Exercise & Osteoarthritis

Osteoarthritis, the most typical condition people refer to with the term “arthritis,” is among the most common of orthopedic conditions experienced.

Prevalence of this condition has nearly doubled in the last 30 years, and it is projected to be about 75-95% by 2050.

Similarly, the amount of joint replacements done are projected to increase by 71-85% by 2030.

With that said, the relationship between exercise and osteoarthritis remains relatively misunderstood.

This is true of the general population as well as many healthcare providers, unfortunately.

Thus, the aim of this article is to provide you with an up-to-date on the evidence regarding exercise’s effect on osteoarthritis.

Changes in our understanding of osteoarthritis

The first thing to note is that our understanding of this condition has undergone a dramatic change in recent years.

There are a few points to cover in line with this.

Historically, osteoarthritis has been characterized as a disease of “wear-and-tear.”

In other words, your joints experience small amounts of damage throughout your life, leading to degeneration over time.

Oftentimes, the metaphor “the body is like a car” is used here.

Here’s the problem: the body is nothing like a car at all.

This viewpoint completely ignores the dynamic, adaptive nature of our bodies and joints.

Broadly speaking, osteoarthritis is less-and-less being viewed as a biomechanical problem and more so as a metabolic problem.

Said differently, osteoarthritis is not a local problem isolated to the joint. It is a systemic, whole-body problem with a local presentation.

There’s a few examples of why this is.

Pharmacologically, all drugs that have been created to be “specific” for osteoarthritis have yielded poor outcomes.

Conversely, drugs that address general metabolic health tend to produce good results in osteoarthritic conditions.

For instance, metformin is a medicine used to manage blood glucose in the context of diabetes. However, it tends to greatly reduce symptoms of osteoarthritis as well as slow its progression.

Similarly, liriglutide is a GLP-1RA, one of the weight-loss drugs now on the market. It is meant to treat obesity, but it is also very effective in the management of osteoarthritis.

To reiterate:

• Medicines that are meant to be specific for osteoarthritis have failed to be effective

• Medicines that are used to treat a person’s general metabolic health tend to be very effective in treating osteoarthritis

Fiber intake provides another good example to drive this home.

Eating sufficient fiber on a daily basis is one of the most beneficial nutrition habits you can practice; with this habit reducing your risk of experiencing damn-near every chronic disease there is.

In other words, in regard to all the nutrition targets you can aim for, eating enough fiber will improve your metabolic health more than anything else; most likely.

Consistent with our previous discussion, sufficient fiber intakes have been shown to greatly reduce your risk of developing osteoarthritis.

Again, this is not because fiber is doing anything specific to your joints. It’s because fiber contributes to improving your metabolic health, which in turn enables your joints to be in better health. 

So, how does all of this relate to exercise?

Because a similar trend emerges.

Treating knee osteoarthritis solely with exercises to strengthen the muscles around the knee tends to yield… questionable results (the same would apply for other joints, too, of course).

However, if you treat the human with osteoarthritis with a comprehensive training program that develops real fitness adaptations, then you can see good results.

It’s likely that adopting a comprehensive and complete exercise training routine is the single most effective lifestyle habit you can engage in for improving your health. The remainder of this article will address how this relates to osteoarthritis.

Cycling and osteoarthritis

Most people assume cycling is "easy on the joints" simply because it's low-impact. That's true, but it undersells what's actually happening.

A 2024 study from the Osteoarthritis Initiative followed over 2,600 adults and found that people with any history of cycling had a 21% lower risk of symptomatic knee osteoarthritis compared to non-cyclists. That's the combination of both structural damage on x-ray and frequent knee pain, the outcome that actually matters for quality of life.

The more interesting finding was the dose-response relationship.

People who cycled during just one period of their life (say, only as teenagers) saw some benefit. However, those who maintained cycling across all four life stages the researchers tracked had a 43% lower risk of symptomatic osteoarthritis.

In other words, the more cycling that was done, the greater the benefit.

Now, there are plenty of local adaptations that occur in the knees from cycling. Arguably, though, this is not what was the primary driver of the reduction of risk of osteoarthritis from cycling.

Rather, improving aerobic (cardiovascular) fitness is one of the most potent means to improve your general metabolic health.

The better your metabolic health is, the healthier your joints are likely to remain throughout your life.

It’s worth noting: this wasn't a study of competitive cyclists logging massive miles.

The threshold for being classified as a "cyclist" was participating in the activity at least 20 minutes per session, at least 10 times during a given life period.

That's perfectly accessible for most people.

Running and osteoarthritis

Running is perhaps the most feared activity when it comes to joint health. The assumption is intuitive: all that repetitive impact must be grinding down your cartilage over time.

Except the data tells a very different story.

A 2017 meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy pooled data from 25 studies involving over 125,000 individuals. The researchers compared osteoarthritis rates across three groups: competitive runners, recreational runners, and sedentary controls.

The studies included in this review used varying definitions for what constituted a competitive vs recreational runner.

A safe, generalized definition would be to view competitive runners as those seeking to run at the professional level (or close to) and to view recreational runners as those running for general health & fitness purposes.

Recreational runners had an osteoarthritis prevalence of just 3.5%. Sedentary individuals were 10.2%. And competitive runners came in at 13.3%.

So the people doing no running had nearly three times the rate of hip and knee osteoarthritis as those running recreationally. Meanwhile, elite-level running did appear to carry some increased risk, though even that was only modestly higher than being sedentary.

When the researchers calculated odds ratios, recreational runners showed a lower association with osteoarthritis compared to non-runners. For knee osteoarthritis specifically, recreational running was associated with 17% lower odds compared to controls.

There is another important lesson to be found in the finding that competitive runners have the highest rate of osteoarthritis among the three groups.

It is almost never the case that any exercise is inherently dangerous or bad for you.

Rather, it is only incorrect dosing of an exercise that makes it good or bad for you. Furthermore, what constitutes an appropriate “dose” is different depending on the exercise at hand; which is seen in the difference between running and cycling for osteoarthritis.

The biological explanation fits with what we discussed earlier about osteoarthritis being a metabolic condition. Running is one of the most potent metabolic interventions available.

It improves insulin sensitivity, reduces systemic inflammation, and enhances cardiovascular function. All of these factors likely contribute to joint health in ways that have nothing to do with "protecting" the cartilage from impact.

In fact, cartilage needs loading to stay healthy. It's avascular, meaning it has no direct blood supply. Nutrients reach cartilage cells through compression and decompression cycles, essentially squeezing fluid in and out like a sponge.

Running provides exactly this stimulus.

Resistance training (lifting weights) and osteoarthritis

A 2024 study published in Arthritis & Rheumatology analyzed over 2,600 participants from the Osteoarthritis Initiative, tracking their lifetime history of strength training against knee outcomes.

People with any history of strength training had 17-23% lower odds of frequent knee pain, radiographic osteoarthritis, and symptomatic osteoarthritis compared to those who never lifted.

Again, there was a dose-response relationship.

Those who lifted the most showed a 30% reduction in radiographic osteoarthritis and a 31% reduction in symptomatic disease.

The trend held across all three outcomes: more strength training, better knee health.

What's particularly note-worthy is that these benefits persisted even after adjusting for prior knee injuries.

You might expect people who've hurt their knees to be more likely to take up strength training as rehabilitation, which would bias results toward strength training appearing harmful.

Instead, even accounting for this, the protective association strengthened.

The mechanism likely involves several pathways beyond simply building muscle around the joint.

Stronger muscles improve coordination and joint stability, reducing awkward movement patterns that stress cartilage.

Resistance training also enhances bone density, which matters because the bone underneath cartilage directly influences cartilage health.

But there's another layer to this story that fits with our earlier discussion of osteoarthritis as a metabolic condition.

Your muscles aren't just passive tissue that moves your bones around. They're actually an endocrine organ, capable of producing and releasing hormones into your bloodstream. These muscle-derived hormones are called "myokines," and exercise triggers their release.

Your muscles release dozens of these signaling molecules. Some reduce inflammation throughout your body. Others improve how your cells respond to insulin. Still, others help regulate body fat and support the health of other organs, including your brain.

This helps explain why resistance training benefits extend far beyond the muscles you're actually training. As your muscles grow, this beneficial signal grows, improving metabolic health in ways that ultimately protect your joints.

Consistent with this, resistance training substantially improves insulin sensitivity, reduces inflammation throughout the body, and promotes healthier body composition.

These aren't just nice side effects. For a condition increasingly understood as metabolic in nature, they may be central to how strength training protects against osteoarthritis.

Now, what about people who already have osteoarthritis?

A 2024 meta-analysis in the Journal of Personalized Medicine pooled 27 randomized controlled trials involving over 1,700 participants with existing knee or hip osteoarthritis. Resistance training produced moderate improvements across all three primary outcomes: pain, strength, and function.

The improvements weren't small. Pain, strength, and function all showed meaningful changes that would actually make a difference in someone's daily life.

One finding deserves particular attention. When researchers broke down results by how long people trained, pain and strength improved even with programs lasting four weeks or less.

However, functional improvements required longer commitment, at least five weeks before significant gains appeared.

This makes intuitive sense. Strength gains from your nervous system learning to recruit muscle happen quickly.

Pain reduction likely follows from a combination of those neural changes plus the psychological benefits of engaging in structured activity.

But translating strength into real world function, like walking faster or climbing stairs more easily, takes time for movement patterns to reorganize.

The most reassuring finding involves how consistent the results were across different studies.

For strength outcomes, the consistency was nearly perfect. This means regardless of the specific training approach (aquatic resistance, machines, free weights, or different contraction types) the benefits held.

Both knee and hip osteoarthritis responded similarly to resistance training. Given that hip osteoarthritis research remains relatively limited compared to knee studies, this consistency is encouraging for anyone dealing with hip symptoms.

Using exercise to reduce risk of osteoarthritis

I could go on and on providing examples of how different types of exercise benefit and/or reduce risk of osteoarthritis.

For instance, swimming shows a very similar trend to all that has been discussed here thus far.

Heck, even gardening has favorable outcomes. I wouldn’t necessarily call gardening the best choice for eliciting adaptations, but the point stands nonetheless.

With all of this said, though, there’s an overarching point that is worth driving home.

It is not the case that any one form of exercise is going to be best for the purpose of reducing risk of osteoarthritis.

Rather, to maximally benefit in this pursuit, you should pursue all aspects of fitness.

In other words, you should not JUST seek to improve your strength nor should you JUST seek to improve your cardiovascular fitness.

You should do it all; ideally with a structured, long-term approach.

It’s worth adding that this idea, that a multidisciplinary approach to fitness is better for health than a singular approach, is not isolated to osteoarthritis.

It is also the case for cardiovascular disease, diabetes risk, and just about every other disease you can think of.

Exercising with osteoarthritis

Osteoarthritis will affect everyone slightly differently.

The specific movements that are troublesome or joint positions that are painful will not be the same person to person.

Moreover, the symptoms one experiences will not correspond to what you see on an x-ray.

For instance, in many of the studies mentioned thus far, a distinction is made between radiographic osteoarthritis and symptomatic osteoarthritis.

That is, radiographic osteoarthritis is what you see on an x-ray and symptomatic osteoarthritis is what a person actually experiences.

The point is: these are different things. People can have radiographic osteoarthritis and have zero symptoms. They can have “horrible” radiographic osteoarthritis but very mild symptomatic osteoarthritis.

Most notably: a person can have a progression of their radiographic osteoarthritis but a decrease in their symptomatic osteoarthritis. In other words, their x-ray might look worse but their pain & function might have improved.

So, here’s the bottom line: there’s no cookie cutter exercise prescription that’s going to be best practice for everyone.

Instead the following guidelines will be of more use:

• Work to structure an exercise program that is broad, not singular, in the adaptations it elicits (e.g. pursue cardio and strength; not one or the other).

• Base your selection of exercises on what you enjoy. Nothing else matters if you don’t stick to it. This isn’t a “one-and-done” sort of thing. It’s a “for-the-rest-of-your-life” thing.

• Regress all exercises to a point to where they are tolerable.

• If full range of motion squats are painful, then only do quarter squats.

• If training close to failure (the point at which you can’t do any more reps) is painful, then stop 3-5 reps shy of failure.

• If deadlifts with any weight are painful, then just do reps of touching your toes (e.g deadlifts with no weight)

• If running is painful, try incline walking or fast walking on level ground.

• If anything on two legs is painful, consider cycling.

• If anything at all is painful, then simply repeatedly flex your muscles (seriously).

• Then, once you find an appropriate starting point for you, progress as either your symptoms or fitness allows (whichever is the limiting factor).

Here’s the deal: it does not matter how low you regress an exercise. You may need to regress an exercise so low it feels pointless to do.

However, I can assure you that doing so is as far from pointless as possible: it may be the thing that allows you to eventually do the higher level activity.

In other words, if you don’t regress to what you can tolerate and then actually do it, you may find yourself stuck and unable to move forward.

Understand: something is always better than nothing; no matter what that something is.

Finally, let me add that exercise alone may not be the miracle thing that fixes your osteoarthritis, even when done right.

It is most certainly one of, if not THE, most important things you can do.

However, a more holistic approach may be more effective.

In other words, it is worth not discounting the effect that other lifestyle interventions (nutrition, sleep, stress management, etc.) as well as medical interventions can have on your long-term outcomes.

If you had to pick one place to start, though, exercise is probably your best bet.

As always, if you want help figuring out how to do all of this the right way for you, consider inquiring about 1:1 coaching.

References

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