October 12, 2023

Exercise for Bone Health: A Call to Action

Photo courtesy of Buff Bones®.

Guest blog by Rebekah Rotstein, NCPT, founder of Buff Bones® and member of SWHR Bone Health Working Group


Bone health is something most people take for granted – until it becomes an issue. We expect our bones to support us and allow us to stand, sit, bend, and walk throughout the day. We don’t usually think about how they protect our organs, store minerals, or even secrete hormones. It’s generally only once a diagnosis of osteoporosis or a fracture occurs that we pay attention to our skeletal system and all it does for us.

One in two women over age 50 are estimated to break a bone from osteoporosis, a condition of weakened bone that increases the likelihood of fracture. A woman’s risk of fracturing her hip is equal to her risk of developing breast, uterine, and ovarian cancer combined. With such staggering statistics, bone health must emerge at the forefront of women’s health issues, with a rallying cry centered on preventing osteoporosis and fractures through accessible lifestyle tools and interventions.

Exercise for Bone Health

Exercise is one of the best tools to build and maintain bone mass, to prevent its decline, and to avoid fragility fractures. Just as we exercise to train our muscles, we need to also train our bones. Bone is living tissue which strengthens in response to external forces and use. When we exercise and move our bodies, the bone adapts by becoming stronger in preparation for future activity. But the rate of bone adaptation differs throughout the lifespan.

We develop most of our bone mass during childhood and adolescent years. We reach peak bone mass by our early 30s, at which point we begin to lose bone density. Arriving at menopause, the decline of estrogen leads to accelerated breakdown, which has a cumulative effect of rapid bone loss. According to the Bone Health and Osteoporosis Foundation, women can lose up to 20% of their bone mass in the five to seven years after menopause. In the years following, bone mass continues to decline although at a slower rate; this is the point that exercise is often recommended, since older adults are the most at-risk for the devastating fractures that can occur from osteoporosis.

Bone health is an issue that needs to be examined across all stages of life, with the understanding that exercise cultivates and later preserves bone mass:

The way we exercise will likely differ at various stages of life, but exercise for bone health should be site specific – namely exercise for the spine, hips, and wrists, which are the most common sites of bone loss and fracture.

Exercise for bone health should also always include the following components:

Weight-bearing and Impact: Bone development and strength rely on a combination of compression and tension forces. Upright weight-bearing motions combined with muscle activation, external loads, and added impact can fuel and stimulate bone growth. Non-weight-bearing and non-impact exercises have less effect on bone density, but they shouldn’t be discounted as they can have other benefits related to strength, balance, mobility, function, and coordination, along with stress reduction.

Strength, Resistance, and Progressive Overload: When we use our muscles by lifting weights, working with our own bodyweight, or using resistance tools, we stimulate the bone from the tensile pull of the muscles. Bone is adaptive tissue, which enables it to grow stronger; yet it’s precisely this adaptive characteristic that makes it necessary to continuously stimulate it so that it doesn’t stagnate. Training should include progressive overload, which involves increasing the intensity or challenge of an exercise, to avoid a plateau.

Balance and Coordination: More than 95% of hip fractures are caused by falling, according to the Centers for Disease Control and Prevention, and most falls occur in older age. Balance training is essential to fall prevention, working with eye and head movements along with proprioception (the body’s ability to sense positioning and movement in space) and the sensation in the feet. It’s important to integrate dynamic balance, essentially balance in motion, where you maintain your upright position while moving your base of support, limbs, or center of gravity.  Rather than holding a static position standing on one leg, dynamic balance translates more directly into real life events, such as riding on a moving bus. Dual tasking, where you complete two tasks, such as balancing on one leg while tossing a ball or counting backwards simultaneously, is another useful drill to practice to reduce fall and fracture risk.

Core and Trunk Control: Balance relies on healthy trunk control to keep the body upright and stable. This involves abdominal control and back extensor strength, both of which are important to prevent fractures. Notably, these elements also impact posture and healthy alignment, which can each optimize force distribution throughout the skeleton in loaded weight-bearing positions.

Mobility: Although occasionally overlooked in bone health exercises, mobility is fundamental. Functional exercises like squats that are critical for developing lower extremity strength rely on range of motion at the ankles, knees, and hips. Similarly, the basic act of lifting the arms and performing spine-strengthening exercises like overhead presses require the ability to move the shoulders at nearly 180 degrees. In many ways, all elements of exercise for bone health rely on mobility as their basis.

When osteoporosis or osteopenia are present, take caution with certain movements. Avoid twisting to end range, rounding the back all the way forward, and loading the spine with a rounded back (e.g., lifting the feet and hips in the air when face up.) These movements can increase the risk of a vertebral fracture. Consider consulting a health care provider before starting a new exercise routine or if certain movements cause you pain.

Exercise holds the key to halting the epidemic of osteoporosis and mitigating life-altering fractures. The more we embark on the journey of moving our bodies and caring for our bones, the greater control we have over our future and the better quality of lives we can lead.


Rebekah Rotstein is an industry leader for Pilates, bone health, and movement education. She is the founder of the research-supported Buff Bones® exercise system for bone and joint health, with on-demand classes and trained instructors in more than 30 countries. A former ballet dancer, Rebekah worked in the Sports Medicine department of Smith College as a student athletic trainer as the start of her professional journey. She combines her experience working in settings of athletic training and rehabilitation with her participation in eight cadaver dissections and coursework in fascia research, somatic studies, and visceral manipulation. A diagnosis of osteoporosis at age 28 motivated her to advocate for others with low bone mass and to provide innovative education and programming for them. Rebekah has presented at numerous conferences in the Pilates industry, at the International Osteoporosis Foundation Worldwide Conference, and for the International Association for Dance Medicine and Science. She is a member of the Ambassador Leadership Council for the Bone Health and Osteoporosis Foundation, an ambassador for American Bone Health, serves on the Bone Health Working Group for the Society for Women’s Health Research and worked as a partner of the U.S. Department of Health and Human Services Office of Women’s Health.