Can adults with osteoarthritis or rheumatoid arthritis safely use swimming as exercise, and what precautions are required for severe joint deformities, open skin lesions, or a history of joint infection?

Swimming for Arthritis: Evidence-Based Recommendations

Swimming and aquatic exercise are conditionally recommended for both rheumatoid arthritis and osteoarthritis, providing safe and effective improvements in physical function comparable to land-based exercise, with the added benefit of reduced joint loading. 1

Primary Recommendation

Swimming is a safe exercise option for adults with arthritis that delivers measurable benefits:

• For rheumatoid arthritis patients, the American College of Rheumatology conditionally recommends aquatic exercise based on low certainty evidence showing improvement in physical function, though no difference in pain reduction. 1

• For osteoarthritis patients, the American College of Rheumatology/Arthritis Foundation strongly recommends exercise in general, with aquatic exercise representing one viable option among many exercise modalities. 1

• Research demonstrates that 12 weeks of supervised swimming (45 minutes/day, 3 days/week at 60-70% heart rate reserve) significantly reduces joint pain, stiffness, and physical limitation while improving muscle strength (15-30% increases) and functional capacity in adults with osteoarthritis. 2

Comparative Effectiveness

The evidence shows swimming performs similarly to land-based exercise:

• A randomized controlled trial found no significant differences between swimming and cycling training for reducing joint pain, stiffness, or improving physical function in osteoarthritis patients. 2

• Meta-analysis of 10 randomized controlled trials comparing aquatic to land-based exercise found no differences in function, mobility, or pooled health outcomes. 3

• Swimming may offer superior vascular benefits compared to land-based cycling, with significant improvements in brachial flow-mediated dilation (a measure of endothelial function) observed only in the swimming group. 4

Specific Prescription Parameters

Optimal swimming program structure based on research evidence:

• Frequency: 3 times per week 2, 5
• Duration: 45-60 minutes per session 2, 5
• Intensity: 60-80% of maximum heart rate reserve 2, 5
• Program length: 8-12 weeks minimum 5, 2
• Water temperature: 36-37°C (86-98.6°F) 5

Session structure should include: 5

• Warm-up: 5-10 minutes
• Aerobic component: 20-30 minutes
• Strengthening/flexibility exercises: 15-20 minutes
• Cool-down and relaxation: 5-10 minutes

Safety Considerations and Precautions

Absolute contraindications to aquatic exercise: 5

• Cauda equina syndrome
• Severe diabetic retinopathy
• Uncontrolled cardiovascular disease
• Open skin lesions or wounds (infection risk)
• Active joint infection

Relative precautions requiring medical clearance: 5

• History of joint infection (ensure complete resolution before starting)
• Severe joint deformities (may require modified exercises or supervision)
• Diabetes (requires specific monitoring protocols)
• Heart disease (requires heart rate monitoring)

For patients with diabetes participating in aquatic exercise: 5

• Consume 17 ounces of fluid 2 hours before exercise
• Wear proper footwear in pool areas
• Monitor blood glucose before and after sessions
• Check feet for blisters or damage before and after each session

For patients with cardiovascular disease: 5

• Maintain exercise at 60-80% maximum heart rate (do not exceed)
• Exercise in warm (not hot) water to avoid cardiovascular stress
• Ensure supervised sessions initially

When to Stop or Modify Exercise

Discontinue swimming immediately if: 6

• Unusual or persistent fatigue develops
• Increased weakness occurs
• Decreased range of motion is noted
• Joint swelling or pain lasts more than one hour after exercise

Avoid swimming during: 6

• Active disease flare-ups in rheumatoid arthritis
• Periods of acute joint inflammation
• When morning stiffness is severe (consider afternoon sessions instead)

Practical Implementation Considerations

Advantages of aquatic exercise over land-based options:

• Buoyancy reduces joint loading by approximately 50-80% depending on water depth, making it particularly beneficial for patients with severe pain, multiple painful joints, or obesity. 1, 5

• The low-impact environment allows patients who cannot tolerate land-based exercise to maintain physical activity. 1

• Warm water provides analgesia and muscle relaxation. 5

Barriers to consider:

• The recommendation is conditional partly due to variability in patient comfort with water activities, cost of pool access, and transportation requirements. 1

• Patient preferences and access are critical barriers—if a patient cannot afford pool access or arrange transportation, they will not benefit from the recommendation. 1

• Adherence rates for aquatic exercise are high (81.7% in research studies), with no exercise-related adverse effects reported. 7

Supervision and Professional Guidance

Supervised programs are superior to home-based exercise: 6

• Exercise programs are more effective when supervised by physical therapists, sometimes in a class setting, rather than performed alone at home. 6

• Comprehensive physical therapy and occupational therapy are conditionally recommended for both rheumatoid arthritis and osteoarthritis patients. 1

• Initial assessment by a physical therapist ensures appropriate exercise prescription tailored to joint involvement, disease activity, and functional limitations. 6

Special Populations

For patients with severe joint deformities:

• Aquatic exercise is particularly beneficial as it allows movement through pain-free range of motion with reduced gravitational stress. 1, 5

• Avoid vigorous, repetitive exercises that use unstable joints and avoid overstretching. 6

• Modified exercises and close supervision are essential initially.

For patients with history of joint infection:

• Ensure complete resolution and medical clearance before initiating aquatic exercise. 5

• Open wounds or active infection are absolute contraindications due to contamination risk to both patient and pool. 5

Evidence Quality and Strength

The conditional nature of these recommendations reflects:

• Low to very low certainty evidence for aquatic exercise in rheumatoid arthritis, primarily due to inability to blind participants to exercise interventions. 1

• More robust evidence exists for osteoarthritis, with multiple randomized controlled trials demonstrating benefit, though the overall recommendation for exercise is stronger than for any specific exercise modality. 1

• A 2025 systematic review found that while aquatic exercise significantly improved balance, stiffness, pain, and walking ability compared to non-exercise controls, it did not provide significantly superior benefits compared to other exercise modalities. 8