Pilates for psoriatic arthritis: joints, tendons, the spine and the skin, flares and fatigue, which moves to change, what the evidence shows, and classes

Exercise is part of treatment, alongside medicines

The NHS says medicines are the main treatment, and to exercise regularly. US and European rheumatology guidance recommends physical activity as part of care.

Sources 1, 2, 3

One small Pilates trial, not yet published in a journal

In 48 women, mat Pilates twice a week for 12 weeks improved everyday function, disease activity, tiredness and quality of life against medicines alone. It's an unreviewed thesis with a conference abstract, and the disease score includes patient-rated pain, which expectation can move.

Sources 4, 5

Other exercise trials are small but reassuring

Strength training improved function, and hard interval training raised fitness without raising inflammation on scans.

Sources 6, 7, 8

Adapt for heels, hands and skin

No jumping or long standing in a heel flare, no weight on flat hands with swollen fingers or sore wrists, and padding or changes for kneeling and for skin that flares where it rubs (our suggestions).

In a flare, scale back rather than stop

Keep to gentle movement and breathing, and leave strengthening of hot, swollen joints until they settle. Ask your team about a flare plan.

Sources 9, 10

Look after your heart, and know the urgent signs

Heart disease is more common with psoriatic arthritis, so add walking or other aerobic exercise. Get help the same day for a hot, swollen joint with a high temperature or a painful red eye.

Source 11

What it is

The NHS describes "a long-term condition that causes joint pain, swelling and stiffness", with swollen fingers or toes, nail changes and "feeling drained of energy". "Symptoms can be worse first thing in the morning and may improve with exercise."

Source 1

Who gets it

In 266 studies of people with psoriasis, about 1 in 5 had psoriatic arthritis (the Psoriasis and Psoriatic Arthritis Alliance, PAPAA, says about 3 in 10). The NHS says to see a GP for joint pain, stiffness and swelling that keeps coming back, even if you don't have psoriasis.

Sources 12, 13, 1

Where it shows up

Inflammation where tendons and ligaments attach to bone (enthesitis) affects about 4 in 10 at some point, most often at the Achilles tendon and the sole of the heel, and usually settles without a change of treatment. About a quarter get whole swollen fingers or toes (dactylitis), and about 6 in 10 have nail changes. In an international study of 409 people, about 1 in 4 had the spine or the joints at the base of the spine involved on scans.

Sources 14, 15, 16, 17

Tiredness, flares and the heart

About half have significant tiredness (fatigue). At any time about 1 in 10 are in a flare, and about 1 in 5 have one a year. Heart and circulation disease is more common (11 studies), and Arthritis UK lists exercising regularly among the ways to lower the risk.

Sources 18, 19, 11, 20

The skin

Psoriasis can appear where "shoes, clothing or jewellery rub the skin", and in skin folds it "can be made worse by friction and sweating". PAPAA says "Psoriasis is not generally affected by the chlorine in swimming pool water". In Pilates, that means mats, kneeling, reformer straps and sweat in heated classes.

Sources 21, 22, 13

Medicines

Anti-inflammatory painkillers, steroid injections, disease-modifying medicines (DMARDs) such as methotrexate and biological treatments. Some of these lower your resistance to infection, which is why the joint infection and methotrexate lines are in the warning signs.

Source 1

Where Pilates fits

Low-impact strength for the hips, trunk and legs, spinal extension and rotation, which NICE's exercise programme for spinal disease includes, breathing, and a choice of positions that can spare the heels, hands and knees. The trial used mat Pilates twice a week (our reading of why it suits).

Sources 10, 4

The one Pilates trial: encouraging, not settledEmerging evidence

In Izmir, Turkey, 48 women aged 18 to 65 with psoriatic arthritis were randomised to mat Pilates led by a physiotherapist (groups of 8, 60 minutes twice a week for 12 weeks) or their usual medicines alone; 43 finished. Pilates improved everyday tasks such as putting on socks and getting up from lying, a function score, a disease activity score (it fell by 6.5 points against 1.9), spine movement, tiredness, anxiety and quality of life. Lower back bending and low mood didn't change. No serious side effects were reported; about a quarter had muscle soreness for 3 to 4 days.

It's a master's thesis, presented as a conference abstract and not yet peer reviewed as a journal paper. It included only women, had no comparison class, and the disease activity score includes patient-rated pain, which expectation can move. Our searches found no other Pilates study in psoriatic arthritis.

Sources 4, 5, 23, 24

Other exercise trials: small but reassuringEmerging evidence

In 41 people in Brazil, strength training twice a week for 12 weeks improved function and disease activity scores against medicines alone. In 67 people in Norway, hard interval training for 11 weeks raised fitness but didn't clearly change disease activity or pain, and scans showed "no clear evidence of objectively measured increased inflammation".

Sources 6, 7, 25, 8

The evidence is thin overallStrong evidence

Reviews find few, small exercise trials in psoriatic arthritis, mostly at low or very low certainty, with improvements in function, pain and quality of life and no sign that exercise causes flares. For fatigue in psoriatic arthritis, the evidence is still inconclusive.

Sources 26, 27, 28, 29

The guidelinesStrong evidence

US rheumatologists conditionally recommend exercise over no exercise in active psoriatic arthritis, and low-impact exercise such as tai chi, yoga or swimming over high-impact exercise such as running (low and very low quality evidence). European guidance advocates physical activity as part of standard care. GRAPPA, an international psoriatic arthritis group, conditionally recommends physiotherapy for sore tendon attachments. The NHS says to exercise regularly, with low-impact exercise.

Sources 2, 3, 30, 1

Pilates in spinal arthritisEmerging evidence

In ankylosing spondylitis, a related spinal arthritis, Pilates improved function in a trial of 55 people, and a 2026 network of 59 trials found Pilates improved disease activity, function and pain against usual care. These studies didn't report including people with psoriatic arthritis. Our Pilates for ankylosing spondylitis guide covers them.

Sources 31, 32, 33

Load and the heelsMixed evidence

In 84 people, avoiding aggravating activities went with less inflammation at tendon attachments on ultrasound, but a badminton session didn't change pain in 16 people, and hard interval training didn't increase inflammation on scans. Load heels and tendons gradually; there's no evidence that Pilates harms them.

Sources 34, 35, 8

Sore heels and Achilles

Skip jumping, the reformer's jump board and long standing during a heel flare, and use off-feet strength work. Gentle calf holds and the plantar fascia stretch load the heel gradually. See your team if heel or tendon pain doesn't settle.

Source 15

Swollen fingers and sore wrists

Avoid weight on flat hands in the push-up, leg pulls, side bend and knee hover: use fists, forearms or a wall, or leave them out. Tendon glides keep stiff fingers moving.

The spine

Back extension (the swan, swimming), rotation (the spine twist, the open book) and side bending (the mermaid), with deep breathing, follow NICE's programme for spinal disease. With a stiff or fused spine, the rolling and legs-overhead moves are out, as their move pages say.

Source 10

Skin on the mat and the reformer

Use your own mat and a towel, pad kneeling, wear soft, loose layers, pad reformer straps over sore skin, rinse off after class, and skip heated rooms when your skin is flaring.

Sources 21, 22

Scale back, don't stop

Arthritis UK says to "focus on slow and gentle movement during a flare up, rather than stopping altogether". NICE suggests a flare plan that covers self-care such as exercises and stretching.

Sources 9, 10

On a flare day

Keep sore joints moving gently through their range a few times a day, lower the intensity (for example, 15-minute strolls instead of 30-minute walks), and stretch rather than strengthen hot, swollen joints until they settle. If discomfort lasts more than a couple of hours after exercise, do less next time, not nothing. Ask your team about a flare plan.

Leave strengthening until hot or swollen joints settle, and keep to breathing and gentle range, such as heel slides, ankle circles and hand glides. High-intensity, high-impact or high-volume exercise is the most likely to aggravate symptoms. A flare can last several days; if an activity always brings one on, avoid it.

Tired days

Fatigue fell more with Pilates than without in the one trial, but across studies the evidence on fatigue is inconclusive. Short, gentle sessions are easier to keep up on tired days (our suggestion).

Sources 4, 29

Medicines and infections

Never stop or change your psoriatic arthritis medicines because of exercise or a flare without your team (our suggestion; the NHS says medicines are the main treatment).

If you feel feverish or unwell, rest rather than exercise, as the warning signs say.

Source 1

Weight on flat hands

The Pilates push-up, leg pull front and back, side bend and knee hover, and the reformer's long stretch: fists, forearms or a wall, or leave them out with swollen fingers or sore wrists.

Kneeling

The kneeling side kick and kneeling on the reformer: pad it, or leave it out with sore knees or skin plaques on the knees.

Source 21

Jumping and long standing

The jump board and long standing on hard floors: leave out with heel pain.

Rolling and legs overhead

The roll-over, jack knife, rolling like a ball and the seal: their move pages already say to leave them out with a stiff or fused spine.

Long holds at the end of your range

Stop short with hot, swollen joints. With thin bones, from long-term steroids or after the menopause, the move pages' osteoporosis changes apply.

Chest pain or fainting: call 999

• You get sudden pain or discomfort in your chest that doesn't go away; it can feel like squeezing or pressure, burning or indigestion.
• The pain spreads to your left or right arm, or your neck, jaw, stomach or back.
• You have chest pain and feel sweaty, sick, light-headed or short of breath.
• Someone faints while exercising, can't be woken within 1 minute, or has chest pain or a pounding, fluttering or irregular heartbeat.

Sources 36, 37, 38

Call 999 or go to A&E: a serious skin flare

If you have psoriasis and your skin quickly turns red with white, pus-filled bumps that join together, patches on your feet turn yellow-brown and fill with pus, or red, scaly, pus-filled bumps appear on the tips of your fingers and toes, especially with a fast heartbeat, a high temperature, or feeling hot, cold or shivery.

Source 39

Urgent GP appointment or NHS 111: a hot, swollen joint

Get help the same day for a hot, swollen joint with a fever, or severe pain and swelling that came on suddenly in one joint.

Infection in a joint (septic arthritis) is more likely if your immune system is weakened. Ask for an urgent GP appointment or contact NHS 111 if you have:

• Severe pain that started suddenly, usually in 1 joint.
• Swelling around a joint, or skin around it that has changed colour.
• Difficulty moving a joint.
• Joint pain with a high temperature, or feeling hot, cold or shivery.

Source 40

A red, painful eye

NICE asks for an eye assessment the same day for symptoms of eye inflammation (uveitis), such as eye pain, redness, sensitivity to light or blurred vision. The NHS says to ask for an urgent GP appointment or contact NHS 111; untreated, it can cause the loss of some or all of your vision.

Sources 10, 41

On methotrexate: tell your doctor or call 111 immediately

Call 999 if your lips, mouth, throat or tongue suddenly swell, or you're struggling to breathe. Tell your doctor or call 111 immediately if you get:

• A high temperature, muscle aches or a sore throat (signs of infection).
• A cough that won't go away, chest pain, difficulty breathing or breathlessness.
• Yellowing of your skin or the whites of your eyes.
• Swollen hands, ankles or feet, or peeing much less than usual.
• Bleeding gums, blood in your pee, vomiting blood or unexplained bruising.

Source 42

Back pain with leg symptoms: call 999

Call 999 or go to A&E: loss of feeling or numbness around the genitals or bottom, new trouble peeing or controlling your bladder or bowels, changes in genital sensation during sex or problems with erections or orgasm, or pain, tingling, weakness or numbness in both legs. These are signs of cauda equina syndrome, which needs treating in hospital urgently. Don't drive yourself.

Source 43

See a GP or your rheumatology team

• Joint pain, stiffness and swelling that keeps coming back, even if you don't have psoriasis.
• Pain, heat and swelling that last more than a few days after exercise.
• A whole finger or toe that swells, or heel or tendon pain that doesn't settle.
• Low back pain that started before 45 and has lasted more than 3 months.

Sources 1, 10

Stop exercising

Stop if exercise brings sharp pain or swelling, and check how you're doing the move before trying again with less. Stop and get help for chest pain, palpitations (your heart pounding or fluttering) or unusual breathlessness, and rest if you feel feverish or unwell.

Breathlessness

Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.

Source 44

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 45

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

Source 45

"Exercise damages arthritic joints"Strong evidence

The guidelines recommend exercise as part of care, strength training improved function in a trial, and hard interval training didn't increase inflammation on scans. Hot, swollen joints are rested from strengthening, not from movement.

Sources 2, 3, 6, 8

"Rest completely in a flare"Emerging evidence

Arthritis UK advises slow, gentle movement during a flare rather than stopping altogether.

Source 9

"You need a reformer for real Pilates"Emerging evidence

The one Pilates trial in psoriatic arthritis used mat Pilates only. The reformer is an option, with care for straps on sore feet and kneeling on sore knees.

Source 4

"Pilates treats psoriatic arthritis"Strong evidence

Medicines are the main treatment. Exercise works alongside them, and the one Pilates trial is small and not yet a journal paper.

Sources 1, 4

"Pool chlorine makes psoriasis worse"Emerging evidence

PAPAA says pool chlorine generally doesn't. Friction and sweat can bother psoriasis in skin folds, so rinse off and wear soft, loose clothes.

Sources 13, 22

"If your heels hurt, stop exercising"Emerging evidence

Heel enthesitis often settles without a change of treatment. Swap to off-feet work and load the heel gradually, and see your team if it doesn't settle.

Source 15