The musculoskeletal syndrome of menopause: what physios should know

The musculoskeletal syndrome of menopause is a proposed name for a cluster, not a diagnosis you can confirm or exclude. A 2024 review in Climacteric put the term forward for the musculoskeletal signs and symptoms attributed to falling estrogen at this stage of life, naming arthralgia, loss of muscle mass, loss of bone density and progression of osteoarthritis among them (Wright 2024). No criteria sit behind it, no test confirms it, and no musculoskeletal guideline has adopted it. What is well measured is that menopause musculoskeletal pain is common, and what is not measured is that estrogen loss causes any individual patient's pain.

Patients now bring the phrase into the first minute of an assessment, so you need a position on it. The patient-facing pages are linked as they come up, starting with menopause and joints.

What is the musculoskeletal syndrome of menopause, and is it a diagnosis?

It is a framing device. Used well, it stops you treating four problems as four unrelated coincidences in the same woman and makes you ask about the transition at all, which is the commonest omission in a midlife musculoskeletal assessment. Used badly, it becomes a label that explains everything and therefore investigates nothing.

The practical test is whether the name changes what you do. If a patient's lateral hip pain, her stiff hands in the morning and her first fragility fracture are all filed under one hormonal heading, the tendon does not get loaded, the hand does not get an inflammatory screen and the bone does not get a fracture risk assessment. If the name instead prompts you to ask about the pattern across sites and across the past three years, it has earned its place.

Be straight with patients about the status of the term. Reading the phrase online does not mean a condition has been conferred, and saying so usually comes as a relief, not a disappointment, because the alternative they have often arrived with is that something irreversible has been diagnosed by an article.

How common are musculoskeletal symptoms in perimenopause?

Commoner than before the transition, by a margin that is consistent across a large pooled sample. Kruse and colleagues pooled 37 observational studies published between 1993 and 2024, covering 93,021 women from 22 countries, with perimenopause defined by the STRAW criteria and surgical menopause excluded.

Symptom	Premenopausal	Perimenopausal	Postmenopausal
Muscle or joint pain	40% (95% CI 32 to 49)	57% (95% CI 48 to 65)	59% (95% CI 50 to 67)
Back pain	42% (95% CI 26 to 60)	57% (95% CI 44 to 69)	59% (95% CI 45 to 71)

The pairwise comparisons put the risk ratio for muscle or joint pain at 1.35 for perimenopause against premenopause (95% CI 1.25 to 1.46) and 1.40 for postmenopause (95% CI 1.28 to 1.53), with no meaningful difference between peri and post. For back pain the ratios were smaller, 1.15 and 1.20.

The authors state every caution that belongs with those numbers. Almost every included study was cross-sectional, 35 of the 37, so none of this shows cause. Menopausal status was mostly self-reported, which can misclassify women. Heterogeneity was considerable: I-squared was 88.6 percent for the perimenopausal muscle and joint pain comparison and 95.0 percent for the postmenopausal one, nearer 60 to 67 percent for the two back pain comparisons, and neither geography nor the measurement scale explained it. And the pooled sample is not the population most readers of this page treat: 58,653 of the 93,021 women came from East Asian studies, against about 15,000 from Europe and North America together.

The review also notes that specific diagnoses such as osteoarthritis, tendinopathy, synovitis and bursitis were rarely specified in the source studies, so none of these figures tells you which diagnosis is in front of you.

You will see higher figures quoted, commonly more than 70 percent of women affected with a quarter of them disabled. Both sit in the abstract of the review that named the syndrome, and they are worth tracing, because a patient or a referrer will quote them to you. The review attributes its prevalence figure to one source, a 2020 meta-analysis of 16 studies which found musculoskeletal pain in 71 percent of perimenopausal women (95% CI 64 to 78), 4,144 of 5,836, with 14 of the 16 studies cross-sectional (Lu 2020). So the 70 percent is real, and it is a pooled prevalence from the same kind of recall data as the figures above.

The quarter disabled is a different matter. The cited source reports no disability percentage at all; it reports higher odds of moderate to severe pain after the menopause, and one of its own included studies found that these women often sought care but rarely took work or disability leave. The review's own body text puts the same 25 percent as "severe symptoms" rather than disability. Quote the prevalence if you want it, with its design named, and leave the disability figure alone.

Estrogen and tendon: what the mechanism does and does not explain

The mechanism is real and it does not point the way most clinicians assume. In their review of estrogen and musculoskeletal performance, Chidi-Ogbolu and Baar describe estrogen improving muscle mass and strength and increasing collagen content in connective tissue, while decreasing stiffness in tendon and ligament. High estrogen states, in that account, reduce power and raise the risk of catastrophic ligament injury.

So the one-line story, that less estrogen means a weaker tendon and therefore more tendinopathy, is not a clean chain. Lower stiffness is not the same as better tissue, and the performance effect runs the other way: in that review it is the high estrogen state that costs power and carries the ligament risk. The stiffness evidence behind it is knee laxity measured across the menstrual cycle in young women, engineered ligament grown from human cells, and ovariectomized rats, not postmenopausal human tendon. And the same review states plainly that menopause is characterized by increased risk of musculoskeletal injury, accelerated bone and muscle wasting, and reduced sensitivity to anabolic stimuli, which is the part a clinician should carry into the room.

A structured narrative review on menopause and overuse injury argues that estrogen loss reduces collagen synthesis and elasticity and so predisposes to Achilles and rotator cuff problems (Ansari 2026). On the tissue direction the two agree, since less estrogen means less collagen and a stiffer tendon in both accounts. Where they part is the inference, and Ansari rests it on mechanism reviews rather than on incidence data, with several of its own tables, including its loading and protein numbers, carrying no citation at all. Nobody has shown that estrogen loss caused the tendon problem in front of you.

What this means in the room is modest and useful. You can tell a patient honestly that hormonal change plausibly affects tendon and muscle tissue, that nobody has shown it causes her particular tendon problem, and that the loading program is the same either way. The body composition change is better measured than the tendon one, and smaller than the headlines suggest: in the SWAN cohort, lean mass moved from a gain of about 0.06 kg a year before the transition to a loss of about the same size during it, a change of slope that begins around two years before the final period and flattens out about 18 months after it (Greendale 2019). Over 15 years that came to a fall of 2.7 percent in the proportion of the body that is lean, and less in some of the cohort's ethnic groups, which is a reason to train and measure rather than a reason to alarm.

Perimenopause musculoskeletal symptoms, site by site

The clinical work is still site by site, and every one of these has a staged program already written for patients.

Presentation	What it is treated as	Where to send the patient
Diffuse aching and stiffness, worst in the morning	Pattern recognition plus the usual screening for inflammatory disease	Joint pain in menopause
Lateral hip pain	Gluteal tendinopathy, loaded as a tendinopathy	Gluteal tendinopathy and menopause
Painful stiff shoulder with capsular restriction	Frozen shoulder, with its own staged plan	Frozen shoulder and menopause
Strength and muscle complaints	Progressive resistance training, measured	Muscle and bone loss
Low bone density, fragility fracture	Loading plus a fracture risk assessment	Osteoporosis program
Leaking, urgency, heaviness	Pelvic floor assessment and training	Pelvic floor in menopause

One row deserves a note, because patients arrive certain of the link. The only study in the pooled review that looked at shoulder diagnoses by menopausal status, 197 perimenopausal against 113 premenopausal women, found adhesive capsulitis the commonest diagnosis in both groups and no significant difference between them, 35 percent against 32 percent. The same study did find one difference, in its second commonest diagnosis: shoulder synovitis was commoner in the perimenopausal group, 25.1 percent against 6.2 percent. So treat the stiff shoulder as a frozen shoulder at any age, say that the timing may be the coincidence it looks like, and examine the shoulder rather than reaching for either label.

Where a woman presents with joint pain and muscle loss together, the staged condition program is perimenopause joint pain and muscle loss, which carries the warning list and the phases that the topic pages do not.

Why does menopause cause foot and heel pain?

Nobody has shown that it does, and this is the question with the largest gap between search demand and evidence. No prevalence study separates foot or heel pain by menopausal status, and the pooled review above could not report a site-specific figure because its source studies did not collect one.

What exists is mechanism and plausibility. The narrative review above links plantar fasciitis in this group to weakening of the intrinsic foot muscles, arch change and altered gait, citing a review of chronic plantar fasciitis rather than any menopausal cohort, and its loading advice carries no citation at all (Ansari 2026). Plantar heel pain is common in midlife women for reasons that include load, footwear, body weight and calf length, all of which you can assess and treat.

So answer the patient's question in two parts. The timing may well be a coincidence of age, and the heel is treated as plantar heel pain whatever the hormonal picture, through the plantar fasciitis program. The part that does change with the transition is bone, so a woman in her fifties with localized bony tenderness, pain on hopping at one spot, or heel pain that started with a jump in training volume needs the bone considered rather than the plantar fascia assumed.

What to do in clinic

Five additions to a standard musculoskeletal assessment, and none of them takes long.

1. Ask where she is in the transition, in plain words, and whether the musculoskeletal problem started around the same time as other changes. It is information, not a diagnosis.
2. Measure strength, not just range. Grip and a chair stand give you a number to train against and a way to answer the muscle question at the review.
3. Consider bone. The 2024 UK clinical guideline for osteoporosis makes a strong recommendation that a FRAX assessment is performed in any postmenopausal woman, or man aged 50 or over, with a clinical risk factor for fragility fracture, to guide bone density measurement and prompt timely referral or drug treatment where indicated (Gregson 2025). A wrist fracture from a trip is a risk factor, not bad luck. The same guideline makes a second strong recommendation that matters in a musculoskeletal clinic: keep the possibility of a vertebral fracture in mind in any postmenopausal woman, or man aged 50 or over, who turns up with sudden onset back pain, especially thoracic pain, if she has risk factors for osteoporosis, and consider imaging rather than treating it as a strain.
4. Load the tissue the way you would at any other age. For bone the trial evidence that matters most is LIFTMOR, in which 101 postmenopausal women with a T-score below -1.0 did 8 months of twice-weekly, 30 minute, supervised high-intensity resistance and impact training: deadlift, overhead press and back squat at 5 sets of 5 repetitions, the methods giving the load as more than 80 to 85 percent of a one-repetition maximum, with the impact supplied by a jumping chin-up and a drop landing. Lumbar spine bone density rose, femoral neck density held where the control group's fell, every functional measure improved, and one adverse event was reported across more than 2,600 sessions, a low back strain that cost a week (Watson 2018). Read the conditions before you borrow the dose. The first month was body weight and light variants while the women learned the lifts, each instructor took no more than 8 of them, the women had been screened for the conditions and medicines that affect bone and function, anyone with a musculoskeletal or serious cardiovascular problem was excluded, and the authors say they were not powered to assess safety. They also say, in terms, that they do not recommend this protocol in an unsupervised setting even after notable training, because technique cannot be self-monitored. The strength plan is the patient version.
5. Ask about the pelvic floor before prescribing impact or heavy lifting, because a woman who leaks will quietly drop the program rather than tell you why.

Hormone therapy is a prescribing decision and nothing on this page or ours answers it, so the question goes to her own doctor or menopause service with your findings alongside it. And menopause and musculoskeletal health is not a reason to delay the usual screening: new inflammatory patterns, unexplained weight loss and night pain mean what they always mean.

In PocketPhysio you set the sets, repetitions and hold times for each exercise and write the cue in your own words, which is where the strength progression and the pelvic floor caveat belong. It goes out as a link, by SMS or email, or into the Pocket Physio Care app, and WhatsApp is one option as well.

Warning signs, and what they mean on this topic

These are the lines we give patients, word for word, each with its own timing. Three matter particularly in this group: the sudden back pain line, the bleeding after the menopause line and the polymyalgia line.

1. Emergency: if chest pain, pressure or tightness does not ease quickly when you rest, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, feeling sick, feeling light-headed or being short of breath, call emergency services straight away, as this can be a heart attack. If it eases quickly and none of these happen, get medical advice the same day, and do not exercise again until you have been checked.
2. Same day: a joint is hot, red and swollen, or you have joint pain with a high temperature or feel hot, cold or shivery. Get medical advice the same day, and go to an emergency department if you feel very unwell. This can be a sign of infection in the joint, which needs treatment quickly.
3. Same day: back pain that comes on suddenly after lifting, bending, a cough or a sneeze, even without a fall, if you have low bone density (osteoporosis). Get medical advice the same day. This can be a sign of a broken bone in the spine (vertebral fracture). Stop the exercises until you have been checked.
4. Same day: you are over 50 and have aching and stiffness in both shoulders, often in the neck or hips too, that is worst in the morning and lasts more than 45 minutes after you get up. This can be an inflammatory condition (polymyalgia rheumatica) rather than a local joint problem. If you also get a new headache, pain or tenderness at your temples or on your scalp, or jaw pain when you eat or talk, get medical advice the same day, and if your vision changes, call emergency services. Even without those extra signs, see your doctor within a few days about the aching and stiffness.
5. Within a few days: you have not been diagnosed, and several joints in your hands, wrists or feet are painful, swollen and stiff, especially in the morning. This is not an emergency, but see your doctor within a few days, because early treatment can stop the condition getting worse and lower the risk of joint damage.
6. Within a few days: any bleeding from your vagina after your menopause, including spotting or pink or brown discharge, even if it is only a small amount, only happened once, or came on during or after sex. Book an appointment with your doctor within a few days. Bleeding after the menopause is usually not serious, but it has to be checked, because it can be a sign of cancer, and cancer found early is easier to treat.
7. Routine: you have lost height, or your upper back has become more rounded and you are starting to stoop, or you have back pain, or pain that wraps around to your ribs, with no clear cause. Book an appointment with your doctor. A broken bone in the spine can cause this, and it does not always cause the pain you would expect. If the pain came on suddenly, get medical advice the same day.

Never stop or change a prescribed medicine on your own.

The short version

The syndrome is a proposed name for a real cluster, with no criteria and no test, and it is most useful as a prompt to ask about the whole picture. The prevalence evidence that holds up is the 2026 pooled estimate: muscle or joint pain in 57 percent of perimenopausal and 59 percent of postmenopausal women against 40 percent before, from cross-sectional data with high heterogeneity and no causal claim. The tendon mechanism is more complicated than the popular version, foot and heel pain has no prevalence evidence at all, and the clinical work is unchanged: load the tissue, measure strength, assess fracture risk, ask about the pelvic floor, and leave hormone decisions with the prescriber.

References

1. Wright VJ, Schwartzman JD, Itinoche R, Wittstein J. The musculoskeletal syndrome of menopause. Climacteric. 2024;27(5):466-472. https://doi.org/10.1080/13697137.2024.2380363
2. Kruse C, McKechnie T, Dworsky-Fried J, et al. Musculoskeletal manifestations of perimenopause: a systematic review and meta-analysis of 93,021 women. JBJS Open Access. 2026;11(1):e25.00254. https://doi.org/10.2106/JBJS.OA.25.00254
3. Lu CB, Liu PF, Zhou YS, et al. Musculoskeletal pain during the menopausal transition: a systematic review and meta-analysis. Neural Plasticity. 2020;2020:8842110. https://doi.org/10.1155/2020/8842110
4. Chidi-Ogbolu N, Baar K. Effect of estrogen on musculoskeletal performance and injury risk. Frontiers in Physiology. 2019;9:1834. https://doi.org/10.3389/fphys.2018.01834
5. Ansari M, Hussain F, Shopon M, Ajmal H, Asif M, David S. Hormonal shifts and structural strain: a literature review of menopause and perimenopause in relation to overuse injuries and stress fractures. Annals of Rehabilitation Medicine. 2026;50(3):139-149. https://doi.org/10.5535/arm.250134
6. Greendale GA, Sternfeld B, Huang MH, et al. Changes in body composition and weight during the menopause transition. JCI Insight. 2019;4(5):e124865. https://doi.org/10.1172/jci.insight.124865
7. Watson SL, Weeks BK, Weis LJ, et al. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. Journal of Bone and Mineral Research. 2018;33(2):211-220. https://doi.org/10.1002/jbmr.3284
8. Gregson CL, Armstrong DJ, Avgerinou C, et al. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis. 2025;20(1):119. https://doi.org/10.1007/s11657-025-01588-3

Written and checked by the PocketPhysio editorial team. Last updated 2026-10-26.