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Staying Active for Joint Health

Why physical activity protects joints and tendons, how exercise helps osteoarthritis and recovery, and how to stay active safely.

72 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Current international guidelines establish that any bout of physical activity contributes to health, with the 2018 US guidelines specifically recognizing this principle [1]. The 2020 WHO guidelines on physical activity and sedentary behaviour update previous recommendations from 2010 [4]. In children and adolescents aged 6-17, participation in moderate to vigorous physical activities leads to multiple positive health outcomes [2]. Evidence indicates that physical activity is associated with little significant harm, and the benefits generally outweigh the risks [3]. However, randomized controlled trials have failed to provide conclusive evidence that physical activity causes a reduced risk of death [13]. Furthermore, individuals not achieving the WHO guideline for physical activity showed an elevated risk of cancer, even if they were abdominally lean (HR 1.04, 95% CI 1.01 to 1.07) [38]. There may be no minimal or maximal threshold for the benefits of accelerometer-measured intensity-specific physical activity regarding incident type 2 diabetes [18].

Implementation of physical activity promotion faces challenges in surveillance and education. Changes to physical activity guidelines, such as the removal of a 10-min bout criterion, pose challenges for physical activity surveillance [27]. There is widespread omission of basic teaching elements, such as the Chief Medical Officer recommendations and guidance on physical activity, in the undergraduate curricula of all UK medical schools [72]. Policymakers should introduce physical activity promotion into the Quality and Outcomes Framework (QOF) as an individual indicator at a cost of approximately £1 million [5]. ISPAH's Eight Investments That Work for Physical Activity provides a summary of eight areas for action that are supported by scientific evidence and have worldwide applicability [8]. Researchers need to prevent a '24-hour Babel' by coming to agreement about how to collectively define physical activity, sedentary behaviour, and sleep through an inclusive and systematic consensus process [15].

Interventions aimed at maintaining activity show variable but promising results. Maintenance interventions may help people continue to be physically active and improve physical function and health-related quality of life [6]. Brief interventions to increase physical activity appear to be cost-effective on the whole, although there is notable variation between studies [17]. In the Allez Hop programme, the proportion of participants meeting the health-enhancing physical activity (HEPA) recommendations increased from 33.1% to 42.3% between baseline and first follow-up [12]. In the Workplace Challenge programme, at follow-up, 65.0% of inactive participants were taking part in sport and 85.6% were meeting recommended moderate to vigorous physical activity guidelines [39]. Consensus was reached in 46/49 (94%) statements regarding clinical and exercise professionals’ opinion of physical activity prescreening and contraindications for participating in postpartum physical activity [73]. Traditional Chinese medicine comprehensive therapy for exercise-related musculoskeletal injuries suggests potential benefits, though randomized controlled trials are needed for definitive efficacy assessment [36]. Findings question whether total hip arthroplasty should be prioritized only for those patients who have severe hip osteoarthritis symptoms, but require confirmation in a trial [24]. Most differences in functional outcomes for patients with hand, wrist, or elbow disorders following a scapular exercise program did not reach the minimum threshold to be considered clinically important [71]. About 15 times more physical activity of at least moderate intensity is needed to achieve similar results regarding the joint association of device-measured physical activity and abdominal obesity with incident cardiovascular disease [7].

How It Works

The 2018 US physical activity guidelines recognize that any bouts of physical activity count for health [1]. In children and adolescents aged 6-17, participating in moderate to vigorous physical activities leads to multiple positive health outcomes [2]. A consensus statement presents the accord on the effects of physical activity on children’s and youth’s fitness, health, cognitive functioning, engagement, motivation, psychological well-being, and social inclusion [47]. There is little evidence that physical activity is associated with significant harm, and the benefits generally outweigh the risks [3].

Inverse non-linear dose–response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults [9]. Light-intensity physical activity accounts for the majority of physical activity energy expenditure (51–59%) and is an accessible public health target [10]. Approximately 15 times more physical activity of at least moderate intensity is needed to achieve similar results regarding the joint association of device-measured physical activity and abdominal obesity with incident cardiovascular disease [7]. The highly interconnected role of cardiorespiratory fitness in the association between physical activity and cardiometabolic health suggests limited direct effects of physical activity on cardiometabolic health beyond its impact on cardiorespiratory fitness [45].

Sustained physical activity in older age is associated with improved overall health [11]. Much of the evidence regarding physical activity and ageing is based on longitudinal associations from observational and randomised controlled intervention studies in relatively healthy community-dwelling older adults [14]. A coaching intervention to enhance physical activity and prevent falls in community-dwelling people aged 60+ years improved daily steps, moderate-to-vigorous physical activity, hours per week of walking, overall well-being, quality of life, and disability [31]. In the Allez Hop programme, the proportion of participants meeting the health-enhancing physical activity recommendations increased from 33.1% to 42.3% between baseline and first follow-up [12].

Relative to no aerobic activity, 10–149, 150–300, 301–600, and >600 min/week of leisure-time physical activity were associated with a lower risk of mortality from influenza and pneumonia by 21%, 41%, 50%, and 41%, respectively [49]. About 30-40 min of moderate-to-vigorous physical activity per day attenuate the association between sedentary time and risk of death, which is lower than previous estimates from self-reported data [44]. The joint association between daily time spent in physical activity, sedentary behaviour, and sleep and all-cause mortality was examined using compositional analysis [25]. Acknowledging the possibility that not all daily metabolic equivalent task units are the same is an important step towards realising the full potential of bodily movement for promoting health [41].

Exercise may improve pain and function in knee osteoarthritis with low to moderate certainty, but it is uncertain whether differences are clinically important [30]. Aquatic exercise appears to provide meaningful pain relief for musculoskeletal disorders, with benefits that may persist during follow-up [29]. The addition of wearable activity tracker use did not have any effect on perceived joint function or health-related quality of life in people with hip and knee osteoarthritis [28]. Pain is modulated by many factors, and the relationship between pain and tissue becomes less predictable the longer pain persists [51]. Pain science education may act as a mechanism of action for exercise interventions and is less successful when delivered standalone [42].

Exercise interventions implemented at ≤12 weeks after total knee arthroplasty primarily improved functional performance, whereas those lasting >12 weeks resulted in greater gains in muscle strength and joint flexibility [22]. Findings from a secondary analysis of propensity matched data question whether total hip arthroplasty should be prioritized only for patients with severe hip osteoarthritis symptoms, but require confirmation in a trial [24]. The absence of a control group in a prospective case series on trigger finger management demonstrates feasibility and short-term clinical improvement but cannot establish superiority over other conservative treatments [34].

Moderate treadmill exercise following an initial period of short-term immobilization has a positive impact on tendon-bone interface healing, whereas prolonged immobilization has a detrimental effect on physical recovery in a murine model [40]. There was no significant difference between early and delayed lengthening exercises for acute hamstring injury regarding reinjury rates within 12 months after return to sport [52].

Suggestions from community football players for improving exercise-training programmes included reducing duration, increasing the range of drills/exercises, and promoting injury prevention benefits [16]. Many coaches are unaware of the benefits of exercise-training programmes and do not deliver them, leading to low compliance and limited success in injury prevention [32]. A consensus statement outlines approaches that may identify determinants and modifiers of cardiorespiratory fitness exercise response and recommends future research to better understand exercise response variability [21]. The ProPASS consortium aims to bring together existing and future observational studies of thigh-worn accelerometry to produce evidence on the associations of physical activity, sitting, and sleep with long-term health outcomes and longevity [20]. Researchers need to come to agreement about how to collectively define physical activity, sedentary behaviour, and sleep through an inclusive and systematic consensus process [15].

What the Evidence Shows

General Health and Mortality

The 2018 US physical activity guidelines recognise that any bouts of physical activity count for health [1]. However, randomised controlled trials have failed to provide conclusive evidence that physical activity causes a reduced risk of death [13]. Exercise therapy is not associated with an increased risk of non-serious adverse events (risk ratio 0.96) and appears to reduce the risk of serious adverse events such as hospitalisation and pneumonia (risk ratio 0.62) [62]. Physical activity is associated with a decreased risk of all-cause dementia (pooled relative risk 0.80, 95% CI 0.77 to 0.84), Alzheimer’s disease (0.86, 95% CI 0.80 to 0.93) and vascular dementia (0.79, 95% CI 0.66 to 0.95) [75]. Compared with obesity-low physical activity, there was no survival benefit of being normal weight if physical activity levels were low [55].

Specific Joint and Musculoskeletal Conditions

Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence [33]. Exercise therapy is effective for some adolescents with patellofemoral pain but not all, and adherence to exercises is a challenge [59]. Those doing home exercises three times per week or more are four times more likely to be recovered after 12 months for patellofemoral pain [59]. Future research should focus on optimizing current exercise regimens for people with knee osteoarthritis and exploring how to improve adherence while minimizing symptom exacerbation by other exercise modalities [65].

Interventions, Adherence, and Implementation

Brief advice in primary care is a cost-effective way to improve physical activity among adults, provided short-term mental health gains are considered [35]. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective [23]. Despite scientific evidence, many coaches are unaware of the benefits of exercise training programmes and do not deliver them, leading to low compliance and limited success in injury prevention [32]. To realise the greatest effects in reducing musculoskeletal injury and concussion risk in schoolboy rugby players, players should complete the pre-activity movement control exercise programme at least three times per week [63].

Physical activity interventions that combine self-monitoring with other components provide an additional modest yet sustained increase in step count compared with self-monitoring alone [60]. There was no significant effect of an augmented exercise referral scheme using web-based behavioural support on weekly moderate-to-vigorous physical activity at 12 months between the groups [54]. Treatment groups using Web 2.0 applications differed significantly in trajectories of minutes/day of physical activity, with a greater change at 3 months for Web 2.0 than Web 1.0 (7.3 min/day, 95% CI 2.4 to 12.3) [58]. A school-based intervention resulted in a significant group-by-time interaction for mean minutes of moderate-to-vigorous physical activity per day in favour of the intervention group (adjusted difference between groups at follow-up=3.85 min, 95% CI (0.79 to 6.91), p≤0.01) [53]. Teachers at intervention schools recorded a greater increase in weekly minutes of physical activity implemented than teachers assigned to the control schools by approximately 44.2 min (95% CI 32.8 to 55.7) from baseline to 12-month follow-up [61].

At follow-up, 65.0% of inactive participants in a Workplace Challenge were taking part in sport and 85.6% were meeting recommended moderate-to-vigorous physical activity guidelines [39]. Results from a formal 2-year cluster randomised-controlled trial confirmed that the Youth-Physical Activity Towards Health programme was effective in improving youth fundamental movement skills proficiency [56]. At 18 months, a multi-strategy intervention had effects on children’s weekday sedentary behaviour (−27 min) for the physical activity intervention, and on children’s average day physical activity (5.5 min) for the sedentary behaviour intervention [67].

Methodology and Definitions

Approximately 65 min per day of walking and 5 min of stair climbing were each linked to a more favourable cardiometabolic profile, while the adverse effects of sitting became pronounced above 12 hours per day [37]. The modest volume of the prospective epidemiological evidence base and the moderate consistency between observational and laboratory evidence inhibits definitive conclusions regarding light-intensity physical activity and adult cardiometabolic health and mortality [74]. There may be no minimal or maximal threshold for the benefits of physical activity on incident type 2 diabetes [18].

Practical Considerations

Guidelines and Surveillance

The 2018 US physical activity guidelines recognise that any bouts of physical activity count for health [1]. Changes to these guidelines, such as the removal of a 10-min bout criterion, pose challenges for physical activity surveillance [27]. Communication to raise awareness and knowledge of the physical activity guidelines must be supported by policies, environments, and opportunities for physical activity [43]. Policymakers are proposed to introduce physical activity promotion into the Quality and Outcomes Framework (QOF) as an individual indicator at a cost of approximately £1 million [5]. Broad-based application of the framework for driving physical activity policy will aid in moving from isolated interventions to sustainable, population-wide gains in physical activity [46].

Measurement and Research Methodology

The costs and benefits of harmonising existing questionnaires should be considered, along with the potential introduction of device-based measures for measuring physical activity and sedentary behaviour in the UK [48]. Much of the evidence regarding physical activity and ageing is based on longitudinal associations from observational and randomised controlled intervention studies, as well as quantitative and qualitative social studies in relatively healthy community-dwelling older adults [14]. Lessons learnt and recommendations for future research have been summarised as 'roadmaps' to encourage moving the field of physical activity towards achieving population-level impact globally [19]. The FIMS 2019 consensus statement on sport and exercise genomics should regularly be updated on the basis of new information emerging from sport and exercise medicine and genomics of health and disease [26].

Clinical Outcomes and Disease Associations

Consistently and increasingly active individuals had around 20–40% lower risk of all-cause mortality and 30–40% lower risk of cardiovascular disease mortality [50]. Approximately 15 times more physical activity of at least moderate intensity is needed to achieve similar results regarding the joint associations of device-measured physical activity and abdominal obesity with incident cardiovascular disease [7]. In cancer survivors, adhering to physical activity guidelines (150–300 min per week) was associated with 23% lower risk of incident cardiovascular disease compared with those with the lowest physical activity duration (0–75 min per week) [68]. Surpassing physical activity guidelines (≥300 min per week) was associated with 37% lower risk of incident cardiovascular disease in cancer survivors compared with those with the lowest physical activity duration (0–75 min per week) [68].

Patient Engagement and Education

Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term for the management of chronic musculoskeletal pain, with moderate quality of evidence [33]. Infographics for exercise for intermittent claudication aim to encourage patients to make exercising a regular habit by highlighting potential benefits and providing clear guidelines and safety messages [57]. Suggestions from community football players for improving exercise-training programmes included reducing duration, increasing the range of drills/exercises, and promoting injury prevention and other benefits [16].

Population Health and Paediatric Activity

School-age children spend 7–8 hours a day being sedentary [69]. Only 33% of boys and 21% of girls aged 4–15 years in England meet the minimum levels of physical activity for basic health benefits [69].

Key Evidence

  • [L5] The 2018 US PA guidelines opened new horizons for PA and exercise medicine practice by recognising that any bouts of PA count for health. [1] (10.1136/bjsports-2018-100397)
  • [Paper] The panel agreed on 10 major themes with strong scientific evidence that, in children and adolescents aged 6-17, participating in moderate to vigorous physical activities led to multiple positive health outcomes. [2] (10.1136/bjsports-2020-102261)
  • [L5] There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks. [3] (10.1136/bjsports-2021-104634)
  • [Paper] These 2020 WHO guidelines update previous WHO recommendations released in 2010. [4] (10.1136/bjsports-2020-102955)
  • [L5] The authors propose that policymakers should introduce physical activity promotion into the Quality and Outcomes Framework (QOF) as an individual indicator at a cost of approximately £1 million. [5] (10.1136/bjsm.2010.073726)
  • [L1] Maintenance interventions may help people continue to be physically active and improve physical function and health-related quality of life. [6] (10.1136/bjsports-2025-110444)
  • [L3] About 15 times more physical activity of at least moderate intensity is needed to achieve similar results. [7] (10.1136/bjsports-2023-107252)
  • [Paper] ISPAH's Eight Investments That Work for Physical Activity provides a summary of eight areas for action that are supported by scientific evidence and have worldwide applicability. [8] (10.1136/bjsports-2020-103635)
  • [L1] Inverse non-linear dose–response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults. [9] (10.1136/bjsports-2022-105669)
  • [L5] LPA is an accessible public health target and a potentially valuable complement to existing PA guidelines, as it accounts for the majority of PA energy expenditure (51–59%). [10] (10.1136/bjsports-2025-111179)
  • [L3] Sustained physical activity in older age is associated with improved overall health. [11] (10.1136/bjsports-2013-092993)
  • [L4] The proportion of participants meeting the health-enhancing physical activity (HEPA) recommendations increased from 33.1% to 42.3% between baseline and first follow-up. [12] (10.1136/bjsm.2009.070201)
  • [L5] RCTs have failed to provide conclusive evidence that physical activity causes a reduced risk of death. [13] (10.1136/bjsports-2017-098995)
  • [Paper] Much of the evidence presented in the statements is based on longitudinal associations from observational and randomised controlled intervention studies, as well as quantitative and qualitative social studies in relatively healthy community-dwelling older adults. [14] (10.1136/bjsports-2018-100451)
  • [L5] Researchers need to prevent this looming ‘24-hour Babel’ by coming to agreement about how to collectively define PA, SB and sleep through an inclusive and systematic consensus process. [15] (10.1136/bjsports-2021-104487)
  • [L1] Suggestions from players about potential improvements to the training programme and its future implementation included reducing duration, increasing range of drills/exercises and promoting its injury prevention and other benefits to players. [16] (10.1136/bjsports-2013-092816)
  • [L1] Given the commonly accepted thresholds, they appear to be cost-effective on the whole, although there is notable variation between studies. [17] (10.1136/bjsports-2015-094655)
  • [L2] There may be no minimal or maximal threshold for the benefits. [18] (10.1136/bjsports-2022-106653)
  • [Paper] We have summarised lessons learnt and recommendations for future research as 'roadmaps' in progress to encourage moving the field of physical activity towards achieving population-level impact globally. [19] (10.1136/bjsports-2019-101001)
  • [L5] The ProPASS consortium aims to bring together existing and future observational studies of thigh-worn accelerometry to produce evidence on the associations of physical activity, sitting, and sleep with long-term health outcomes and longevity. [20] (10.1136/bjsports-2019-100786)
  • [Paper] The consensus statement outlines approaches that may identify determinants and modifiers of CRF exercise response and recommends future research to better understand exercise response variability. [21] (10.1136/bjsports-2018-100328)
  • [L1] The interventions implemented at ≤12 weeks primarily improved the functional performance, whereas those lasting >12 weeks resulted in greater gains in the muscle strength and joint flexibility. [22] (10.1186/s13018-025-06430-7)
  • [L1] There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. [23] (10.1136/bjsports-2022-105747)
  • [L3] These findings question whether THA should be prioritized only for those patients who have severe hip OA symptoms, but require confirmation in a trial. [24] (10.1016/j.arth.2025.04.032)
  • [L2] The joint association between daily time spent in physical activity, sedentary behaviour and sleep and all-cause mortality was examined using compositional analysis. [25] (10.1136/bjsports-2020-102345)
  • [L5] This guiding reference should regularly be updated on the basis of new information emerging from the area of sport and exercise medicine as well as from the developments and challenges in genomics of health and disease in general in order to best protect the athletes, patients and all other relevant stakeholders. [26] (10.1136/bjsports-2019-101532)
  • [Paper] Changes to the PA guidelines, such as removal of a 10-min bout criterion, pose challenges for PA surveillance. [27] (10.1136/bjsports-2020-102621)
  • [L1] The addition of WAT-use did not have any effect on perceived joint function or HRQoL. [28] (10.1186/s12891-024-08238-8)
  • [L1] AQE appears to provide meaningful pain relief for musculoskeletal disorders, with benefits that may persist during follow-up. [29] (10.1186/s12891-026-09953-0)
  • [L1] Exercise may improve pain and function with low to moderate certainty, but it is uncertain whether differences are clinically important. [30] (10.1097/corr.0000000000003476)
  • [L1] However, this programme improved other physical activity measures (ie, daily steps, MVPA, hours per week of walking), overall well-being, quality of life and disability. [31] (10.1136/bjsports-2023-107027)
  • [L1] The study highlights that despite scientific evidence, many coaches are unaware of the benefits of these programmes and do not deliver them, leading to low compliance and limited success in injury prevention. [32] (10.1136/bjsports-2012-091797)
  • [L1] Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. [33] (10.1136/bjsports-2016-097383)
  • [L4] Because of the absence of a control group, these findings demonstrate feasibility and short-term clinical improvement but cannot establish superiority over other conservative treatments. [34] (10.1016/j.jhsg.2026.101038)
  • [Paper] BA is a cost-effective way to improve PA among adults, provided short-term mental health gains are considered. [35] (10.1136/bjsports-2013-092897)
  • [L4] These findings suggest potential benefits of this treatment approach, though randomized controlled trials are needed for definitive efficacy assessment. [36] (10.1186/s13018-025-05768-2)
  • [L5] The resource also delivered the first pooled analysis exploring physical activity type in relation to cardiometabolic health, showing that approximately 65 min per day of walking and 5 min of stair climbing were each linked to a more favourable cardiometabolic profile, while the adverse effects of sitting became pronounced above 12 hours per day. [37] (10.1136/bjsports-2025-111283)
  • [L2] Similarly, individuals not achieving the WHO guideline for physical activity showed an elevated risk, even if they were abdominally lean (HR 1.04, 95% CI 1.01 to 1.07). [38] (10.1136/bjsports-2024-108708)
  • [Paper] At follow-up, 65.0% of inactive participants were taking part in sport and 85.6% were meeting recommended MVPA guidelines. [39] (10.1136/bjsports-2017-097716)
  • [L5] Moderate treadmill exercise following an initial period of short-term immobilization has a positive impact on tendon-bone interface healing, whereas prolonged immobilization has a detrimental effect on physical recovery. [40] (10.1177/2325967125s00320)
  • [L5] Acknowledging the possibility that not all daily METs are the same in our scientific inquiry is an important step towards realising the full potential of bodily movement for promoting health. [41] (10.1136/bjsports-2017-098693)
  • [L1] PSE may act as a mechanism of action for exercise interventions, and is less successful delivered standalone. [42] (10.1186/s12891-025-09313-4)
  • [Paper] Communication to raise awareness and knowledge of the physical activity guidelines must be supported by policies, environments and opportunities for physical activity. [43] (10.1136/bjsports-2020-102324)
  • [L1] About 30-40 min of MVPA per day attenuate the association between sedentary time and risk of death, which is lower than previous estimates from self- reported data. [44] (10.1136/bjsports-2020-103270)
  • [L4] The highly interconnected role of CRF in the association between PA and cardiometabolic health suggests limited direct effects of PA on cardiometabolic health beyond its impact on CRF. [45] (10.1136/bjsports-2023-107451)
  • [Paper] Broadbased application of this framework will aid in moving from isolated interventions to sustainable, population-wide gains in PA. [46] (10.1136/bjsports-2025-110686)
  • [Paper] The consensus statement presents the accord on the effects of physical activity on children’s and youth’s fitness, health, cognitive functioning, engagement, motivation, psychological well-being and social inclusion, as well as presenting educational and physical activity implementation strategies. [47] (10.1136/bjsports-2016-096325)
  • [Paper] We recommend that the costs and benefits of harmonising the existing questionnaires are considered, along with the potential introduction of device-based measures. [48] (10.1136/bjsports-2018-100355)
  • [L3] Relative to no aerobic activity, 10–149, 150–300, 301–600 and >600 min/week were associated with lower risk (by 21%, 41%, 50% and 41%). [49] (10.1136/bjsports-2022-106644)
  • [L1] Consistently and increasingly active individuals had around 20–40% lower risk of all-cause mortality and 30-40% lower risk of CVD mortality. [50] (10.1136/bjsports-2024-109122)
  • [L5] Instead, pain is modulated by many factors, and the relationship between pain and tissue becomes less predictable the longer pain persists. [51] (10.1136/bjsports-2017-098983)
  • [L1] There was no significant difference between groups for reinjury rates within 12 months after return to sport. [52] (10.1136/bjsports-2020-103405)
  • [L1] There was a significant group-by-time interaction for mean minutes of MVPA per day in favour of the intervention group (adjusted difference between groups at follow-up=3.85 min, 95% CI (0.79 to 6.91), p≤0.01), including significantly more vigorous physical activity (2.45 min, p≤0.01), equating to 27 min more MVPA per week. [53] (10.1136/bjsports-2014-094523)
  • [L1] There was no significant effect of the intervention on weekly MVPA at 12 months between the groups recorded in ≥10 min bouts (mean difference 11.8 min of MVPA, 95% CI: −2.1 to 26.0; p=0.10) or without bouts (mean difference 13.7 min of MVPA, 95% CI: −26.8 to 54.2; p=0.51). [54] (10.1136/bjsports-2020-103121)
  • [L2] Compared with obesity-low physical activity, there was no survival benefit of being normal weight if physical activity levels were low. [55] (10.1136/bjsports-2021-104827)
  • [Paper] Results from a formal 2-year cluster randomised-controlled trial confirmed the programme was effective in improving youth FMS proficiency. [56] (10.1136/bjsports-2018-099745)
  • [Paper] The infographic aims to encourage patients to make exercising a regular habit by highlighting potential benefits and providing clear guidelines and safety messages. [57] (10.1136/bjsports-2019-101930)
  • [L1] Treatment groups differed significantly in trajectories of minutes/day of physical activity (p=0.0198), through a greater change at 3 months for Web 2.0 than Web 1.0 (7.3 min/day, 95% CI 2.4 to 12.3). [58] (10.1136/bjsports-2016-096890)
  • [Paper] Exercise therapy is effective for some adolescents but not all, and adherence to exercises is a challenge, with those doing home exercises three times per week or more being four times more likely to be recovered after 12 months. [59] (10.1136/bjsports-2016-096268)
  • [L1] Physical activity interventions that combine self-monitoring with other components provide an additional modest yet sustained increase in step count compared with self-monitoring alone. [60] (10.1136/bjsports-2021-105198)
  • [L1] Teachers at intervention schools recorded a greater increase in weekly minutes of PA implemented than teachers assigned to the control schools by approximately 44.2 min (95% CI 32.8 to 55.7) from baseline to 12-month follow-up. [61] (10.1136/bjsports-2020-103764)
  • [L1] Exercise therapy was not associated with an increased risk of non-serious adverse events (risk ratio 0.96) and appeared to reduce the risk of serious adverse events such as hospitalisation and pneumonia (risk ratio 0.62). [62] (10.1136/bjsports-2021-104367)
  • [L1] To realise the greatest effects, players should complete the programme at least three times per week. [63] (10.1136/bjsports-2016-097434)
  • [L1] Future research should focus on optimizing current exercise regimens for people with knee OA and exploring how to improve adherence while minimizing symptom exacerbation by other exercise modalities. [65] (10.1186/s12891-025-08746-1)
  • [L1] At 18 months, there were intervention effects on children’s weekday SB (−27 min) for the PA intervention, and on children’s average day PA (5.5 min) for the SB intervention. [67] (10.1136/bjsports-2022-105825)
  • [L3] Adhering to PA guidelines (150–300 min per week) and surpassing them (≥300 min per week) were associated with 23% and 37% lower risk of incident CVD, respectively, compared with those with the lowest PA duration (0–75 min per week). [68] (10.1136/bjsports-2024-108734)
  • [L5] It highlights that school-age children spend 7–8 hours a day being sedentary and that only 33% of boys and 21% of girls aged 4–15 years in England meet the minimum levels of physical activity for basic health benefits. [69] (10.1136/bjsports-2013-093018)
  • [L1] However, most of these differences did not reach the minimum threshold to be considered clinically important. [71] (10.1016/j.jht.2024.07.006)
  • [Paper] There is widespread omission of basic teaching elements, such as the Chief Medical Officer recommendations and guidance on PA, which has been endorsed by all four UK Departments of Health. [72] (10.1136/bjsports-2012-091380)
  • [L5] Consensus was reached in 46/49 (94%) statements. [73] (10.1136/bjsports-2024-109104)
  • [L1] Nevertheless, the modest volume of the prospective epidemiological evidence base and the moderate consistency between observational and laboratory evidence inhibits definitive conclusions. [74] (10.1136/bjsports-2017-097563)
  • [L1] PA was associated with a decreased risk of all-cause dementia (pooled relative risk 0.80, 95% CI 0.77 to 0.84), Alzheimer’s disease (0.86, 95% CI 0.80 to 0.93) and vascular dementia (0.79, 95% CI 0.66 to 0.95). [75] (10.1136/bjsports-2021-104981)

See Also

  • Osteoarthritis

References

[1] Short and sporadic bouts in the 2018 US physical activity guidelines: is high-intensity incidental physical activity the new HIIT?. British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2018-100397

[2] Physical activity and health in Chinese children and adolescents: expert consensus statement (2020). British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-102261

[3] Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2021-104634

[4] World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-102955

[5] Physical activity in the UK: a unique crossroad?. British Journal of Sports Medicine. 2010. DOI: 10.1136/bjsm.2010.073726

[6] Effectiveness of maintenance interventions promoting physical activity following exercise therapy for chronic conditions: an umbrella review. British Journal of Sports Medicine. 2026. DOI: 10.1136/bjsports-2025-110444

[7] Joint associations of device-measured physical activity and abdominal obesity with incident cardiovascular disease: a prospective cohort study. British Journal of Sports Medicine. 2023. DOI: 10.1136/bjsports-2023-107252

[8] Infographic. ISPAH’s Eight Investments That Work for Physical Activity: infographic, animation and call to action. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2020-103635

[9] Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose–response meta-analysis of large prospective studies. British Journal of Sports Medicine. 2023. DOI: 10.1136/bjsports-2022-105669

[10] Unlocking the potential of light-intensity physical activity for public health: a call to action for research. British Journal of Sports Medicine. 2026. DOI: 10.1136/bjsports-2025-111179

[11] Taking up physical activity in later life and healthy ageing: the English longitudinal study of ageing. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2013-092993

[12] Allez Hop, a nationwide programme for the promotion of physical activity in Switzerland: what is the evidence for a population impact after one decade of implementation?. British Journal of Sports Medicine. 2010. DOI: 10.1136/bjsm.2009.070201

[13] Physical activity and longevity: how to move closer to causal inference. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2017-098995

[14] Copenhagen Consensus statement 2019: physical activity and ageing. British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2018-100451

[15] Preventing the ‘24-hour Babel’: the need for a consensus on a consistent terminology scheme for physical activity, sedentary behaviour and sleep. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2021-104487

[16] What do community football players think about different exercise-training programmes? Implications for the delivery of lower limb injury prevention programmes. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2013-092816

[17] Are brief interventions to increase physical activity cost-effective? A systematic review. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2015-094655

[18] Accelerometer-measured intensity-specific physical activity, genetic risk and incident type 2 diabetes: a prospective cohort study. British Journal of Sports Medicine. 2023. DOI: 10.1136/bjsports-2022-106653

[19] Towards better evidence-informed global action: lessons learnt from the Lancet series and recent developments in physical activity and public health. British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2019-101001

[20] Emerging collaborative research platforms for the next generation of physical activity, sleep and exercise medicine guidelines: the Prospective Physical Activity, Sitting, and Sleep consortium (ProPASS). British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2019-100786

[21] Precision exercise medicine: understanding exercise response variability. British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2018-100328

[22] Changes in knee outcome measures following later-stage exercise interventions implemented ≤ 12 weeks vs. > 12 weeks after total knee arthroplasty: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06430-7

[23] Economic evaluations of fall prevention exercise programs: a systematic review. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2022-105747

[24] Total Hip Arthroplasty versus Education and Exercise: A Secondary Analysis of Propensity Matched Data Comparing Outcomes Across Hip Osteoarthritis Symptom Severity. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.032

[25] Joint association between accelerometry-measured daily combination of time spent in physical activity, sedentary behaviour and sleep and all-cause mortality: a pooled analysis of six prospective cohorts using compositional analysis. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2020-102345

[26] Sport and exercise genomics: the FIMS 2019 consensus statement update. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2019-101532

[27] How can global physical activity surveillance adapt to evolving physical activity guidelines? Needs, challenges and future directions. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-102621

[28] Effects of self-monitoring physical activity with wearable activity trackers on perceived joint function and health-related quality of life in people with hip and knee osteoarthritis: a secondary analysis of a cluster-randomised clinical trial. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08238-8

[29] The dose-response relationship of aquatic exercise for musculoskeletal pain relief: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09953-0

[30] Cochrane in CORR®: Exercise for Osteoarthritis of the Knee. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003476

[31] Effect of a coaching intervention to enhance physical activity and prevent falls in community-dwelling people aged 60+ years: a cluster randomised controlled trial. British Journal of Sports Medicine. 2024. DOI: 10.1136/bjsports-2023-107027

[32] The reach and adoption of a coach-led exercise training programme in community football. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2012-091797

[33] Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2016-097383

[34] Effectiveness of Proximal Interphalangeal Joint Orthosis and Therapeutic Exercise in the Management of Trigger Finger: A Prospective Case Series. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101038

[35] Is brief advice in primary care a cost-effective way to promote physical activity?. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2013-092897

[36] Clinical study of traditional Chinese medicine comprehensive therapy for Exercise-Related musculoskeletal injuries using musculoskeletal ultrasound observation. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05768-2

[37] Prospective Physical Activity, Sitting and Sleep consortium (ProPASS): addressing methodological and geographical barriers to inform global public health guidelines, interventions and precision medicine. British Journal of Sports Medicine. 2026. DOI: 10.1136/bjsports-2025-111283

[38] WHO guidelines on waist circumference and physical activity and their joint association with cancer risk. British Journal of Sports Medicine. 2025. DOI: 10.1136/bjsports-2024-108708

[39] Bright spots, physical activity investments that work: Workplace Challenge. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2017-097716

[40] Poster 234: Improvement of Tendon-Bone Interface Healing by Moderate Treadmill Exercise Combined with Knee Brace Immobilization Following an Anterior Cruciate Ligament Reconstruction in a Murine Model. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00320

[41] Do all daily metabolic equivalent task units (METs) bring the same health benefits?. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2017-098693

[42] Pain science education and exercise interventions for people with knee or hip osteoarthritis: a systematic review, content and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09313-4

[43] Maximising the impact of global and national physical activity guidelines: the critical role of communication strategies. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-102324

[44] Joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middle-aged and older individuals. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-103270

[45] Fitness-related physical activity intensity explains most of the association between accelerometer data and cardiometabolic health in persons 50–64 years old. British Journal of Sports Medicine. 2024. DOI: 10.1136/bjsports-2023-107451

[46] Driving physical activity policy for improved population health demands political action. British Journal of Sports Medicine. 2025. DOI: 10.1136/bjsports-2025-110686

[47] The Copenhagen Consensus Conference 2016: children, youth, and physical activity in schools and during leisure time. British Journal of Sports Medicine. 2016. DOI: 10.1136/bjsports-2016-096325

[48] How are we measuring physical activity and sedentary behaviour in the four home nations of the UK? A narrative review of current surveillance measures and future directions. British Journal of Sports Medicine. 2019. DOI: 10.1136/bjsports-2018-100355

[49] Leisure-time physical activity and mortality from influenza and pneumonia: a cohort study of 577 909 US adults. British Journal of Sports Medicine. 2023. DOI: 10.1136/bjsports-2022-106644

[50] Physical activity trajectories and accumulation over adulthood and their associations with all-cause and cause-specific mortality: a systematic review and meta-analysis. British Journal of Sports Medicine. 2025. DOI: 10.1136/bjsports-2024-109122

[51] Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2017-098983

[52] Early versus delayed lengthening exercises for acute hamstring injury in male athletes: a randomised controlled clinical trial. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2020-103405

[53] ‘Physical Activity 4 Everyone’ school-based intervention to prevent decline in adolescent physical activity levels: 12 month (mid-intervention) report on a cluster randomised trial. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2014-094523

[54] Randomised controlled trial of an augmented exercise referral scheme using web-based behavioural support for inactive adults with chronic health conditions: the e-coachER trial. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-103121

[55] Device-measured physical activity, adiposity and mortality: a harmonised meta-analysis of eight prospective cohort studies. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2021-104827

[56] Bright spots physical activity investments that work: Youth-Physical Activity Towards Health (Y-PATH). British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2018-099745

[57] Infographic. Exercise for intermittent claudication. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2019-101930

[58] Using Web 2.0 applications to promote health-related physical activity: findings from the WALK 2.0 randomised controlled trial. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2016-096890

[59] 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). British Journal of Sports Medicine. 2016. DOI: 10.1136/bjsports-2016-096268

[60] Do physical activity interventions combining self-monitoring with other components provide an additional benefit compared with self-monitoring alone? A systematic review and meta-analysis. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2021-105198

[61] Multi-strategy intervention increases school implementation and maintenance of a mandatory physical activity policy: outcomes of a cluster randomised controlled trial. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2020-103764

[62] Infographic. Benefits and harms of exercise therapy in people with multimorbidity. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2021-104367

[63] Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2016-097434

[65] Effect of aerobic exercise on cardiopulmonary fitness among people with knee osteoarthritis: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08746-1

[67] Transform-Us! cluster RCT: 18-month and 30-month effects on children’s physical activity, sedentary time and cardiometabolic risk markers. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2022-105825

[68] Wearable device-measured physical activity and incident cardiovascular disease in cancer survivors. British Journal of Sports Medicine. 2025. DOI: 10.1136/bjsports-2024-108734

[69] Is the lack of physical activity strategy for children complicit mass child neglect?. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2013-093018

[71] Effectiveness of a scapular exercise program on functional outcomes in patients with hand, wrist or elbow disorders: A comprehensive systematic review with meta-analysis. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2024.07.006

[72] Physical activity education in the undergraduate curricula of all UK medical schools. Are tomorrow's doctors equipped to follow clinical guidelines?. British Journal of Sports Medicine. 2012. DOI: 10.1136/bjsports-2012-091380

[73] International Delphi study of clinical and exercise professionals’ opinion of physical activity prescreening and contraindications for participating in postpartum physical activity. British Journal of Sports Medicine. 2025. DOI: 10.1136/bjsports-2024-109104

[74] How does light-intensity physical activity associate with adult cardiometabolic health and mortality? Systematic review with meta-analysis of experimental and observational studies. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2017-097563

[75] Physical activity as a protective factor for dementia and Alzheimer’s disease: systematic review, meta-analysis and quality assessment of cohort and case–control studies. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2021-104981

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