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Musculoskeletal Syndrome of Menopause describes a cluster of joint, muscle, tendon, cartilage and bone changes associated with the hormonal changes of perimenopause and menopause.
Reported features include:
● Widespread joint pain and stiffness
● Reduced muscle mass and strength
● Increased risk of sarcopenia
● Bone-density loss and fracture risk
● Osteoarthritis-related symptoms
● Tendon and ligament problems
● Frozen shoulder
● Reduced physical capacity
More than 70% of women may experience musculoskeletal symptoms during the menopause transition, although the exact prevalence varies depending on how symptoms are defined. The original authors estimated that around 25% may experience disabling symptoms.
Importantly, MSM should not become a shortcut diagnosis for every new pain complaint. The 2026 Indian Menopause Society guideline describes it as a conceptual construct rather than an established diagnostic entity and recommends excluding other causes such as vitamin D deficiency, thyroid disease, anaemia, autoimmune disorders and osteoarthritis.
Oestrogen does much more than regulate the menstrual cycle.
Bone:
Oestrogen helps regulate bone turnover. When oestrogen levels fall, bone resorption increases and bone mineral density can decline, increasing the risk of osteoporosis and fragility fractures.
Muscle:
Oestrogen contributes to muscle maintenance. Ageing combined with hormonal changes can accelerate reductions in lean muscle mass and strength.
Joints and cartilage:
Oestrogen has anti-inflammatory effects and interacts with tissues within and around joints. Its decline may contribute to increased joint pain and stiffness and may influence osteoarthritis progression.
Tendons and ligaments:
Hormonal changes may also affect connective-tissue biology, although the relationship between menopause and individual tendon injuries is complex and continues to be researched.
AAOS describes declining estradiol as an important contributor to increased joint inflammation, arthritis risk, bone loss and reduced muscle maintenance.
A woman recovering from a tendon injury, joint problem or surgery during midlife may have several factors affecting rehabilitation simultaneously.
Reduced muscle mass can lower the available capacity to tolerate load. Reduced bone density may change exercise and impact considerations. Joint stiffness and pain can reduce activity, which then creates another cycle of deconditioning.
Sleep disturbance, fatigue and other menopause symptoms can further influence exercise tolerance and recovery behaviour.
However, physiotherapists should avoid telling patients that “menopause means you heal slowly.” Recovery depends on the specific tissue, injury, age, activity level, nutrition, sleep, medical conditions and treatment. The stronger clinical message is that menopause can create a different rehabilitation context that needs to be recognised.
A menopause-informed assessment should look beyond the painful joint.
Ask about:
● Menopause or perimenopause stage
● Current pain and stiffness
● Previous fractures
● Falls and balance
● Changes in strength
● Physical activity levels
● Sleep quality
● Training history
● Work and daily activity demands
● Previous tendon or joint problems
● Relevant medical conditions and medications
Functional testing can include sit-to-stand performance, gait, balance, single-leg tasks, grip strength where appropriate and resistance-training capacity.
Bone-health risk should also be considered. A patient with suspected osteoporosis or a history suggesting fragility fracture may require medical assessment before higher-impact loading.
Exercise is one of the most important tools available to physiotherapists working with menopausal women.
The 2026 Indian Menopause Society guideline recommends exercise as part of first-line supportive management of musculoskeletal symptoms and emphasises maintaining muscle and bone health. NICE also specifically recommends physical activity to maintain muscle mass and strength during menopause.
Progressive resistance exercise should be central to rehabilitation.
Depending on the patient’s ability, programmes can include:
● Squats or sit-to-stands
● Step-ups
● Hip-hinge exercises
● Rows
● Pressing movements
● Calf raises
● Resistance-band exercises
● Progressive free-weight training
The goal is not simply to “exercise more.” The muscles need a progressively increasing stimulus to maintain or improve strength.
Weight-bearing activity can complement resistance training and support bone health.
Walking, stair climbing and appropriately selected impact activities may be useful, but the programme must be matched to fracture risk, bone density, joint symptoms and training experience.
Balance becomes particularly important when muscle strength, activity levels or bone health are declining.
Single-leg balance, step training, lower-limb strengthening and functional movement exercises can help maintain independence and reduce falls risk.
Manual therapy still has a role, particularly when a patient presents with joint stiffness, restricted movement or pain that limits exercise participation.
Depending on the assessment, treatment may include:
● Joint mobilisation
● Soft-tissue techniques
● Movement-with-mobilisation techniques
● Myofascial techniques
● Education about self-mobility
But manual therapy should not become the primary long-term strategy for menopause-related musculoskeletal problems.
A stiff shoulder may benefit from mobilisation, but the broader programme should also address shoulder strength and function. A painful knee may respond to manual treatment, but progressive lower-limb strengthening remains important.
The principle is simple: use manual therapy to help the patient move, then use exercise to build capacity.
Menopause-related joint pain can resemble osteoarthritis, inflammatory arthritis or other conditions.
The 2026 Indian guideline specifically advises clinicians to investigate alternative causes before attributing persistent musculoskeletal symptoms to menopause.
Referral should be considered when there is:
● Persistent joint swelling
● Significant morning stiffness
● Unexplained weight loss
● Fever or systemic symptoms
● Severe or rapidly worsening pain
● Recurrent fractures
● Neurological symptoms
● Significant trauma
● Symptoms suggesting inflammatory or autoimmune disease
Physiotherapists should recognise the menopause connection without assuming that every symptom is hormonal.
A menopause-informed physiotherapy service does not require every therapist to become a menopause specialist.
It means understanding that a woman in her 40s, 50s or 60s may present with a combination of joint pain, reduced strength, poor sleep, reduced activity and bone-health concerns rather than one isolated orthopaedic problem.
The physiotherapist can:
Screen for relevant menopause-related factors.
Assess strength, mobility, balance and functional capacity.
Identify red flags and indications for medical referral.
Prescribe progressive resistance exercise.
Address mobility and pain with appropriate manual therapy.
Educate patients about maintaining physical activity.
Coordinate with physicians, dietitians or menopause specialists when needed.
APTA education has similarly highlighted the importance of recognising menopause-related changes across musculoskeletal, pelvic-floor and core health rather than treating them as completely separate issues.
It is an emerging clinical concept rather than a universally established diagnosis with formal diagnostic criteria. AAOS now provides educational information on MSM, while the 2026 Indian Menopause Society guideline describes it as a conceptual construct.
The menopause transition is associated with changes in body composition and can contribute to loss of lean muscle mass, particularly alongside normal age-related changes and reduced physical activity.
Yes. Progressive resistance exercise is strongly relevant for maintaining muscle strength and supporting bone health. It should be adapted to the individual’s fitness, joint health and fracture risk.
Yes. Exercise, strengthening, mobility work, education and appropriately selected manual therapy can form part of management. Persistent or unusual symptoms should still be assessed for other medical causes.
No. Menopausal hormone therapy is a medical decision based on the individual’s symptoms, risks, benefits and preferences. Physiotherapists should not prescribe it but can coordinate care with the patient’s menopause-trained medical professional.
Musculoskeletal Syndrome of Menopause gives physiotherapists a useful framework for understanding the joint pain, muscle loss, stiffness and reduced physical capacity that can emerge around menopause. The practical focus is early assessment, progressive strengthening, mobility, bone-health awareness and appropriate referral—helping women remain strong, active and functionally independent through midlife and beyond.