Exercise guide
Regular exercise is recommended for people with haemophilia: strong muscles help protect your joints, and exercise is good for your bones, balance and weight. With modern treatment most sports are possible, and the lowest-risk choices include swimming, walking and cycling.
The main questions are timing and risk: when to exercise around your treatment, which sports carry the highest risk of a bleed, how to look after a target joint, and what to do if a bleed starts. Much of this is expert consensus rather than trial evidence, and your haemophilia team and physiotherapist decide what's right for you.
This guide sets out what the World Federation of Hemophilia (WFH), the National Health Service (NHS) and the Haemophilia Society say, with joint exercises based on the WFH's exercise booklet. It also covers von Willebrand disease, and women and girls with low clotting factor levels.
The NHS says get regular exercise to keep your joints healthy, and a physiotherapist can help you decide what's right for you. The WFH recommends regular activity for strong bones and muscles, coordination, a healthy weight and self-esteem, and the Haemophilia Society says strong muscles support your joints and make injury less likely.
In 8 trials (233 males), no harms were reported, and some found less pain and better joint movement and strength. Strength training raised knee and elbow strength, and aerobic exercise didn't increase bleeds or the amount of factor used.
With standard factor, levels peak after each injection and then fall, so the WFH suggests morning doses for daytime activity, a US booklet says time your treatment soon before you exercise, and St George's Hospital suggests treatment on the days you play sport. This is consensus advice, and your team sets your doses.
The WFH encourages non-contact sports such as swimming, walking, cycling and golf, and advises against collision sports unless your treatment covers them and you understand the risks. The NHS says don't do contact sports such as rugby or boxing unless your haemophilia team says it's safe.
A target joint has had 3 or more bleeds on its own in 6 months. See a physiotherapist before a new sport, start with gentle range and holding exercises, and remember the WFH booklet's rule: no gain with pain.
An early bleed can feel like tingling, bubbling or tightness in a joint, then swelling, warmth, pain and stiffness. Stop, treat it straight away with your usual medicine, and contact your haemophilia team. A head injury is always a 999 call.
Haemophilia is a rare condition that affects how your blood clots, so you bleed more easily than other people. Haemophilia A is a lack of clotting factor 8 and haemophilia B a lack of factor 9; they cause the same symptoms. Women with the altered gene (carriers) can have symptoms, though less often and less severe than in men.
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Severity depends on how much clotting factor you have, measured in international units per decilitre (IU/dL): under 1 is severe, 1 to 5 moderate, and over 5 up to 40 mild. People with severe haemophilia can bleed into joints and muscles with no obvious injury; people with mild haemophilia may bleed only after an injury or surgery.
The UK haemophilia registry lists 6,898 males with haemophilia A and 1,372 with haemophilia B, 12,389 people with von Willebrand disease (7,902 of them female), and 943 women and girls with factor 8 levels below 40 IU/dL.
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Joint bleeds are most common in the elbows, knees and ankles. Bleeds can also happen in muscles, including deep ones such as the iliopsoas in the groin, the calf and the forearm, where swelling can press on nerves. Repeated joint bleeds damage the joint over time, which is called haemophilic arthropathy.
Severe haemophilia usually needs preventive injections of clotting factor up to 3 times a week, often at home (prophylaxis). Mild and moderate haemophilia are usually treated when bleeding starts, or before surgery or dental work. Other medicines include emicizumab, which gives steady protection without the peaks and dips of factor, desmopressin and tranexamic acid.
Von Willebrand disease is a lack of von Willebrand factor, a protein that helps blood clot. The NHS says types 1 and 2 are the most common and usually cause mild symptoms, and type 3 is rare and more severe; the Haemophilia Society says type 3 affects about 1 in 500,000 people. Heavy periods are a common sign.
A Cochrane review found 8 small trials (233 males aged 8 to 49, lasting 4 to 12 weeks). None reported harms, though none measured them, and none favoured the group that didn't exercise. Some found less pain, especially with exercise in water, and better joint movement and strength. None reported bleeds or quality of life, and the authors say the results should be treated with caution.
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Across 7 studies in adults, strength training raised knee and elbow strength, by a small to moderate amount with elastic bands and a moderate amount with weights or machines. A review of 14 studies found it looked safe when it was supervised, adapted to the person and covered by enough factor, and lighter loads than usual still built strength.
In 7 studies of exercise in water, Nordic walking, treadmill running, cycling and swimming, neither bleeds nor the amount of factor used went up, and health measures improved. The authors found it safe when supervised by experts, but too few studies to set specific amounts.
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In 104 boys with moderate or severe haemophilia, collision-type activities such as basketball or wrestling made a bleed 2.7 to 3.7 times as likely in the next few hours. But for a typical active child, that accounted for only 1 of 5 bleeds a year, and each 1% rise in factor level meant 2% fewer bleeds. Across 36 studies, people with haemophilia have become more active as preventive treatment has improved.
Across 12 studies (1,210 people), bone density was lower in people with haemophilia than in people without it. The WFH recommends preventing joint bleeds, regular exercise and enough vitamin D and calcium, with weight-bearing activity as far as your joints allow.
The trials are small and short, and most are in men with severe haemophilia at specialist centres. In 18 strength training trials, only 11% said what factor cover people had and 28% gave a pain limit, so they can't tell you how to plan around treatment or pain. The WFH's advice on sport is all expert consensus. Preventing and treating bleeds is the job of your treatment, not exercise.
Regular physical activity and fitness for bone health, muscle strength, coordination, a healthy weight and self-esteem; non-contact sports; and a talk with a physiotherapist before starting a new sport, especially if you have a target joint.
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Regular exercise to keep your joints healthy, with a physiotherapist's help to choose it. St George's adds that the general guidelines apply: 150 minutes of moderate activity or 75 minutes of vigorous activity a week, and strength exercises on 2 or more days, chosen with your doctor and physiotherapist.
Exercise and fitness should be part of your everyday routine. There are very few sports you can't take part in, and activities such as swimming and cycling, which take weight off your joints, are encouraged. Talk to your haemophilia team before starting, especially after a long break.
This plan is our editorial starting point. Build towards 150 minutes a week of moderate activity with lower-risk choices; add strength training 2 or 3 times a week with bands, machines or your own body weight, starting light and staying pain-free (the strength trials ran for 5 weeks or more); do a joint routine for your knees, ankles and elbows on most days; and warm up for 5 to 10 minutes every time, as the Haemophilia Society suggests.
This is consensus advice from guidelines and haemophilia centres; no source gives an exact number of minutes or hours. Your team sets your doses, so don't change them yourself.
Factor levels rise after each injection and then fall, so the WFH says it makes sense for most people to inject in the morning, when they're more active, and that sport is better supported by your factor level at the time you play. The US National Hemophilia Foundation's booklet says time your treatment soon before you're active, St George's suggests arranging treatment on the days you play sport, and the Haemophilia Society says your schedule can be planned so your levels are highest when you're most active.
The WFH says the longer a product lasts, the less the timing of injections matters.
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For haemophilia A, emicizumab gives steady protection without peaks and troughs, so there's no peak to time. It isn't used to treat a bleed, so breakthrough bleeds still need your treatment plan.
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The Haemophilia Society says some riskier activities may be done safely when a bleeding disorder is mild or moderate, so discuss them with your centre. Some parents give treatment on school sports days.
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The WFH encourages non-contact sports such as swimming, walking, jogging, golf, badminton, archery, cycling, rowing, sailing and table tennis. The Haemophilia Society says swimming, cycling and walking work well.
The WFH advises against high-contact and collision sports, such as football, hockey, rugby, boxing and wrestling, and high-speed activities such as motocross and skiing, unless you're on preventive treatment that covers them and you understand the risks. The NHS says don't do contact sports such as rugby or boxing unless your haemophilia team says it's safe. Haemophilia Foundation Australia adds sports with repetitive or extreme movements, or great heights.
The US National Hemophilia Foundation's "Playing it safe" booklet rates activities from 1 (low risk) to 3 (high risk), and says the ratings are not recommendations: they come from injury rates in the general population, not people with bleeding disorders. The WFH and the US ratings differ on football: the WFH lists it with collision sports, and the booklet rates it 2 to 3.
The WFH suggests seeing a physiotherapist first, especially with a target joint; custom mouthguards for all contact sports; and organised sport, where protective kit and supervision are more likely, over casual games. St George's says wear the right protective equipment, because a direct blow can cause a bleed.
Once a bleed has settled, as your physiotherapist advises. The supine heel slide page's dose is 10 slow repetitions each side, once or twice a day; the ankle circles page's is 10 slow circles each way with each foot; the elbow bend and straighten page's is 10 slow repetitions, up to 4 times a day; and the knee-to-wall page's is 10 slow rocks per side, daily. Do the forearm turns without a weight at first, and skip the knee-to-wall rock if your ankle is swollen or sore (our suggestion, following the WFH booklet).
Holds first, then moving, in the WFH booklet's order; its dose is to hold for several seconds and repeat until the muscle feels tired. The seated knee extension page's dose is 3 sets of 10 to 15 each leg, 2 to 3 days a week, and the band row page's is 3 sets of 10 to 15, stopping 2 to 3 reps short of failure. For the rest, 5 to 10 slow repetitions is our editorial starting point. Stop for any new pain.
3D demoQuad set (static quads)Beginner · No equipment
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoTibialis raiseBeginner · No equipment
3D demoSlow calf raiseBeginner · A wall
3D demoSit to stand from a chairBeginner · A bench or box
3D demoWall sitBeginner · A wall
3D demoLow step-upBeginner · A step
3D demoBand rowBeginner · A band + An anchor point
3D demoWall push-upBeginner · A wall
3D demoGlute bridgeBeginner · No equipmentThe WFH booklet's goal is to hold a single-leg stand for 30 seconds, then with your eyes closed, near a wall. For the heel-to-toe walk, 10 steps twice beside a wall is our editorial starting point; for the heel walk, the booklet says add a few steps each day.
All rated 1 or 1.5 in the US ratings. The recumbent bike and elliptical trainer pages' dose is 10 to 20 minutes at a moderate effort to start, building towards 30, and the indoor rowing page's is 3 rounds of 4 to 5 minutes at a pace you could hold a conversation at.
3D demoRecumbent exercise bikeBeginner · Cardio machine
3D demoStationary cyclingBeginner · Cardio machine
3D demoElliptical trainerBeginner · Cardio machine
3D demoTreadmill walkingBeginner · Cardio machine
3D demoIndoor rowing (rowing machine)Beginner · Cardio machine
Front crawl (freestyle swimming)Intermediate · Other / check instructionsA single joint that has had 3 or more bleeds with no obvious injury within 6 months in a row, the WFH says.
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The WFH booklet says holding exercises, where a muscle tightens without the joint moving, are an excellent way to start when muscles are very weak or joints are very painful. Soon after a bleed, two or three repetitions may be all you can manage, and discomfort usually means you've done enough for that session.
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If a new pain starts during exercise, the booklet asks whether it's muscle tiredness or a new bleed. It also says think about your other joints: a knee exercise may be too much for a damaged ankle on the same leg.
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Braces or splints can protect a target joint during activity, especially without factor cover, the WFH says. Haemophilia centres' physiotherapists check your joints, often once a year, and can tailor your exercises; Oxford's centre gym has a bike that can be set up for any amount of knee movement.
A joint bleed often starts with an aura: a tingling or bubbling feeling and tightness in the joint. Then come swelling or warmth, pain, stiffness and loss of movement. A muscle bleed can feel tight, hot or stiff, and make an arm or leg hard to move.
Stop exercising straight away. Treat the bleed as soon as you can with your usual medicine, then contact your haemophilia team, or NHS 111 if they're not available. Protection, rest, ice, compression and elevation (PRICE) can ease pain and swelling, but they don't stop a bleed.
Advice on ice ranges from 10 to 20 minutes at a time. The WFH says 15 to 20 minutes, soon after the bleed starts, never directly on the skin, and notes a debate about whether cooling slows clotting. The Haemophilia Society's booklets say about 15 minutes every 2 hours, 20 minutes on and 20 off, or 10 minutes repeated every 10 minutes if symptoms last, and warn that leaving it on too long can weaken the muscle. Follow your centre's plan.
Rest the joint in its most comfortable position, often slightly bent. After a hip, knee or ankle bleed, the WFH suggests keeping weight off it for about a week, using crutches, until its movement and strength are back, then building up gradually with a physiotherapist.
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Muscle bleeds are usually treated for 5 to 7 days or longer. A bleed into the iliopsoas, the deep muscle at the front of the hip, can cause pain in the lower tummy, groin or lower back and make it hard to straighten your hip or stand up from sitting; it can be mistaken for appendicitis. It may need strict bed rest, and activity waits until the pain has gone and your hip straightens again.
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The Haemophilia Society says primary school sport isn't usually competitive or rough, so children should be able to join in with all of it unless they have a problem or are recovering from a bleed. Children with severe bleeding disorders should avoid contact sports, and parents should talk to physical education (PE) staff.
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A head injury is always serious. The US booklet says a head blow with signs of concussion in a child with a bleeding disorder may be life threatening: in the UK, call 999.
The NHS says avoid sports or activities likely to cause injuries, particularly if your symptoms are more severe, and avoid ibuprofen, other anti-inflammatory painkillers and aspirin. The Haemophilia Society says swimming, cycling and walking work well, and to check with your haemophilia centre before starting an exercise programme.
Carriers can have symptoms of haemophilia. The UK registry lists 943 women and girls with factor 8 levels below 40 IU/dL, which is within the range for mild haemophilia, so the same advice on bleeds and sport can apply.
NICE (the National Institute for Health and Care Excellence) says testing for a bleeding disorder such as von Willebrand disease should be considered if you've had heavy periods since your first period and you or your family have a history that suggests one. Our anaemia guide covers exercise with heavy periods.
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The Haemophilia Society suggests heel-to-toe walking and single-leg stands holding a chair, stretching daily, and strength training with light weights, bands or your own body weight. It suggests talking to your physiotherapist first.
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Weight-bearing exercise such as walking, plus water exercise or an exercise bike, and strength training help keep bones strong, the Haemophilia Society says. Bone density tends to be lower with haemophilia.
Start with 5 to 10 minutes of gentle activity such as walking, then move your joints through their range. Afterwards, hold stretches for 15 to 30 seconds and breathe slowly.
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With a target joint or joint damage: jump squats, box jumps, skipping, pogo hops and burpees, until your physiotherapist says your joints are ready. Jumping rope is rated 2 and trampolines 2.5 to 3, and the WFH booklet saves small jumps for last, never on a swollen or painful knee or ankle.
Powerlifting is rated 3, while strength training is 1.5. Strength training looks safe when it's supervised, adapted to you and covered by enough factor, so keep loads moderate and ask your centre about factor cover for heavier training.
Don't force range on a damaged joint: discomfort usually means you've done enough for that session.
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Only if your haemophilia team says it's safe.
Stop at the first sign, and let your physiotherapist guide your return.
Our suggestions: the haemophilia joint exercises on most days between bleeds. The arthritis, hypermobility and resistance band routines build strength (swap full push-ups for wall push-ups if an elbow is a target joint); in the joint care workout, keep the circles small around a target joint; in the foot and ankle routine, leave out the ankle bounces with a target ankle; and in the knee workout, do the first half only and leave the deep squats and reverse Nordics to your physiotherapist. Swim and cycle for low-risk cardio.
A 20-minute routine for haemophilia between bleeds: joint range, isometric holds, light strength and balance for the knees, ankles and elbows, at your own pace.
20 minBeginner15 movesA dumbbell, A bench or boxA 30-minute joint-friendly circuit built like the GLA:D and ESCAPE-pain programmes: a gentle warm-up, chair, step and band strength moves, balance, then stretches.
30 minBeginner14 movesA bench or box, A stepA 25-minute low-load routine for hypermobile joints: hip, trunk and shoulder control plus balance, done slowly in the middle of your range.
25 minBeginner15 movesA bench or box, A wallA 25-minute session for healthy joints: slow circles to take every joint through its range, then a strength circuit for hips, knees, ankles, shoulders and grip.
25 minBeginner13 movesA wall, A bench or boxA full-body resistance band workout: squats, rows, push-ups, presses, pull-aparts, band walks, good mornings and flyes.
30 minBeginner9 movesA band, An anchor pointA 15-minute barefoot routine for stronger toes, arches, calves and ankles, finishing with balance. You need only a towel, a wall and a resistance band.
15 minBeginner11 movesA wall, Other / check instructionsA 25-minute session for knees that don't currently hurt: thigh and hamstring strength, single-leg control, then an optional full-range block with knees over toes.
25 minBeginner13 movesA bench or box, A wallA 30 to 45-minute beginner pool swim: a shoulder warm-up on the side, easy lengths, a main set of repeats with rests, and an easy swim down, any stroke.
35 minBeginner5 movesOther / check instructionsA steady bike ride for a first triathlon or fitness: 5 to 10 minutes easy, a ride you can talk through, optional short faster bursts and an easy cool-down.
45 minBeginner4 movesCardio machine, A wallA 25-minute standing cardio circuit with no jumping: marching, step jacks, sit-to-stands, punches, step-ups and wall push-ups, with a seated option for most moves.
25 minBeginner9 movesA bench or box, A stepA 40-minute strength and balance session for over-65s, built from the Otago home programme and NHS exercises, using a chair, a counter and a step.
40 minBeginner18 movesA bench or box, Something with weightThe walking plan builds to 150 minutes a week; the resistance band plan adds strength 3 days a week with bands.
A free 8-week walking plan for beginners: build to 150 minutes of brisk walking a week, with intervals, hills and two short strength sessions.
6 training days40 minBeginner3 days a weekAn 8-week resistance band workout plan: three full-body sessions a week at home or away, with how to choose bands, add tension and anchor them safely.
3 training days35 minBeginnerThis is general information, not a diagnosis. In the US, call 911 where this page says 999.
If you can, treat any bleeding straight away with your usual medicine before going, and contact your haemophilia team after calling 999. Don't drive yourself to A&E. The NHS lists:
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The Haemophilia Society says bleeding in the head can follow a blow or happen with no obvious cause: a bad or worsening headache, being sick, confusion, drowsiness, slurred speech, a stiff neck, weakness, or trouble with bright light or vision. It's an emergency. Bleeding in the throat or neck is an emergency too, because it can block the airway.
If you have pain, swelling, tingling or numbness in a joint or muscle, which could be a bleed; blood in your pee, which may be bright pink, red or dark brown; you're worried about any bleeding; or you're bleeding and don't have medicine to treat it. Treat any bleeding first if you can, and call NHS 111 if your team isn't available.
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Pins and needles, tingling, a change of colour in the skin over the muscle or swollen veins are more serious signs: contact your team straight away. So is pain in the groin, lower tummy or lower back with a hip you can't straighten, which can be a bleed into the iliopsoas.
Call your haemophilia centre if a bruise is on your head or neck; comes with swelling, numbness or tingling; hurts; makes it hard to move; has a lump that grows or doesn't go away; or followed a blow to your head or stomach.
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The NHS says don't take aspirin, ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs), and check with your haemophilia team before any new medicine. The Haemophilia Society suggests paracetamol instead.
For chest pain that feels tight or like squeezing, or spreads to your arms, neck or jaw; severe difficulty breathing; or someone passing out and not responding normally. After a fall, any knock to the head is a 999 call with haemophilia, and the NHS's general advice is: call 999 if someone may have hurt their head, back, neck or hip or can't get up, and get help from NHS 111 if they may be in pain, injured or unwell.
St George's Hospital says that 20 years ago people with haemophilia were discouraged from sport for fear of bleeding, but with prophylaxis from an early age an active lifestyle is now encouraged. The NHS and the WFH recommend regular exercise.
Aerobic exercise didn't increase bleeds or factor use in 7 studies. Collision-type activities raised the risk for a few hours in one study, but for a typical active child accounted for only 1 of 5 bleeds a year, and strong muscles help protect your joints.
The Haemophilia Society says there are very few sports you can't take part in. The WFH lists many non-contact sports, and the US ratings put walking, golf, an exercise bike, an elliptical trainer and tai chi in the lowest-risk group too.
The WFH says collision sports should be avoided unless your treatment is enough to cover them and you understand the risks, and the NHS says not unless your team says it's safe. Emicizumab isn't used to treat a bleed, and a head injury is still a 999 call.
The WFH booklet says "No gain with pain": a new pain may be a bleed, and discomfort usually means you've done enough for that session.
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Carriers can have symptoms of haemophilia, 943 women and girls in the UK are registered with factor 8 levels below 40 IU/dL, and more women than men are registered with von Willebrand disease.
Yes, and it's recommended: the NHS says get regular exercise to keep your joints healthy, and a physiotherapist can help you choose. Strong muscles support your joints, and trials of exercise in haemophilia reported no harms. Talk to your haemophilia team before starting something new, especially after a long break.
The World Federation of Hemophilia encourages non-contact sports such as swimming, walking, jogging, golf, badminton, archery, cycling, rowing, sailing and table tennis. A US booklet rates swimming, walking, golf, an exercise bike, an elliptical trainer and tai chi as low risk.
The NHS says don't do contact sports such as rugby or boxing unless your haemophilia team has told you it's safe. The World Federation of Hemophilia advises against collision sports, including football, unless your treatment covers them and you understand the risks, while a US booklet rates football 2 to 3 on its 3-point scale. Your team and physiotherapist can help you weigh up a sport you love.
With standard factor, levels are highest after an injection, so the World Federation of Hemophilia suggests morning doses for daytime activity and a US booklet says time treatment soon before you're active. Some centres suggest treatment on the days you play sport. This is consensus advice and your team sets your doses, so don't change them yourself.
Emicizumab gives steady protection without the peaks and dips of factor, so there's no peak to time your activity around. It isn't used to treat a bleed, so breakthrough bleeds still need your treatment plan, and the advice on contact sports still applies.
Yes, with care: strength training raised knee and elbow strength in studies, and a US booklet rates it low to moderate risk. Our suggestion: start light, build up slowly, avoid maximal lifts (powerlifting is rated high risk), and ask your centre about factor cover for harder sessions.
Stop straight away, treat it with your usual medicine as soon as you can, then contact your haemophilia team, or NHS 111 if they're not available. Protection, rest, ice, compression and elevation can ease the pain but don't stop the bleed. Call 999 for a head injury, a serious injury or a sudden bad headache.
A joint bleed often starts with tingling or a bubbling feeling and tightness, then swelling, warmth, pain and stiffness. The World Federation of Hemophilia's exercise booklet says check any new pain carefully, because it may be a bleed rather than tiredness, and the NHS says treat bleeding as soon as possible. If you're not sure, treat it and call your team.
After a hip, knee or ankle bleed, the World Federation of Hemophilia suggests keeping weight off the joint for about a week, with crutches, until its movement and strength are back. Then build up gradually with your physiotherapist, starting with gentle range and holding exercises.
Gentle range of movement, holding exercises, then light strength and balance work, which is the order the World Federation of Hemophilia's exercise booklet uses. Braces or splints can protect a target joint during activity, and a physiotherapist should check new sports first.
Yes: the Haemophilia Society says swimming, cycling and walking work well. The NHS advises avoiding sports likely to cause injuries if your symptoms are more severe, and carriers can have bleeding symptoms too, so ask your haemophilia centre.
No: the NHS says don't take aspirin, ibuprofen or other anti-inflammatory painkillers with haemophilia, and check with your team before any new medicine. Paracetamol is usually used instead.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
