Physical therapy should start before the injury

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The World Health Organization estimates that approximately 1.71 billion people worldwide live with musculoskeletal conditions, which collectively represent the leading contributor to disability globally.

That insight matters because physical function rarely changes without signals. Pain may be the most obvious warning, but stiffness, fatigue, reduced mobility, and declining performance can also indicate that the body is struggling to meet its demands. For people who exercise, compete, or perform at high levels, those changes can be especially easy to rationalize. The temptation is often to train through them, hoping that greater effort will restore what has changed.

A systematic review conducted to inform the World Health Organization’s guidelines on physical activity and sedentary behavior analyzed 116 randomized controlled trials involving more than 25,000 adults aged 60 and older living in the community. The review found that exercise reduced the rate of falls by 23 percent, with balance and functional exercise producing a 24 percent reduction. Programs combining multiple forms of exercise, commonly balance, functional, and resistance training, were also associated with fewer falls. 

The evidence extends beyond falls themselves. Another systematic review and meta-analysis of 25 randomized controlled trials published in the National Library of Medicine involving more than 7,000 older adults found that exercise significantly reduced the risk of fall-related injuries, including injuries requiring medical care and fractures. Together, these findings illustrate the value of building and maintaining physical capacity before a loss of function becomes consequential. They also reinforce a central question for physical therapy: what might change if people sought professional guidance while their movement, strength, and balance were still manageable rather than waiting until an injury forces the issue? 

For Tracy Karas, founder of Better Fit Therapy, that question sits at the center of how physical therapy can serve people across the lifespan. Karas believes the profession has a valuable role to play in identifying physical warning signs, maintaining function, and helping individuals prepare for the activities they value. She argues that people frequently dismiss the body’s early signals because they appear manageable.

“The body rarely waits until an injury becomes severe before communicating that something is wrong,” Karas says. “Pain, stiffness, fatigue, and declining performance can all be signals that deserve attention. The earlier we respond, the more opportunity we have to address the problem before it reshapes how a person moves.”

Karas sees a recurring pattern in people who continue exercising after something feels wrong. A person may experience pain during an exercise, move around until it subsides and decide the problem has passed. Someone else may notice increasing fatigue or a gradual decline in performance and respond by training harder. “When performance begins to decline, the answer is not automatically to demand more from the body,” she says. “Sometimes declining performance is the body’s way of revealing that it is fatigued, compensating for an injury or operating beyond its current capacity.”

That distinction often becomes particularly important because the body may adapt around an injury. A person who experiences pain in one area may unconsciously change how they walk, train, or perform an activity. The initial discomfort could fade while the altered movement pattern remains. Karas says that when people wait until the problem becomes severe, physical therapists may have to address both the original injury and the compensations that developed afterward.

She recalls one patient who broke her foot and decided against physical therapy. Karas had encouraged her to begin care so she could return to her activities more effectively, but the patient chose to resume her routine independently. Roughly a year later, Karas notes that the patient contacted her saying, “I am broken everywhere.”

According to Karas, the patient was experiencing pain and difficulty walking and could no longer comfortably perform ordinary activities. She says the experience illustrated how an untreated injury can evolve into a much broader functional problem. 

“An injury does not always remain confined to the place where it began,” Karas says. “When someone changes the way they move to protect an injured area, the body can gradually build an entirely different pattern around that original problem. By the time they seek care, we may be treating the injury and the adaptations that developed because it was ignored.”

For her, maintenance physical therapy is a form of preparation rather than an admission that something has gone wrong. “The purpose of maintenance care is to keep people capable of doing what they value,” she says. “Prevention should be about preserving performance and function, not restricting the life a person wants to live.”

The same principle can often apply later in life. The CDC recommends that adults 65 and older include aerobic activity, muscle strengthening, and balance activities in their weekly routines, reflecting the importance of preserving physical capacity as people age. “Older adults deserve an activity plan that recognizes their whole person,” Karas says. “Exercise becomes considerably more meaningful when it is informed by someone’s medical history, movement patterns, and individual goals. The objective is to preserve the ability to live independently and continue participating in the activities that give life meaning.”

Karas believes many people simply do not understand the scope of a physical therapist’s role. “The public perception of physical therapy has been shaped largely by what happens after an injury,” Karas says. “If people understand PT only as a place they go when something is already wrong, they miss the profession’s broader role in preserving movement, function, and physical capacity.”

Her preferred model places the individual and their goals at the center of the relationship. She sees the therapist as a professional partner who can help people understand their physical capacity and make informed decisions about how they train, recover, and remain active.

“The most valuable intervention is often the one that preserves someone’s ability to move before that ability is compromised,” Karas says. “The work we do today can determine how easily a person moves, performs, and lives tomorrow.”