By Dr. Fabian Poletti

AS the FIFA World Cup dominates headlines around the world, many football fans are feeling inspired to get active again.

For some, that means dusting off old boots and heading back onto the pitch.

But what if you suffer from knee osteoarthritis? Is football still an option, or should it be avoided altogether?

The answer is more nuanced than a simple yes or no.

For decades, people with osteoarthritis were often advised to rest painful joints and avoid strenuous activity.

Modern research has completely changed that view. Today, exercise is considered one of the most effective non-drug treatments for knee osteoarthritis and is recommended by virtually every major clinical guideline worldwide.

However, not all exercise is created equal.

Many patients are surprised to learn that complete rest is often more harmful than movement itself.

When people reduce activity because of pain, muscles weaken, balance deteriorates and joints become less stable.

This creates a vicious circle in which inactivity leads to greater disability, more pain and a progressive loss of confidence in everyday movements.

One of the challenges in osteoarthritis is that pain does not always correlate closely with the degree of structural damage visible on scans or X-rays.

Some patients experience significant symptoms despite relatively modest radiological changes, while others with advanced osteoarthritis report surprisingly little discomfort.

For this reason, pain should not automatically be interpreted as a sign that the joint is being damaged further.

In many cases, carefully graded exercise can reduce symptoms, improve mobility and help patients regain confidence in using the affected joint.

Experts now describe what is known as the “dual effect” of physical activity. When exercise is appropriately prescribed and adapted to an individual’s condition, it can protect joints, reduce pain and improve function.

On the other hand, excessive, poorly planned or high-impact activity may increase mechanical stress and accelerate joint deterioration.

This distinction is particularly important in the knee, one of the joints most commonly affected by osteoarthritis.

Far from simply strengthening muscles, exercise acts directly on several biological processes involved in the disease. Osteoarthritis is no longer viewed as merely a consequence of ageing and wear-and-tear.

It is increasingly recognised as a complex condition involving chronic low-grade inflammation, metabolic dysfunction and changes affecting the entire joint.

Regular physical activity helps reduce systemic inflammation, improves insulin sensitivity and lowers the production of inflammatory molecules associated with obesity and metabolic syndrome.

These effects are especially relevant because many patients with knee osteoarthritis also struggle with excess weight and other metabolic conditions.

Within the joint itself, controlled movement appears to stimulate beneficial cellular responses. Moderate mechanical loading helps maintain cartilage health, supports joint lubrication and reduces the activity of enzymes involved in cartilage breakdown.

Exercise may even help counteract some of the cellular ageing mechanisms that contribute to osteoarthritis progression.

Researchers now recognise that exercise influences the disease at a cellular level. Regular physical activity improves mitochondrial function, reduces oxidative stress and helps regulate inflammatory pathways associated with ageing.

These effects may partly explain why physically active individuals often maintain better joint function and quality of life despite having radiological evidence of osteoarthritis.

The synovial membrane, which lines the joint and produces lubricating fluid, also appears to benefit from regular movement.

By improving the circulation of synovial fluid, exercise enhances cartilage nutrition and may help reduce the low-grade inflammation frequently associated with knee osteoarthritis.

The challenge lies in choosing the right type of activity. As a general rule, activities that involve smooth, repetitive movement are usually better tolerated than those requiring sudden acceleration, twisting or impact.

For most people with knee osteoarthritis, low-impact aerobic exercise combined with muscle strengthening provides the greatest benefits.

Walking remains one of the safest and most accessible options, helping improve balance, proprioception and quadriceps strength.

Swimming and water-based exercise are excellent alternatives, particularly for individuals with more advanced symptoms or cardiovascular limitations.

Cycling, whether outdoors or on a stationary bike, can also be highly beneficial, although those with significant kneecap-related pain may require adjustments.

Tai chi, therapeutic yoga and Pilates have likewise demonstrated positive effects on pain, mobility, sleep quality and psychological wellbeing.

What about football itself?

Traditional football presents certain challenges. Sprinting, sudden changes of direction, jumping, tackling and repetitive twisting movements can place substantial stress on arthritic knees.

For individuals with moderate to advanced osteoarthritis, these demands may increase symptoms and raise the risk of injury.

That does not necessarily mean football must be abandoned forever.

One increasingly popular alternative is Walking Football; a modified version of the game specifically designed for older adults and people with mobility limitations.

As the name suggests, running is prohibited. The pace is slower, physical contact is minimised, and the emphasis shifts towards skill, teamwork and enjoyment rather than intense competition.

Research suggests that Walking Football can deliver many of the cardiovascular, muscular and social benefits of traditional football while significantly reducing joint loading and injury risk.

For former players reluctant to give up the sport they love, it may offer an ideal compromise.

Beyond the physical benefits, Walking Football offers something equally important: social connection. Many older adults stop exercising because they lose motivation when activity becomes repetitive or isolated.

Team-based sports create a sense of belonging, routine and enjoyment that can dramatically improve long-term adherence to exercise programmes.

For retirees living on the Costa del Sol, where Walking Football leagues and recreational groups continue to grow in popularity, the sport can provide both a health intervention and an important social outlet.

Activities that generally warrant greater caution include prolonged running on hard surfaces, high-intensity interval training that has not been individually adapted, competitive squash, tennis on hard courts and sports involving frequent collisions or abrupt directional changes.

Importantly, these should not be viewed as absolute prohibitions.

The suitability of any activity depends on factors such as symptom severity, joint alignment, muscle strength, body weight, previous injuries and overall fitness.

Perhaps the most overlooked benefit of exercise is that its effects extend far beyond the knee. Regular physical activity improves blood sugar control, reduces systemic inflammation and provides well-established benefits for mental health.

Given the strong links between chronic pain, anxiety and depression, these broader effects are particularly valuable for many osteoarthritis sufferers.

So, can you play football if you have knee osteoarthritis?

For some people, carefully adapted recreational football remains possible. For many others, Walking Football may represent the smarter and safer choice.

The key message is that movement is not the enemy. In fact, when appropriately prescribed, exercise remains one of the most powerful tools we have to slow functional decline, reduce pain and improve quality of life.

As the World Cup reminds us of the joy that football brings, perhaps the lesson for arthritic knees is simple: keep moving — just choose the right game.

Dr Fabian Poletti is a UK fellowship-trained Consultant Orthopaedic and Trauma Surgeon, FRCS (Eng), FEBOT, MSc (Imperial), DIC.

He held senior clinical posts at the UK’s NHS and is listed on the GMC Specialist Register.

He later served as Chief Physician in Denmark and has extensive experience across both the Spanish public and private healthcare systems.

He currently practises in Marbella, Estepona and Gibraltar.

Further information is available at www.drpoletti.com/en, with consultations in Marbella, Estepona and Gibraltar.

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