe, with enough repetition of a similar topic, we will hit the proverbial tipping point and attitudes of both clinicians and patients will change.

Well, one such very important (and controversial) study was very recently published in the Journal of the American Medical Association (JAMA Internal Medicine).

So what makes this study different?

Lots!

This was a giant population based cross sectional cohort study in a completely random but representative sample of adults in Finland aged 41-76.

Essentially they took 602 random adults, gave them a history and physical evaluation of their shoulders and then did high quality 3T MRI’s on both shoulders.  They had 3 radiologists independently read the MRI’s of both shoulders of each person.  These doctors were completely blinded to both clinical symptoms the people may be experiencing as well as what the other radiologists found.

They then classified the rotator cuff tendons of each shoulder in 1 of 4 categories:

• Normal
• Tendinopathic changes (think tendonitis)
• Partial thickness tears
• Full thickness tears

Before we get into the results let’s ask why they even did this study and why it’s so darn important.

We know shoulder pain is extremely common.  It affects 18-31% of the general population each month and is the 3^rd most common reason people go and see their doctors for musculoskeletal injuries.

Issues with the rotator cuff are determined to be responsible by clinicians an astounding 85% of the time.  Equally astounding is that doctors order special imaging of the shoulders 50% of initial visits, even before trying any rehab.  In fact, a shocking 82% of General Practitioners view shoulder imaging as essential. 

Side note – I would guess 100% of patients also view it as essential!

But is it?

Maybe this increased imaging just leads to more interventions.

Imaging guided injections have increased 46 fold since the year 2000 and rotator cuff repairs have increased between 2 and 7 fold in high income countries over the same period.

So then, the question begs…..are the imaging findings causing this rapid increase in interventions?

In this study sample, 18% of folks had current shoulder symptoms and 60% of people reported shoulder pain in the past (these findings agree with the general population at large).

Here are the findings from the study and why it caused such a kurfluffle (I’ve been trying to crowbar that word into a blog for years).

Of the 602 people that had MRI’s

• 585 had MRI abnormalities of their rotator cuffs
  • 25% were tendinopathy
  • 62% had partial tears and
  • 11% had complete tears of their cuffs.
• Of the 70 people with full tears, 37% had full tears in BOTH SHOULDERS
• There was a clear age-related progression where those in their 40’s largely had tendinopathic changes, while those a little older had partial and complete tears starting around age 55.
• In fact, no one under 45 had a complete tear but 28% of those over 70 had complete tears.
• So if there were 602 people, that means 1204 shoulders
  • Rotator cuff abnormalities were seen in 96% of those without symptoms and 98% in those with symptoms.
  • Just as confusing was that the prevalence of tendinopathy and partial tears had zero difference between those with and without pain.
  • Even in the 96 full tendon tears, 78% were in shoulders of people with NO SYMPTOMS.

Ok let’s take a breath and think about what the implications of this study are.

Of the total study, 99% of people aged 41 and older had at least 1 rotator cuff abnormality on MRI. 

Yes…..99%.

Even partial tendon tears were present in 43% of people 45 years old or younger.

MOST rotator cuff issues were seen in people with NO PAIN, highlighting the lack of concordance between a person’s symptoms and what is found on MRI.

This completely challenges the routine attribution of shoulder symptoms to a person’s imaging.

Why?

BECAUSE EVERYONE (literally 99% of people over 41) HAVE IMAGING ISSUES OF THEIR SHOULDERS!

So as clinicians we need to shift our thinking from ‘does an abnormality exist?’ – because it almost certainly does – to ‘does the imaging abnormality plausibly explain the persons clinical findings.

This INCLUDES full tendon tears as with increasing age this is very common, and this study showed that the large majority had no pain whatsoever!

Another thing to think about as a derivative of this paper is that whole body MRI’s have zero value as far as shoulders go and will likely do much more harm then good as again, 99% of people will have a finding in their shoulder and most will have no pain!

So essentially all of you reading this would have shoulder findings if you had an MRI, whether you have pain or not.  What really matters is seeing a qualified professional that is able to link any symptoms you are experiencing with MRI findings……otherwise the imaging alone really serves no purpose.

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Or maybe it’s worse than that, maybe you’re one of the unfortunate souls (like my wife recently) who tore their ACL skiing or like a patient of our clinic last week who tore his achilles playing pickleball.

You get to a certain point and you wonder if all these recreational activities are really worth the risk.
A recent study, helps put those concerns into perspective, showing that recreational exercise variety may be one of the most underrated longevity tools.

Researchers followed 110,000+ adults for more than 30 years, tracking the types of physical activity people did and how consistently they did them. They then compared this with death rates from all causes, including heart disease, cancer, and respiratory disease.

Most common activities such as, walking, jogging, running, cycling, resistance training, stair climbing, and racquet sports, were linked to lower mortality. Benefits increased with activity but plateaued at higher volumes (more isn’t always better).

Most importantly this long term observational study found that people who regularly did a greater variety of activities had a ~19% lower risk of death, even when total exercise volume was the same.

In other words someone who walks, lifts, runs and plays sports does better long-term than someone who only walks or only lifts or only runs, even if weekly minutes are identical.

So it’s not just how much you move, it’s how varied your movement challenges are. This makes complete sense. Some activities will challenge our cardiovascular system, some will challenge strength and help build muscle mass, some will build power or challenge mobility, balance or co-ordination. Having a more rounded approach to your exercise selection increases the odds that you are addressing most of the key areas of your physical health.

But it’s not just the physical movement diversity component at play here. The varied cognitive challenges associated with pursuing and learning different activities may help mitigate some of the key factors associated with aging and some forms of chronic disease. You may even become a super ager.

And the varied environments with different social networks can’t be ignored either. Our social circle starts to naturally shrink as we get older. A variety of recreational endevours are a fantastic way to both build and maintain a stronger social network. Your social community and supports are key pillar of your overall health.

We all know that being active lowers your risk of disease and early death. But don’t just move more, challenge yourself to pick more ways to move. Your body thrives with variety.

So next time you’re wrestling with that “is it all worth it” question, remember your healthspan (quality of life) and lifespan, quite literally depends on it.

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