While the adverse effects of obesity on cardiovascular health and metabolic disorders are widely known, its impact on musculoskeletal health is often overlooked. Excess body weight places excessive stress on bones, joints, and muscles, leading to a higher risk for musculoskeletal conditions. However, an increasingly compelling treatment approach has emerged amid this growing challenge: integrating physical activity as a therapeutic intervention. Research and clinical evidence have shed light on the remarkable benefits of physical activity as an effective treatment modality for this specific patient population.

The most common musculoskeletal condition in those with obesity is osteoarthritis. Individuals with a BMI greater than 30 are twice as likely to have osteoarthritis and 20 times more likely to need a total joint replacement. Not only do individuals with obesity have an increased risk for total joint replacement, but also their BMI independently predicts a younger age for hip and knee replacement (Tables 1 and 2).  

Obesity also increases the risk for soft tissue injuries due to muscle imbalances, biomechanical factors, and higher trauma, such as fractures and dislocations, even in lower energy trauma.

Physical activity is an effective treatment to reduce the impact of obesity on musculoskeletal health. Regular exercise can help mitigate weight-related strain on the joints by increasing muscle strength and improving biomechanical function of the affected joint.

The postural changes associated with pre-obesity and obesity can increase the risk for decreased mobility and balance. When a person’s center of gravity is shifted, the biomechanical forces on joints are altered, creating increased wear, weakness, and pain. Physical activity focusing on core stability and balance can reduce the abnormal forces on joints. Improvement and increased strength of muscles around a joint can unload the stress on a joint brought on by the increase in body mass. Increased physical activity has been shown to decrease inflammation in the body, which may be caused by excess adipose tissue.

Here are some ways to treat patients with musculoskeletal conditions and obesity:

• Start by meeting your patient at the level of physical activity that they are at. If they are very sedentary, start with chair exercises and focus on short bouts of activity. Even 3- to 5-minute bouts of activity are beneficial.
• Patients with physical limitations, such as those with pain or poor balance and strength, can often tolerate seated isometric exercises.
• Cardio gliders or marching in place can provide aerobic activity without increased joint stress.
• Progress to seated resistance exercises using simple props, such as a soup can or a resistance band around the thighs.
• If a patient has access to equipment, suggest low-impact aerobic activity, such as pedaling on a stationary bike or recumbent biking.
• Walking in a pool is another great way to take the weight off their joints, and patients often appreciate being able to move without pain.
• Focus on improving functional strength, such as getting out of a chair, squatting down to the ground, and eventually walking.
• Communicate the importance of adding resistance training to their program to develop and maintain muscle mass while working toward their weight loss goals.
• Patients with obesity may benefit from specific recommendations for physical activity. A simple exercise prescription of 30 minutes of moderate-intensity exercise 5 days a week may not provide the best assistance.
• Continue to inquire about the types of activity they enjoy and the barriers to activity they face.

Obesity and musculoskeletal conditions often go hand in hand, exacerbating the latter. However, an active lifestyle and regular physical activity can play a pivotal role in mitigating the adverse effects of obesity on the musculoskeletal system in your patients. Together, you can create a shared plan that can improve their strength, QOL, and well-being.

For clinicians looking for more information on treating musculoskeletal conditions in patients with obesity, the American College of Sports Medicine and their Exercise Is Medicine initiative provide excellent resources for people with physical limitations. The OMA algorithm section on physical activity and the OMA infographics and exercise prescriptions pad are also great tools.