Does Exercise Help or Hurt Osteoarthritis? Understanding Pain and Your Joints
If you have osteoarthritis and your knee hurts when you walk, being told to exercise can feel contradictory, misguided, or even insensitive.
In clinic, I regularly hear some version of: “If it hurts when I use it, shouldn't I rest it? I don’t want to make it worse, it already hurts.”
Of course, these are reasonable thoughts. For years, osteoarthritis (OA) was commonly described as “wear and tear,” which creates a pretty convincing mental picture: the joint is wearing out, movement creates more wear, and therefore a logical conclusion might be that the safest thing to do is protect it by using it less. Our understanding of osteoarthritis has changed considerably, however, and you may be surprised to know that exercise is one of the most consistently recommended treatments for OA. The major clinical guidelines recommend therapeutic exercise as a core part of managing OA, and research shows that exercise can improve pain and physical function1–3.
The harder question is what to do when exercise itself hurts.
First, why are we talking about osteoarthritis now?
Arthritis has an enormous impact in Canada. A new Canadian economic analysis, commissioned by Arthritis Society Canada, estimates that 6.1 million Canadians were living with a modelled arthritis condition in 20254. When healthcare costs, lost productivity and broader effects on people's lives were considered, the total economic and social burden was estimated at $142.4 billion in 20254. The report projects that nearly 10 million Canadians could be affected by 20554.
These are enormous numbers, but the impact of arthritis is much easier to see, and in my view more devastating, when you see it up close. Chronic joint pain can change the way people live. I see people become afraid to exercise or worry that they've “overdone it.” Sometimes they begin avoiding activities they love. Their social world gets smaller. They worry about maintaining their independence or being able to care for themselves and the people they love. This is not what I want for anyone and an important reason to get the message about exercise and arthritis out.
Osteoarthritis is more than “wear and tear”
Osteoarthritis, or OA, is the most common form of arthritis1–3. In this article, we're talking specifically about osteoarthritis, rather than other forms of arthritis that can behave quite differently.
OA affects the whole joint. Changes can involve cartilage, bone and other tissues in and around the joint, and the condition is much more complex than cartilage simply being worn away through use2. So, while “wear and tear” is an easy phrase to understand, it isn't a particularly helpful way to think about OA. If we imagine cartilage like the tread on a tire, it makes perfect sense to think that every kilometre we put on it brings us a little closer to wearing it out, but human joints don't work like tires.
Researchers have actually looked at whether exercise causes structural damage in osteoarthritic knees. In a systematic review of nine randomized controlled trials involving 702 participants, Bricca and colleagues found that joint-loading exercise did not appear harmful to articular cartilage in people living with, or at increased risk of, knee OA5. The authors were careful to rate the certainty of the evidence as low, meaning we would benefit from more research in this area 5.
Another systematic review looked specifically at what happens in the knee with long-term exercise. Overall, exercise did not worsen arthritis seen on X-rays or cause further cartilage damage compared with not exercising 6. The researchers did find one possible change on MRI, but the evidence was uncertain and the significance of this finding is not yet clear5,6.
We see a similar picture when we look at arthritis biomarkers. A quick reminder first, however: biomarkers are indirect measures and don't tell us everything we want to know about long-term clinical outcomes. A systematic review examining molecular markers related to cartilage and inflammation also found no evidence that exercise therapy was harmful to knee joints 7.
Taken together, the evidence is reassuring; it does not support the idea that appropriately prescribed exercise wears out an osteoarthritic knee.
If it hurts, doesn't that mean I'm damaging my joint?
This is where things get a little more complicated…
Pain matters. If you are feeling it, it is real, and it deserves to be taken seriously. Pain, however, is not a direct measure of how much structural damage is happening inside a joint 8,9. If it were, we would expect the people with the greatest structural changes on imaging to consistently have the most pain; we don't see that8,9.
A systematic review found a surprisingly wide mismatch between knee pain and osteoarthritis seen on X-rays 8. Some people had knee pain without corresponding X-ray changes, while others had clear signs of OA on X-ray without reporting pain8. The authors concluded that neither knee pain nor X-ray findings are precise proxies for the other 8. More recent research has continued to demonstrate this mismatch. A 2025 study examining commonly used X-ray and MRI features found that structural imaging could not reliably predict an individual's knee pain and symptoms 9.
This does not mean that the structure of the joint is irrelevant or that pain should be ignored. It means that pain is more complicated than just damage that we can see with imaging. This is important for many reasons, as it guides both research and how we assess your OA clinically. For our purposes here, it helps us to understand that not every painful sensation should be interpreted as evidence that the joint is being harmed, or reason to be afraid of movement. We also need to remember that, there are also consequences to moving less.
Exercise really is an important part of osteoarthritis treatment
Let’s take a look at why exercise is an important part of OA care.
NICE recommends therapeutic exercise tailored to the individual for all people with osteoarthritis 3. Its guideline specifically tells clinicians to prepare patients (you) for the fact that joint pain can initially increase when therapeutic exercise begins, while explaining that regular, consistent exercise can reduce pain and improve function and quality of life over time 3. In other words, some people may notice more discomfort when they first begin exercising, but this doesn't mean the exercise isn't helping or that things will continue in that direction.
The American College of Rheumatology/Arthritis Foundation strongly recommends exercise for knee, hip and hand OA, while OARSI includes structured land-based exercise among its core treatments for knee OA 1,2. We have a lot of research behind these recommendations.
Large reviews involving thousands of people with osteoarthritis have found that regular exercise can improve pain, physical function, walking ability and quality of life10,11. Different types of exercise can be helpful, including aerobic exercise, strengthening and a combination of different activities 10,11.
What about safety?
The research is reassuring, but there is an important limitation. In one large review, fewer than one in five studies provided enough information about unwanted effects from exercise to properly assess them10. Among the studies that did, there was no clear difference between people who exercised and those who didn't10. So, while these findings are reassuring, like most things in medicine, we can't say that exercise is completely without risk, and we need more research.
Overall, avoiding exercise because you have OA isn't what the evidence supports. In fact, avoiding it may mean missing out on improvements in your pain and function, along with the many other health benefits of regular exercise.
How much pain is okay?
This is a really important question, and it would be wonderfully convenient if research gave us a universal number, for example “Up to 3/10 is fine. At 4/10, stop.” Unfortunately, it doesn't.
First, what do the guidelines say?
The ACR/Arthritis Foundation guideline specifically notes that there is no uniformly accepted pain threshold at which a person with OA should or should not exercise. It recommends an individualized approach that considers the person's symptoms, preferences, abilities and other health concerns 2. As we have already explored, we do know that some discomfort with exercise does not automatically mean harm and NICE explicitly advises clinicians to tell people with OA that joint pain may initially increase when they begin therapeutic exercise 3.
Now, let’s explore some of the evidence.
Some newer research that I find fascinating, has found that people can experience discomfort during exercise while having less pain sensitivity afterwards12,13. I hope to see more research on this in the future, but for now, while these are interesting findings, unfortunately, they do not give us a validated “safe pain” cutoff, and they certainly don't mean that more pain is better. For now, I think the most useful way to think about pain during exercise is as information rather than an automatic stop sign.
So, an increase in discomfort can happen, particularly when starting or progressing exercise, and it doesn't automatically mean you have injured the joint. From here, I counsel my patients that significant or rapidly escalating pain, a new hot or markedly swollen joint, recent trauma, or an unusual rapid change in symptoms deserves assessment rather than simply being pushed through. NICE specifically identifies recent trauma, prolonged morning stiffness, rapid worsening, deformity and a hot swollen joint among atypical features that should prompt consideration of other or additional diagnoses 3.
You might be thinking, what about an arthritis “flare”? Even that term isn't as straightforward as it sounds. A systematic review found substantial variation in how OA flares were defined in research; pain was central in the definitions, but swelling, effusion, mobility limitations and other features also appeared14. So, this brings us back to an individual approach, listening to your body, working with your healthcare provider and watching for the warning signs we discussed above.
So, to sum this up, I don't think the best advice is “push through the pain.” I also don't think advice should be as simple as “stop whenever it hurts.” There is a lot of useful space between those two extremes and finding that balance can take some trial and error.
What exercise should I do if I have OA?
The advice to “just move more” can become frustrating. Yes, movement matters and yes, just about anything can be helpful; but, when someone is already worried about hurting their joint, being sent away with “just do something” isn't always particularly helpful. Aerobics, walking, cycling, strengthening exercises, aquatic exercise, neuromuscular exercise and mind-body approaches such as Tai Chi have all been studied in knee and hip OA2,10,11. There isn't one exercise program that is right for everyone. This is where working with someone to tailor a plan to you can be really helpful. Your plan needs to make sense for you. Some of what I consider when working with my OA patients is: which joints are affected, what you can currently do (or don’t do) and why, what activities you enjoy, what equipment or facilities you have access to, what other health conditions you are managing, and how your symptoms respond.
If you have become quite inactive, your starting point may be modest. A mistake I often see is that people try to return to an activity at the same level they were doing it months, years or even decades earlier. While I love and commend the enthusiasm, I generally tell people to start with less than they think, then adjust from there. We are not looking to make up for lost time! It is easier to gradually progress forward to find your sweet spot, but an injury can really set you back.
A well-rounded plan might include strengthening, aerobic activity, stretching, and some balance work. It doesn't necessarily require a gym; the appropriate approach depends on your starting point, abilities and your interests. Aerobic activity can include options such as walking, cycling or swimming, and different forms of exercise can be combined2,10. Tai chi can also incorporate balance work and is strongly recommended for knee and hip OA in the ACR/Arthritis Foundation guideline 2. Don’t forget to pay attention to how you respond and adjust the plan as needed.
When I am helping to build a plan with a patient, another piece of advice that I like to give that sounds really simple but is really important is being intentional and detailed with your plan. Choose an activity you can realistically do, decide when you are going to do it, who you will do it with (or alone), where you will do it, and consider a plan B if something gets in the way of your original plan. This might mean making a list of some of your favourite online workout videos in case it is raining when you wanted to jog. For me it means taking both a swimsuit and workout clothes to the gym every day in case the pool is closed or if the weight room is looking really full and I want to hit the pool instead.
If all of this feels too difficult to figure out on your own, don’t let this get in your way. Getting help is completely reasonable. I would highly recommend working with your health care provider to build a plan. Also, if you feel that you would benefit from more support, supervised exercise is another option; both NICE and the ACR/Arthritis Foundation guideline recognize a role for supervised exercise, and the ACR guideline notes that exercise programs tend to produce better outcomes when supervised2,3. Depending on your needs, that support might come from a physiotherapist or another appropriately qualified exercise professional.
If pain is the thing standing in your way, talk with your healthcare provider. OA management can include both non-drug and medication approaches, depending on your specific circumstances1,2. Managing pain may be an important part of helping you stay active.
Your joints are meant to move
One of the hardest things about chronic pain is how quietly it can begin changing a person's life. This might look like you stop taking the longer walks because your knee bothered you last time. It might be that you start avoiding stairs. Perhaps, you turn down an outing because you're not sure how far you'll have to walk. Bit by bit, you can find yourself organizing more of your life around protecting a painful joint or joints. I see this fear in clinic, and I understand where it comes from. When something hurts, protecting it feels sensible, but as we have seen, when it comes to osteoarthritis, movement is part of the care.
So, we are back to where we started in our discussion; let’s review. Exercise is recommended across major OA guidelines because it can improve pain and function1–3,10,11. While the evidence is never as perfect as we would like, studies looking directly at cartilage and other structural changes do not support the idea that appropriate exercise simply wears an osteoarthritic knee out5–7. This doesn't mean ignoring pain, nor does it mean forcing yourself through severe symptoms, and it certainly doesn't mean that everyone with OA should follow the same exercise program. It means we can move away from being afraid of movement and start asking a much more useful question:
What kind of movement can I do, and what support do I need to keep doing it?
Let’s start there and see where it takes us. If you are looking for more guidance, reach out to your health care team; we would love to help you build a plan that fits your health, your symptoms and your goals.
*Disclaimer: The information contained within this post is for general educational and information purposes only; no doctor-patient relationship is formed. It is not professional medical advice, diagnosis, treatment, or care, nor is it intended to be a substitute, therefore. If you have any concerns or questions about your health, always seek the advice of a qualified healthcare professional.
References:
1. 1. Bannuru, R. R. et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr. Cartil. 27, 1578–1589 (2019).
2. Kolasinski, S. L. et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res. 72, 149–162 (2020).
3. (NICE), N. I. for H. and C. E. Osteoarthritis in over 16s: diagnosis and management (NG226). https://www.nice.org.uk/guidance/NG226/chapter/recommendations (2022).
4. Burden of Arthritis in Canada - Canadian Centre for Economic Analysis.
5. Bricca, A., Juhl, C. B., Steultjens, M., Wirth, W. & Roos, E. M. Impact of exercise on articular cartilage in people at risk of, or with established, knee osteoarthritis: a systematic review of randomised controlled trials. Br. J. Sports Med. 53, 940–947 (2018).
6. Ginckel, A. V., Hall, M., Dobson, F. & Calders, P. Effects of long-term exercise therapy on knee joint structure in people with knee osteoarthritis: A systematic review and meta-analysis. Semin. Arthritis Rheum. 48, 941–949 (2019).
7. Bricca, A. et al. Impact of Exercise Therapy on Molecular Biomarkers Related to Cartilage and Inflammation in Individuals at Risk of, or With Established, Knee Osteoarthritis: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials. Arthritis Care Res. 71, 1504–1515 (2019).
8. Bedson, J. & Croft, P. R. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskelet. Disord. 9, 116 (2008).
9. Hill, B. G., Eble, S., Moschetti, W. E. & Schilling, P. L. The Discordance Between Pain and Imaging in Knee Osteoarthritis. J. Am. Acad. Orthop. Surg. 33, e786–e794 (2025).
10. Yan, L. et al. Comparative efficacy and safety of exercise modalities in knee osteoarthritis: systematic review and network meta-analysis. BMJ 391, e085242 (2025).
11. Varongot-Reille, C. et al. Effectiveness of exercise on pain intensity and physical function in patients with knee and hip osteoarthritis: an umbrella and mapping review with meta-meta-analysis. Disabil. Rehabilitation 46, 3475–3489 (2024).
12. Lee, S. et al. Association of Pain During Exercise With Exercise‐Induced Hypoalgesia in People With Knee Osteoarthritis. Arthritis Care Res. 77, 900–905 (2025).
13. Ram, A. et al. The influence of education on pain during and following acute exercise in people with knee osteoarthritis: A randomised controlled trial. Musculoskelet. Sci. Pract. 77, 103314 (2025).
14. Cross, M. et al. Defining Flare in Osteoarthritis of the Hip and Knee: A Systematic Literature Review — OMERACT Virtual Special Interest Group. J. Rheumatol. 44, 1920–1927 (2017).
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