If you have osteoporosis or osteopenia, being told to “exercise more” is not specific enough. The better question is: what kind of exercise helps you stay strong and independent while respecting your fracture risk?
For many people, the answer includes progressive strengthening, weight-bearing activity, balance training and practice with real-life movements. Physical therapy can be especially useful when osteoporosis is combined with weakness, poor balance, a previous fracture, back pain, fear of falling or uncertainty about which movements are safe.
The goal is not to make a person fragile or afraid to move. It is to help them load the body intelligently, improve the muscles that protect mobility, reduce fall risk and modify movements when fracture risk makes that appropriate.
What can physical therapy do for osteoporosis?
Physical therapy does not replace osteoporosis diagnosis or medication when medication is indicated. It addresses a different part of fracture prevention: how you move, how strong you are, and how likely you are to fall.
A therapist may assess leg and hip strength, posture, gait, balance, transfers, stair ability, confidence with daily activities and the movements you use at home or during exercise. The program can then be progressed around your actual abilities rather than a generic list of “bone exercises.”
The Bone Health & Osteoporosis Foundation recommends weight-bearing and muscle-strengthening activity for bone health, along with exercises that address posture, balance and function. It also recommends discussing exercise with a clinician or physical therapist when fracture risk is high or a fracture has already occurred. (BHOF)
At Pacific Bone & Joint, this is one reason I view physical therapy and bone-health evaluation as complementary rather than competing approaches. One addresses function and safe loading. The other addresses why bone may be weak and whether additional treatment is needed.
Which exercises are usually most useful?
A good osteoporosis program is usually broader than walking alone.
Progressive resistance training
Strengthening the legs, hips, back and upper body can improve the muscular capacity needed for walking, stairs, getting out of a chair and recovering from a loss of balance. Resistance can come from body weight, bands, machines or free weights.
The important word is progressive. If an exercise is always easy, it may not provide enough stimulus to improve strength. At the same time, progression should reflect the person’s fracture history, technique and medical condition.
BHOF suggests muscle-strengthening exercise about two to three days per week for many adults, while emphasizing individualized safety. (BHOF)
Weight-bearing activity
Walking, stair climbing and other activities performed upright against gravity can be part of a bone-health program. Higher-impact activities can provide greater skeletal loading, but they are not automatically appropriate for everyone with osteoporosis.
Someone with mild osteopenia, good balance and no fragility-fracture history is very different from someone with multiple vertebral compression fractures and severe balance impairment. The International Osteoporosis Foundation recommends tailoring activity to the individual’s fracture risk and capabilities. (IOF)
Balance and functional training
A stronger bone can still fracture in a hard fall. That is why fracture prevention is not only about bone density.
Balance training may include controlled changes in stance, reaching, stepping, turning and responding to progressively more challenging situations. Functional training can focus on the activities that matter in everyday life, such as rising from a chair, carrying groceries, navigating stairs or walking over uneven surfaces.
For someone who feels unsteady, these exercises should be challenging enough to create adaptation without creating an unnecessary fall hazard.
Are there exercises people with osteoporosis should avoid?
There is no single blacklist that applies to every person with osteoporosis. Risk depends on bone density, previous fractures, spinal alignment, balance, strength and how an activity is performed.
However, people at high risk for vertebral fracture may need to modify loaded or repeated spinal flexion, forceful twisting, abrupt high-impact activity and poorly controlled heavy lifting. BHOF specifically cautions people with osteoporosis, particularly those with vertebral fractures, about excessive forward bending and twisting of the spine. (BHOF)
That does not mean “never bend over.” Daily life requires bending. Physical therapy can teach strategies such as hip hinging, keeping loads close to the body, improving leg strength and choosing a safer way to accomplish a task.
The International Osteoporosis Foundation similarly recommends caution with trunk flexion and powerful twisting in people at increased fracture risk while supporting progressive resistance and aerobic activity when appropriately prescribed. (IOF)
What if I already had a compression fracture or hip fracture?
A prior fragility fracture changes the conversation.
After a fracture, rehabilitation may be needed to restore walking, transfers, strength and confidence. But the fracture itself is also a signal to ask whether osteoporosis has been adequately evaluated and treated.
If a fracture occurred after a relatively minor fall or low-energy event, simply finishing rehabilitation without addressing the underlying bone health can miss an important opportunity for prevention.
The physical-therapy plan may also need modification depending on the fracture location and healing stage. A person recovering from a hip fracture has different restrictions and priorities than someone with an old vertebral compression fracture.
Can physical therapy increase bone density?
Exercise can provide a beneficial mechanical stimulus to bone, and resistance and weight-bearing programs can help maintain or improve bone health. But the changes in bone density from exercise are generally modest and variable.
That is why I would not frame physical therapy as a substitute for osteoporosis treatment. Its value is broader: improving strength, balance, posture, mobility and the ability to function safely while giving the skeleton an appropriate loading stimulus.
For a patient at high fracture risk, medication, nutrition, calcium and vitamin D adequacy, fall-risk reduction and treatment of secondary causes may all matter alongside exercise.
When is a physical therapist especially helpful?
Individualized therapy is particularly worth considering when you:
- Have osteoporosis plus poor balance or a history of falls
- Have had a fragility fracture
- Have significant weakness or difficulty getting out of a chair
- Are afraid to exercise because of fracture risk
- Have back pain or known vertebral compression fractures
- Are unsure how to modify gym, yoga, Pilates or household movements
- Need to return to activity after a fracture or period of inactivity
- Want a progressive strengthening plan rather than a generic handout
When should bone health be evaluated too?
Physical therapy can improve function, but it cannot tell you by itself why your bones are weak.
An orthopedic or bone-health evaluation may be useful when there has been a low-energy fracture, unexpected loss of height, known osteoporosis, recurrent fractures, prolonged steroid use or other risk factors for secondary osteoporosis. Depending on the situation, evaluation may include bone-density testing, laboratory work and discussion of medication.
New severe back pain after a minor movement or fall, inability to bear weight after an injury, a new deformity, or significant hip/groin pain after a fall deserves prompt medical assessment rather than simply starting an exercise program.
The practical takeaway
Osteoporosis is not a reason to stop moving. It is a reason to make movement more purposeful. A well-designed program should build strength, challenge balance, preserve mobility and teach safer ways to load the spine and hips when fracture risk is elevated.
For some people, a home program is enough. For others, especially those with prior fractures, poor balance, significant weakness or uncertainty about safe loading, physical therapy can provide the assessment and progression that a generic exercise sheet cannot.
If you have osteoporosis or osteopenia and want help deciding how to exercise safely, Pacific Bone & Joint can evaluate both the movement side and the bone-health side of the problem and help determine the appropriate next step.
Sources and Further Reading
- Bone Health & Osteoporosis Foundation. Be Bone Strong: Exercise to Stay Healthy. Current patient guidance. https://www.bonehealthandosteoporosis.org/preventing-fractures/exercise-to-stay-healthy/
- Bone Health & Osteoporosis Foundation. Starting a New Exercise Program. Current patient guidance. https://www.bonehealthandosteoporosis.org/patients/treatment/exercisesafe-movement/starting-a-new-exercise-program/
- International Osteoporosis Foundation. Exercise for individuals with osteoporosis. Current professional guidance. https://www.osteoporosis.foundation/health-professionals/prevention/exercise/exercise-individuals-with-osteoporosis
- Giangregorio LM, et al. Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International. 2014.
