Effects of Exercise and Physical Activity on Knee Osteoarthritis


Exercise is one of the most discussed and controversial nonpharmacologic management strategies for osteoarthritis (OA) of the knee. Health care providers and patients share varied and often pseudoscientific beliefs regarding the effects of exercise on knee OA formulated on outdated notions of the etiology, pathophysiology, and progression of the condition. Based on the contemporary literature, regular light to moderate physical activity has both preventive and therapeutic benefits for individuals with knee OA. Exercise regimens with strong evidence of benefit include those that focus on aerobic/cardiovascular conditioning and lower extremity strength training. Health care providers should confidently incorporate exercise recommendations into clinical management and offer patients evidence-based and individually tailored exercise prescriptions to help manage the painful and often disabling symptoms of this condition.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.


    Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

    1. 1.

      Guccione AA, Felson DT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Pub Health. 1994;84(3):351–8.

    2. 2.

      Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991–1994. J Rheumatol. 2006;33(11):2271–9.

    3. 3.

      Public Health and Aging: Trends in Aging --- United States and Worldwide MMWR 2003; 52(06);101–106.

    4. 4.

    5. 5.

      Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–3.

    6. 6.

      • Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis & Rheumatism 2008;59(9):1207–1213. This study highlights the lifetime risk of symptomatic knee OA. Awareness should encourage health care providers to develop preventive strategies and provide early interventions.

    7. 7. Obesity is a primary risk factor for knee OA and a wide range of metabolic/cardiovascular illnesses. Health care providers should be familiar with the prevalence data to better educate patients and facilitate meaningful change.

    8. 8.

      Gabriel SE, Crowson CS, Campion ME, et al. Direct medical costs unique to people with arthritis. J Rheumatol. 1997;24(4):719–25.

    9. 9.

      Maetzel A, Li LC, Pencharz J, Tomlinson F, Bombardier C. The economic burden associated with osteoarthritis, rheumatoid arthritis and hypertension: a comparative study. Ann Rheum Dis. 2004;63(4):395–401.

    10. 10.

      A National Public Health Agenda for Osteoarthritis 2010

    11. 11.

      Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis. Clin Orthoped Rel Res. 2004;427S:S6–S15.

    12. 12.

      Leigh JP, Seavey W, Leistikow B. Estimating the costs of job related arthritis. J Rheumatol. 2001;28(7):1647–54.

    13. 13.

      Guccione AA, Felson DT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Pub Health. 1994;84(3):351–8.

    14. 14.

      Michaud CM, McKenna MT, Begg S, Tomijima N, Majmudar M, Bulzacchelli MT, et al. The burden of disease and injury in the United States 1996. Popul Health Metr. 2006;4:11.

    15. 15.

      Iannone F, Lapadula G. The pathophysiology of osteoarthritis. Aging Clin Exp Res. 1003;15(5):364–72.

    16. 16.

      Pelletier-Martel J, Lajeunesse D. New thoughts on the pathophysiology of osteoarthritis: One more step toward new therapeutic targets. Current Rheumatology Reports. 2006;88(1):30–6.

    17. 17.

      Bonnet CS, Walsh DA. Osteoarthritis, angiogenesis and inflammation. Rheumatology. 2005;44(1):7–16.

    18. 18.

      Cicuttini FM, Baker J, Hart DJ, Spector TD. Association of pain with radiological changes in different compartments and views of the knee joint. Osteoarthritis and Cartilage. 1996;4:143–7.

    19. 19.

      Altman RD, Hochberg MC, Moskowitz RW, et al. Recommendations for the medical management of osteoarthritis of the hip and knee-2000 update. Arthritis Rheum. 2000;43:1905–15.

    20. 20.

      Bosomworth N. Exercise and knee osteoarthritis: benefit or hazard? Canadian Family Physician. 2009;55(9):871–8.

    21. 21.

      Bellucci G, Seedhom BB. Mechanical behavior of articular cartilage under tensile cyclic load. Rheumatology. 2001;40:1337–45.

    22. 22.

      Fukubayashi T, Kurosawa H. The contact area and pressure distribution pattern of the knee. A study of normal and osteoarthritic knee joints. Acta Orthop Scand. 1980;51:871–9.

    23. 23.

      Hall AC, Urban JPG, Gehl KA. The effects of hydrostatic pressure on matrix synthesis in articular cartilage. J Orthop. 1991;9:1–10.

    24. 24.

      Roos EM, Dahlberg L. Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis. Arthritis Rheum. 2005;52(11):3507–14.

    25. 25.

      Kiviranta I, Tammi M. Moderate running exercise augments glycosaminoglycans and thickness of articular cartilage in the knee joint of young beagle dogs. J Orthopaed Res. 1988;6(2):188–95.

    26. 26.

      Otterness IG, Eskra JD, Bliven ML, et al. Exercise protects against articular cartilage degeneration in the hamster. Arthritis Rheum. 1998;41:2068–76.

    27. 27.

      Galois L, Etienne S, Grossin L, et al. Moderate-impact exercise is associated with decreased severity of experimental osteoarthritis in rats. Rheumatology (Oxford). 2003;42:692–3.

    28. 28.

      Hallet M, Andrish JT. Effects of exercise on articular cartilage. Sports Medicine & Arthroscopy Review. 1994;2(1):29–37.

    29. 29.

      Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long term incidence of gonarthrosis. Sports Medicine. 1999;27(3):143–56.

    30. 30.

      • Oiestad BE, Engebretsen, L, Storheim K, Risberg MA. Knee Osteoarthritis After Anterior Cruciate Ligament Injury A Systematic Review Am J Sports Med 2009; 37(7): 1434–1443. This systematic review found that previously reported levels of post–ACL repair knee OA were inaccurate. They report a lower than previously described risk for knee OA after ACL repair.

    31. 31.

      Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheu. 2004;50(10):3145–52.

    32. 32.

      Porat A, Rooa E. High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes. Ann Rheum Dis. 2004;63:269–73.

    33. 33.

      Golightly Y, Callahan L, Guskiewicz K. Early-onset arthritis in retired national football league players. J Phys Act Health. 2009;6:638–43.

    34. 34.

      Kujala UM, Kettunen J, Paananen H, et al. Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Arthritis Rheum. 1995;38(4):539–46.

    35. 35.

      Sandmark H, Vingard E. Sports and risk for severe osteoarthrosis of the knee. Scandinavian J Med Sci Sports. 1999;9(5):279–84.

    36. 36.

      Theilin N, Holmberg S, Thelin A. Knee injuries account for the sports-related increased risk of knee osteoarthritis. Scandinavian J Med Sci Sports. 2006;16(5):329–33.

    37. 37.

      McAlindon TE, Wilson PW, Aliabadi P, et al. Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham Study. Am J Med. 1999;106(2):151–7.

    38. 38.

      Cheng Y, Macera CA, Davis DR, et al. Physical activity and Self-reported, physician-diagnosed osteoarthritis: is physical activity a risk factor? J Epidemiol. 2000;53(3):315–22.

    39. 39.

      Hannan MT, Felson DT, Anderson JJ, Naimark A. Habitual physical activity is not associated with knee osteoarthritis: the Framingham study. J Rheumatol. 1993;20(4):704–9.

    40. 40.

      Manninen P, Riihimaki H, Heliovaara M, Suomalainen O. Physical exercise and risk of severe knee osteoarthritis requiring arthroplasty. Rheumatology. 2001;40(4):432–7.

    41. 41.

      Urquhart D, Tobing J. What is the effect of physical activity on the knee joint? A aystematic review. Medicine & Science in Sports & Exercise. 2001;43(3):432–42.

    42. 42.

      Michel BA, Fries JF, Bloch DA, et al. Osteophytosis of the knee: association with changes in weight-bearing exercise. Clin Rheumatol. 1992;1(2):235–8.

    43. 43.

      •• Chakravarty EF, Hubert HB, Lingala VB, et al. Long Distance Running and Knee Osteoarthritis: A Prospective Study. American Journal of Preventive Medicine 2008; 35(2):133–138. Patients and clinicians frequently presume that weight-bearing activity, especially running, will accelerate or increase knee OA. This study calls into question the accuracy of this presupposition and should prompt readers to reconsider their understanding of the association of knee OA and regular weight-bearing exercise.

    44. 44.

      Whaley M, Brubaker P, Otto R. ACSM’s guidelines for exercise testing and prescription. 7th ed. Baltimore: Lippincott Williams and Wilkins; 2006.

    45. 45.

      • Hagiwara Y, Ando A, Chimoto E, et al. Changes of articular cartilage after immobilization in a rat knee contracture model. Journal of Orthopaedic Research 2009; 27(2):236–242. In a rat model, as little as 1 week of forced joint immobility resulted in altered articular cartilage integrity. These changes highlight potential and incompletely understood risks for knee OA development and progression.

    46. 46.

      Hortobagyi T, Westerkamp L, Beam S, et al. Altered hamstring-quadriceps muscle balance in patients with knee osteoarthritis. Clin Biomech. 2005;20(1):97–104.

    47. 47.

      Shrier I. Muscle dysfunction versus wear and tear as a cause of exercise related osteoarthritis: an epidemiological update. Br J Sports Med. 2004;38:526–35.

    48. 48.

      Brucini M, Duranti R, Galletti R, et al. Pain thresholds and electromyographic features of periarticular muscles in patients with osteoarthritis of the knee. Pain. 1981;10:57–66.

    49. 49.

      Vecchiet L, Vecchiet J, Giamberardino MA. Referred muscle pain: clinical and pathophysiologic aspects. Curr Pain Headache Reports. 1999;3:489–98.

    50. 50.

      Kovar PA, Allegrante JP, MacKenzie CR, et al. Supervised fitness walking in patients with osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 1992;116(7):529–34.

    51. 51.

      Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64:544–8.

    52. 52.

      Brosseau L, Pelland L, et al. Efficacy of Aerobic Exercises For Osteoarthritis (part II): A Meta-analysis Physical Therapy Reviews, 2004; 9(3);125-145(21).

    53. 53.

      Ettinger WH, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. JAMA. 1997;277(1):25–31.

    54. 54.

      Mangione KK, McCully K, Gloviak A, et al. The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci. 1999;54(4):M184–90.

    55. 55.

      Topp R, Woolley S, Hornyak J, et al. The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee. Arch Phys Med Rehabil. 2002;83:1187–95.

    56. 56.

      Jan MH, Lin JJ, Liau JJ, et al. Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther. 2008;88(4):427–36.

    57. 57.

      Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28(7):1655–166.

    58. 58.

      Mikesky AE, Mazzuca SA, Brandt KD, et al. Effects of strength training on the incidence and progression of knee osteoarthritis. Arthritis Care Res. 2006;55(5):690–9.

    59. 59.

      Lange AK, Vanwanseele B, Fiatarone Singh MA. Strength training for treatment of osteoarthritis of the knee: A systematic review. Arthritis Care Res. 2008;59(10):1488–94.

    60. 60.

      Jenkinson CM, Doherty M, Avery AJ, et al. Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: randomised controlled trial. BMJ. 2009;339:b3170.

    61. 61.

      Thomas K, Muir K, et al. Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ. 2002;325:752–5.

    62. 62.

      Slemenda C, Brandt K, et al. Quadriceps weakness and osteoarthritis of the knee. Ann Int Med. 1997;127(2):97–104.

    63. 63.

      Hurley MV, Scott DL. Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime. Rheumatology. 1998;37(11):1181–7.

    64. 64.

      McAlindon TE, Cooper C, Kirwan JR, Dieppe PA. Determinants of disability in osteoarthritis of the knee. Ann Rheum Dis. 1993;52:258–62.

    65. 65.

      Reilly S, Jones A, Muir K, Doherty M. Quadriceps weakness in knee osteoarthritis: the effect on pain and disability. Ann Rheum Dis. 1998;57:588–59460.

    66. 66.

      Sharma L, Dunlop DD, Cahue S, et al. Quadriceps strength and osteoarthritis progression in malaligned and lax knees. Ann Int Med. 2003;138(8):613–9.

    67. 67.

      Silva L, Valim V, et al. Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial Physical Therapy January 2008; 88(1):12–2

    68. 68.

      Foley A, Halbert J, et al. Does hydrotherapy improve strength and physical function in patients with osteoarthritis—a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme. Ann Rheum Dis. 2003;62:1162–7.

    69. 69.

      Lund H and Weile U. A Randomized Controlled Trial of Aquatic and Land-Based Exercise in Patients with Knee Osteoarthritis Journal of Rehabilitation Medicine 2008;40 (2):137-144(8).

    70. 70.

      Bareis E, Lund H, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2007 Oct 17;(4).

    71. 71.

      Myeong SL, Pittler M, Ernst E. Tai chi for osteoarthritis: a systematic review. Clin Rheumatol. 2007;27(2):211–8.

    72. 72.

      Song R, Lee E, Lam P, Bae S. Effects of tai chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: a randomized clinical trial. J Rheumatol. 2003;30(9):2039–44.

    73. 73.

      Wang C, Schmid CH, Hibberd PL, et al. Tai Chi is effective in treating knee osteoarthritis: a randomized controlled trial. Arthritis Care Res. 2009;61(11):1545–53.

    74. 74.

    75. 75.

      Morrison JB. The mechanics of the knee joint in relation to normal walking. J Biomech. 1970;3:51–61.

    76. 76.

      Park H, Park J, Yu R. Relationship of obesity and visceral adiposity with serum concentrations of CRP, TNF-α and IL-6. Diab Res Clin Pract. 2005;69(1):29–35.

    77. 77.

      Cicuttini F, Baker J, Spector T. The Association of obesity with osteoarthritis of the hand and knee in women:a twin study. J Rheumatology. 1996;23:1221–6.

    78. 78.

      Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7):2026–32.

    79. 79.

      Felson D, Zhang Y. Weight loss reduces the risk for symptomatic knee osteoarthritis in women the framingham study. Ann Int Med. 1992;116(7):535–9.

    80. 80.

      Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis and Cartilage. 2005;13(1):20–7.

    81. 81.

      Christensen R, Bartels E, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis. 2007;66:433–9.

    82. 82.

      Peltonen M, Lindroos A, Torgerson J. Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment. PAIN. 2003;104(3):549–57.

    83. 83.

      Powell A, Teichtahl AJ, Wluka AE, Cicuttini FM. Obesity: a preventable risk factor for large joint osteoarthritis which may act through biomechanical factors. Br J Sports Med. 2005;39:4–5.

    84. 84.

      Spector T, Hart D, Doyle D. Incidence and progression of osteoarthritis in women with unilateral knee disease in the general population: the effect of obesity. Ann Rheum Dis. 1994;53(9):565–8.

    85. 85.

      Messier S, Loeser R. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the arthritis, diet, and activity promotion trial. Arthritis Rheum. 2004;50(5):1501–10.

    86. 86.

      Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137–62.

    87. 87.

      Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. The American college of rheumatology criteria for the classification and reporting of osteoarthritis of the knee. Arthritis Rheum. 1986;29:1039–49.

    Download references


    No potential conflicts of interest relevant to this article were reported.

    Author information

    Correspondence to Allison Bailey.

    Rights and permissions

    Reprints and Permissions

    About this article

    Cite this article

    Esser, S., Bailey, A. Effects of Exercise and Physical Activity on Knee Osteoarthritis. Curr Pain Headache Rep 15, 423–430 (2011) doi:10.1007/s11916-011-0225-z

    Download citation


    • Pain
    • Arthritis
    • Knee osteoarthritis
    • Exercise
    • Physical activity
    • Quadriceps strength
    • Weight management
    • Weight loss
    • Diet
    • Traumatic injury
    • Cycling
    • Aerobics
    • Cardiovascular exercise
    • Therapy