Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review

Antoranz, Yoel; Ruiz Freire, Manuel; Tejero-González, Carlos Mª

doi:10.3390/physiologia5040051

Open AccessSystematic Review

Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review

by

Yoel Antoranz

^1,*

,

Manuel Ruiz Freire

² and

Carlos Mª Tejero-González

¹

Department of Physical Education, Sport and Human Movement, Universidad Autónoma de Madrid, 28049 Madrid, Spain

²

Faculty of Education, Universidad del Atlántico Medio (UNAM), Ctra. de Quilmes, 37, Tafira Baja, 35017 Las Palmas, Spain

^*

Author to whom correspondence should be addressed.

Physiologia 2025, 5(4), 51; https://doi.org/10.3390/physiologia5040051 (registering DOI)

Submission received: 23 September 2025 / Revised: 24 November 2025 / Accepted: 26 November 2025 / Published: 30 November 2025

(This article belongs to the Section Exercise Physiology)

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Abstract

Background/Objectives: Osteoporosis is a global health issue characterized by decreased bone mineral density (BMD), which increases the risk of fractures in adulthood. Adolescence, particularly the pubertal stage, is a critical period for maximizing BMD, and physical activity is a key modifiable factor in this process. The aim of this study was to conduct a systematic review of physical exercise interventions aimed at improving BMD in adolescents. Methods: The PRISMA methodology was applied, with searches conducted in PubMed, Web of Science, and SPORTDiscus. Included studies involved participants aged 11 to 18 years, structured physical activity interventions, and valid methods for assessing bone quality. Studies that included supplementation, lacked sufficient intervention details, or had no comparison group were excluded. Results: A total of 1464 articles were identified, of which 17 met the inclusion criteria and were analyzed. The results suggest that strength training programs and impact activities (such as football, volleyball, plyometric exercises, or running) appear to show benefits for bone development compared to control groups or non-osteogenic activities. The combination of strength and impact may reduce the time required to achieve measurable improvements. Non-osteogenic activities such as swimming and cycling showed no benefits on their own but may be beneficial when combined with resistance or impact training. The qualitative analysis indicates a certain risk of bias across the studies included. Conclusions: Although available evidence indicates that exercise programs involving strength or impact activities of around 8 months in duration and with a frequency of three sessions per week can be beneficial, these recommendations should be interpreted with caution due to the heterogeneity and limited number of studies, as well as the low certainty of the evidence. The combination of strength and impact exercises seems to shorten the intervention time required to achieve measurable improvements to approximately 6 months. These interventions appear to be most effective during early and middle adolescence, but current data do not consistently support sex-related differences.

Keywords:

osteoporosis; puberty; bone health; strength training; impact exercise

1. Introduction

Osteoporosis is a major global health issue and imposes a considerable annual economic burden [1,2]. It is a skeletal disorder that may affect a substantial proportion of women over 50 years of age and men, particularly those older than 65 [3,4,5]. Its onset and progression are largely determined by bone mineral density (BMD) [3], defined as the concentration of mineral content within the skeletal system [6]. Bone tissue undergoes continuous modeling and remodeling processes through the coordinated activity of osteoclasts and osteoblasts [6]. It serves as a reservoir for calcium, magnesium, and phosphorus and is essential for maintaining mineral homeostasis and the structural integrity of the skeleton [7].

BMD is a parameter commonly used to assess bone quality and is frequently employed to estimate the risk of developing osteoporosis or sustaining fractures [8]. Its measurement is performed primarily through dual-energy X-ray absorptiometry (DXA), regarded as the gold standard [2,5,9,10], although tomographic techniques (QCT, pQCT, HR-pQCT) and ultrasonography (QUS) may also be utilized [9].

Several factors influence bone BMD. Approximately 80% of its variance is primarily determined by genetic factors, such as sex, race, and hormonal influences [7,8]. However, this percentage should be interpreted as an estimate, as studies involving families and twins suggest that between 50% and 85% of BMD variation can be attributed to genetic inheritance, mainly through specific genes such as LRP5 and ESR1 in children and adolescents [11]. Age and sex also exert an influence, with women and older adults being at greater risk of having reduced BMD [11].

Beyond genetic influences, evidence indicates that between 20% and 40% of BMD variance may be associated with modifiable lifestyle factors, depending on the study, primarily modulated by dietary habits such as calcium and protein intake (which supports the action of IGF-I), vitamin D levels, and physical activity [7,8,11]. In addition, some studies suggest that higher socioeconomic status and residing in urban areas—particularly in low- and middle-income countries—are associated with higher BMD [10,11]. These percentages come from different studies and represent approximate estimates rather than exact values; therefore, they should not be interpreted as directly comparable or additive.

Bone tissue formation begins during fetal development [12]. One of the most critical periods is puberty, during which there is a marked increase in bone growth and mineralization [13]. During this stage, it may be developed to 95% of its final form, representing a window of opportunity to achieve a high peak bone mass [1,7,14,15] thereby reducing the risk of osteoporosis and fractures in adulthood and later life [11]. Bone mass loss is a gradual and common process associated with aging; however, it may be accelerated or exacerbated by various factors, ultimately leading to the disease [16].

The World Health Organization (WHO) defines osteoporosis as a systemic skeletal disease characterized by the deterioration of the bone tissue microarchitecture [17,18,19]. It is marked by a decline in bone mass and strength, resulting from deficiencies in the continuous remodeling process, thereby increasing the risk of fractures [18,19]. The condition predominantly affects postmenopausal women due to the reduction in estrogen levels, which enhances osteoclastic activity and accelerates bone mass loss [19,20].

Although osteoporosis primarily affects older adults, there is scientific consensus that osteoporosis can be considered a “pediatric disease” [2]. An increase of just 10% in peak bone mass could delay the onset of the disease by up to 13 years [2]. The most effective prophylaxis involves optimizing peak bone mass, particularly during puberty and adolescence [2,16], which would contribute to healthier aging.

Bone tissue is a living tissue that responds to muscular activity, which exerts a positive influence [11]. Mechanical loading and the minor deformations imposed on bones trigger biochemical responses through cellular mechanotransduction [21]. Mechanosensors detect applied loads and initiate reactions that increase osteocyte activity, inhibit osteoclast formation, and promote osteoblast function [21]. This process stimulates increases in peak bone mass and BMD in mechanically stressed areas [21]. with maximal effectiveness during growth and development [22]. However, according to Frost’s classical Mechanostat theory and later Ferretti et al., mechanical stress on bone must not exceed certain limits, above which the risk of tissue injury or damage increases [1,23,24]. Therefore, identifying the types and doses of physical exercise that provide optimal skeletal stimulation is of great value.

Various studies in sports such as swimming and cycling indicate that these low-impact activities do not substantially stimulate bone mass synthesis [2,25,26].

High-impact sports involving jumping, running, or resistance training appear to be the most effective activities for promoting bone development and formation [20,27], generating greater mechanical stress, in line with the previously mentioned Mechanostat theory [1].

As previously noted, women have a higher biological risk of developing osteoporosis [11,19,20]. This is not solely a biological issue but also a social one. Women have traditionally had lower access to sports participation, resulting in reduced involvement overall [28], although this trend is currently reversing [28].

Therefore, the aim of this work is to conduct a systematic review of training methods, sports, and physical education programs that enhance or stimulate BMD development during puberty, evaluating their effectiveness in relation to activity type, volume, intensity, frequency, phase of adolescence, and the sex of the student or athlete. Based on the reviewed literature, we hypothesize that physical activity programs involving impact-loading exercises and/or resistance training, performed at least three times per week for 60 min per session, would increase bone mineral density (BMD) in adolescents, and that combined modalities would produce greater adaptations than each modality alone.

2. Materials and Methods

2.1. Study Design and Search Strategy

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology [29]. The review was not recorded in any public registry. The search was performed during May 2025. The databases consulted were PubMed, Web of Science (WoS), and SPORTDiscus. The search engine query used was as follows:

(“resistance training” OR “plyometric training” OR “strength training” OR “physical education” OR “school physical activity” OR “sport”) AND (“bone mineral density” OR “bone health”) AND (adolescen* OR teen* OR youth) NOT (animal).

The same search strategy was applied across all three databases. No additional filters were applied during the search. Duplicate records were identified and removed manually using Microsoft Excel by sorting all retrieved references alphabetically by title.

2.2. Inclusion Criteria

The inclusion criteria were determined using the PICOS methodology [30] which considers the following characteristics: participants (P), interventions (I), comparisons (C), outcomes (O), and study design (S). (P) Full-text scientific articles including adolescent populations, with mean ages between 11 and 18 years at the start of the intervention, both male and female, without musculoskeletal pathologies or injuries, and participating in physical activity, exercise programs, physical education, or sports in school, extracurricular, recreational, competitive, or federated contexts. (I) Physical activity–based interventions, including structured exercise programs (e.g., resistance training, plyometrics, sports, or school-based motor activities) aimed at improving bone health or bone mineral density (BMD), or, if not the primary objective, reporting variables related to bone health. (C) Studies comparing the intervention with a control group (no intervention, habitual school-based physical activity, or “non-osteogenic” intervention) allowing assessment of effects. (O) Studies reporting outcomes on BMD or other bone health indicators, measured using valid methods such as DXA, pQCT, QUS, or QCT. (S) Randomized controlled trials (RCTs), quasi-experimental designs, or longitudinal studies with a comparison group.

The age range commonly cited in the scientific literature for adolescence is 10 to 19 years, although it may extend up to 24 years [31]. Based on systematic reviews conducted with adolescent populations by Gonzalez Moreno and Molero Jurado, Lüddeckens, and Tayfur et al., and their inclusion criteria, the present study established a minimum mean age of 11 years and a maximum mean of 18 years at the start of the intervention [32,33,34].

All studies published up to May 2025 were considered, with eligibility restricted to articles written in English.

The following criteria were applied for article exclusion. Studies combining physical activity programs with nutritional supplementation or pharmaceuticals were not included. Articles that did not provide at least minimal details on the type of intervention or on weekly, total, or average physical or sports activity were excluded. Cross-sectional studies, comparative studies without baseline and post-intervention measurements, and studies based solely on associations were also excluded.

2.3. Quality Assessment and Risk of Bias

The articles selected for inclusion in the review were qualitatively assessed following different tools according to the study design: the RoB 2 methodology for RCTs designs, and the ROBINS-I tool, for quasi-experimental or longitudinal designs. Both tools are based on the guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions [30,35]. RoB 2 evaluates specific domains of bias in RCTs, including bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. In contrast, ROBINS-I is designed for non-randomized studies and assesses bias due to confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of the reported result [30,35]. Two researchers (Y.A. and M.R.F.) independently evaluated the articles using this tool. In cases of disagreement, a third researcher (C.M.T.-G.) was consulted to resolve discrepancies.

2.4. Assessment of Certainty of Evidence (GRADE)

To assess the certainty of the scientific evidence for each outcome, the GRADE methodology was applied, following the specific guidance for using it in systematic reviews without meta-analysis or without pooled effect estimates [30,36].

2.5. Data, Variables, and Reviewed Measures

All data used in this review were extracted directly from the included studies without additional analyses. The main variables analyzed were related to bone mineral density (BMD), bone mineral content (BMC), and other biological markers of bone quality or development (e.g., broadband ultrasound attenuation, speed of sound, calcaneal stiffness index, cross-sectional bone area). Data on effect measures and inferential statistics (e.g., p-values, effect sizes, percentage changes) were extracted when reported in the original studies. This information was extracted directly from the included studies without performing any additional analyses. Furthermore, information was collected on other study characteristics, including participants’ age, the intervention protocol or type of activity performed, and the duration of the intervention period. No contact was made with the study authors to obtain information beyond what was reported in the published articles. Results of individual studies and the overall synthesis were presented using structured evidence table summarizing key study characteristics, including author, year, study design, sample size, population characteristics, intervention type, duration, and primary outcomes related to bone health (BMD, BMC, and other relevant markers). No graphical synthesis such as forest plots was performed, but data were organized to allow clear comparison across studies and outcomes.

2.6. Eligibility for Synthesis

The eligibility of studies for the synthesis was determined based on whether the included studies reported relevant data on bone health outcomes following physical activity interventions. This encompassed not only bone mineral density BMD but also BMC and other biological markers of bone quality or development (e.g., broadband ultrasound attenuation, speed of sound, calcaneal stiffness index, cross-sectional bone area). In addition to reporting these outcomes, studies were required to meet all other predefined inclusion criteria. All studies meeting these conditions were incorporated into the overall synthesis without performing any additional subgrouping or analyses.

2.7. Data Extraction and Reliability

A standard data extraction template was developed to extract the main details for every eligible study in terms of author, title, objective, sample size, country, design, physical activity. These first details were used as a basis of the evidence tables. The search process was carried out by all three researchers (Y.A., C.M.T.-G., and M.R.F.). A single researcher (Y.A.) examined every title and abstract to identify potentially relevant studies for review. In cases of uncertainty, both the second (C.M.T.-G.) and third (M.R.F.) researchers verified the selection process. After this initial screening, two authors (Y.A. and M.R.-F.) independently analyzed the remaining studies. In cases of disagreement, a third author (C.M.T.-G.) made the final decision.

3. Results

3.1. Search Results

A total of 1464 records were identified in the scientific literature across the three databases: 621 in WoS, 651 in PubMed, and 192 in SPORTDiscus. Of these, 401 were duplicates. Of the remaining 1063 records, 755 were excluded based on the title and 262 based on the abstract. Full-text evaluation was conducted for the remaining 46 studies (see Figure 1), of which 29 were excluded for failing to meet one or more inclusion criteria. The main reason for exclusion was noncompliance with the predefined age range of the study population. Additional reasons included insufficient details on the characteristics or duration of the intervention, absence of a control or comparison group, and unavailability of the full-text article (see Appendix A, Table A3).

The remaining 17 articles, following qualitative assessment, were included in the review [37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53]. Table 1 presents the included studies, sample details, intervention duration and basic characteristics, as well as the main outcomes. Some studies analyzed additional variables unrelated to BMD or other bone health indicators, such as performance measures or other body composition characteristics; these variables were not considered in the review. Of the included studies, 4 were RCTs, 7 employed longitudinal designs, and 6 were quasi-experimental. This methodological diversity, together with the variability in outcome variables and assessment techniques, resulted in a considerable degree of heterogeneity among the findings.

3.2. Main Outcomes

Ten of the studies included in this review involved interventions or follow-up programs that incorporated resistance training [37,38,40,44,45,47,48,49,51,52,53]. Three of the studies included implemented programs lasting 8–12 min per session, performed two to three times per week [37,38,52]. In all of them, the general trend indicates that the groups performing resistance training in addition to regular physical education achieved significantly greater improvements than the control groups. More specifically, in the study by Bernardoni et al., only girls in Tanner stage II (femoral neck, p = 0.01) and stage III (L3, p = 0.01) showed significant gains, while in Thein-Nissenbaum et al., the group training at higher intensity exhibited superior outcomes (femoral head, L3; p ≤ 0.05) [37,38,52]. In the study by Nichols et al. [49], which implemented resistance training sessions lasting 30–45 min three times per week, significant improvements were observed in the femoral head for the training group (p < 0.01), whereas no changes were found in the control group. In contrast, the study by Blimkie et al. reported no changes in BMD or BMC after 26 weeks of intervention [51]. Studies combining resistance training with other exercise modalities, such as indoor cardiovascular cycling, plyometric training, swimming, or alpine skiing, also reported significant improvements in bone parameters in the experimental groups compared with the control groups [40,44,45,47,48].

Two of the studies included plyometric exercises, both combined with resistance training. In both cases, the intervention groups showed significant improvements in various bone parameters compared with the control groups [45,48].

Four of the included studies involved samples of football players [39,43,46,50]. In the study conducted by Ferry et al., which focused on female athletes, the players showed greater increases in BMD compared with control groups [39]. Similarly, in studies involving male participants, Ubago-Guisado et al. and Vlachopoulos et al. observed that after one year of football training, bone parameters improved significantly more than in cyclists and swimmers [43,50]. In the study by Lozano-Berges et al., which compared different playing surfaces, football players showed greater increases in leg BMD (p < 0.05) and in lumbar spine BMD among those training on non-elastic turf (p < 0.05) [46]. Only one study analyzed volleyball players compared with a control group. For all parameters assessed, the athlete group showed significantly greater increases in BMD after 12 months of training across all measured sites (p < 0.05) [53].

Only one study examined gymnastics as a discipline. In this study, the athlete group showed greater improvements in BMD compared to the control group, although the differences were not always statistically significant [41]. Similarly, only one study analyzed alpine skiing, in this case combined with resistance training, showing significant improvements compared with the control group, as previously mentioned [44]. No studies were found that examined this sport in isolation.

Swimming was analyzed in five studies [39,42,43,47,50]. In four of these, swimmer groups did not show significant improvements compared with control groups. Only one study, in which swimming was combined with resistance and impact training, reported significant improvements in bone parameters compared with both the control group and the swimming-only group [47].

Finally, three studies analyzed cycling [40,43,50]. In the works by Vlachopoulos et al. and Ubago-Guisado et al., cyclists did not show improvements compared with control groups [43,50]. In the trial by Julian et al., only the group performing combined resistance training and high-intensity interval training (HIIT) on a cycle ergometer showed significant improvements compared with the control group (p < 0.05), whereas the resistance plus moderate-intensity continuous training (MICT) group did not [40].

3.3. Study Quality Assessment

The results of the risk of bias assessment showed varying levels of methodological quality among the included studies. The four RCTs were evaluated using the RoB 2 tool [30]. Two of them were judged as having some concerns of bias, whereas the remaining two were rated as having a high risk of bias.

In contrast, the thirteen remaining studies, which followed quasi-experimental or longitudinal designs, were assessed using the ROBINS-I tool [35]. Their results were heterogeneous: four studies were classified as having a moderate risk of bias, seven as having a serious risk of bias, and two as having a critical risk of bias.

The detailed analysis for each study can be found in Appendix A (see Table A1 and Table A2), which includes two separate tables presenting the individual scores and qualitative evaluations for each design.

3.4. Certainty of Evidence (GRADE)

The certainty of evidence for each outcome related to the different sports modalities or types of activity ranged from moderate to very low, with all outcomes except one rated as low or very low. Overall, the certainty of the evidence is considered low. Detailed assessment results for each outcome are presented in Table 2.

Table 1. Summary of included articles.

Author(s)/Year	Title	Aim	Study Design	Participants	Duration	Intervention Details	Main Outcomes
Dowthwaite et al. [52]	A 2-yr, school-based resistance exercise pilot program increases bone accrual in adolescent girls	Evaluate the benefits of a 2-year school-based resistance training intervention	QES	62 girls (11–12.1 years) from the same school; experimental group (n = 41), control group (n = 21)	2 years	Both groups attended 3 PE times/week; the intervention group also performed 2 weekly 8–12 min resistance training sessions, including four multi-joint exercises using body weight, bands, or medicine balls	The intervention group showed greater improvements in BMD and BMC at L1–L4 (4.1%, 5.6%; p < 0.05). Participants with higher performance achieved larger differences versus the control group at L1–L4 and femoral head (5.7%, 8.2%; p < 0.01)
Bernardoni et al. [37]	A school-based resistance intervention improves skeletal growth in adolescent females	Examine the effects of a resistance training program on skeletal growth in perimenarcheal girls	QES	44 girls (11.7 ± 0.3 years) from the same school; experimental group (n = 22), control group (n = 22)	7 months	Resistance exercises 2–3 times/week for 8 min, including multi-joint exercises with body weight, bands, and dumbbells. Other unstructured physical activity was controlled to eliminate its effect on the analysis	Only experimental girls at Tanner stage II (femoral neck, p = 0.01) and Tanner III (L3, p = 0.01) showed significant BMD improvements compared to the control group
Thein-Nissenbaum et al. [38]	Adolescent bone advantages 3 years after resistance trial	Evaluate the effect of a resistance training program on bone adaptation immediately post-intervention and at 3-year follow-up	QES	47 girls (11.6 ± 0.3 years) from the same school; high-intensity training group (HI, n = 16), low-intensity group (LO, n = 14), control group (CON, n = 17).	7 months per year for 2 years	All groups attended regular PE sessions 2–3 times/week. Intervention groups additionally performed 8–12 min of resistance training with bands, dumbbells, and body weight in multiple planes, targeting all major muscle groups	The HI group, which adhered most consistently, showed significantly greater improvements than the control group in BMC (legs, femoral head, L3; p ≤ 0.05) and BMD (femoral head, L3; p ≤ 0.05) at all measurements. Three years post-intervention, they also showed superior BMD and BMC in the legs, femoral neck, subcapital femur, and L3 (p < 0.03)
Ferry et al. [39]	Bone health during late adolescence: Effects of an 8-month training program on bone geometry in female athletes	Investigate short-term structural changes in the hip of high-level adolescent swimmers and football players.	LON	58 postmenarcheal girls from two elite French facilities: football players (n = 26, 15.9 ± 2 years) and swimmers (n = 32, 16.2 ± 0.7 years). Control group: 15 adolescents (16.3 ± 1.2 years)	8 months.	Football players completed 225 training sessions and 30 competitions; swimmers completed 260 sessions.	Football players showed significant BMD improvements versus controls, whereas swimmers did not. Cross-sectional area increased in both groups, more in football players (3.17% vs. 2.31%; p < 0.05). Z-scores indicated improvements in femoral shaft cross-sectional moment of inertia and section modulus for football players (p < 0.001), with no changes in swimmers
Julian et al. [40]	Bone response to high-intensity interval training versus moderate-intensity continuous training in adolescents with obesity	Compare the impact of HIIT versus continuous MICT on bone density, strength, and geometry	RCT	61 adolescents (12–16 years, 60% girls, 40% boys), with obesity from the Pediatric Obesity Center; 49 completed the study. HIIT group (n = 19), MICT group (n = 19), control group (n = 11)	16 weeks	HIIT group performed 15 min 2 times/week of 30 s high-intensity cycling intervals with 30 s active recovery. MICT group performed 45 min twice/week at 60% of initial VO2peak. Both groups also did resistance training with machines and free weights for all major muscle groups and one day/week of aquatic or recreational activities	Total and regional BMD improved in both groups versus controls (p < 0.001). Total and regional BMC also improved in both groups, with greater gains in the HIIT group (p < 0.05)
Courteix et al. [41]	Bone mineral acquisition and somatic development in highly trained girl gymnasts	Analyze skeletal and somatic development in highly trained prepubertal gymnasts at the onset of peak bone mass acquisition	LON	35 girls divided into two groups: experimental (n = 14, 11.57 ± 1.3 years) and control (n = 21, 11.76 ± 1.1 years)	1 year	Gymnasts trained 12–15 h/week plus competitions. Control group included sedentary participants and swimmers training 5–6 h/week	BMD values were significantly higher in gymnasts than in controls in all skeletal regions except whole body (p < 0.05 to < 0.001, depending on the area). Although differences were not significant, the percentage changes in BMD were greater (1.50–21.25%) in gymnasts compared to the controls at all the sites, except the lumbar spine.
Gómez-Bruton et al. [42]	Do 6 months of whole-body vibration training improve lean mass and bone mass acquisition of adolescent swimmers?	Evaluate the effect of a vibration platform training intervention on BMD, BMC, and lean mass in swimmers	RCT	63 swimmers from 4 clubs; control group (n = 23, 14.2 ± 1.9 years; 14 boys, 9 girls), experimental group (n = 40, 15.0 ± 2.2 years; 22 boys, 18 girls)	6 months	Experimental swimmers performed 15–16 min vibration platform sessions 3 times/week, with intensity progressively increased over the 6-month intervention. All participants averaged 10.1 h of weekly training	No significant differences were observed in any variables. Vibration platform training had no effect on BMD, BMC, or lean mass.
Ubago-Guisado et al. [43]	Effect of maturational timing on bone health in male adolescent athletes engaged in different sports: The PRO-BONE study	Describe differences in bone indicators by biological age in athletes participating in osteogenic (OS) and non-osteogenic (NOS) sports	LON	104 boys (12–14 years); OS group (football players, n = 37), NOS group (swimmers, n = 39; cyclists, n = 28)	1 year	Each group trained at least 3 h/week in their respective sport	The OS group showed significantly greater increases than the NOS group for BMC, cross-sectional bone area, and other bone indicators
Álvarez-San Emeterio et al. [44]	Effect of strength training and the practice of alpine skiing on bone mass density, growth, body composition, and the strength and power of the legs of adolescent skiers	Examine the influence of alpine skiing and resistance training on BMD, growth, body composition, and strength in adolescents	QES	39 adolescents (13–16 years); skiers (n = 20, 10 boys, 10 girls; 14.70 ± 1.04 years), control group (n = 19, 10 boys, 9 girls; 14.66 ± 1.45 years)	1 year	Skiers completed an average of 70 h/year ski sessions plus 3 times/week resistance training sessions, including squats (3 × 8) and jumps (3 × 6). Both groups attended 70 PE classes during the school year	Skiers showed greater BMD improvements than controls at L2–L4 (boys, p < 0.05; girls, p < 0.01)
Witzke & Snow [45]	Effects of plyometric jump training on bone mass in adolescent girls	Investigate the effect of a 9-month plyometric jump training program on BMC, balance, and lower-limb performance in girls adolescents	QES	56 adolescent girls; experimental group (n = 25, 14.6 ± 0.4 years), control group (n = 28, 14.5 ± 0.6 years)	9 months	30–45 min sessions, 3 times/week. The first 3 months included resistance training in addition to plyometric exercises	Both groups showed significant increases (p < 0.01) in percent change in BMC: whole body (3.7% vs. 3.6%), femoral neck (4.5% vs. 2.4%), lumbar spine L2–L4 (6.6% vs. 5.3%), and femoral shaft (3.4% vs. 2.3%). Only the intervention group improved BMC at the greater trochanter (3.1% vs. 1.9%)
Blimkie et al. [51]	Effects of resistance training on bone mineral content and density in adolescent females	Determine the effect of 26 weeks of progressive resistance training on lumbar and whole-body BMC and BMD in adolescent girls	QES	32 postmenarcheal girls (14–18 years); experimental group (n = 16, 16.3 ± 0.3 years), control group (n = 16, 16.1 ± 0.2 years)	6 months	Three times/week. First 2 weeks: 2–3 sets of 10 reps for 13 exercises. Next 25 weeks: 4 sets of 10–12 reps in circuit format	No significant differences were observed in BMD or BMC after 26 weeks of training
Lozano-Berges et al. [46]	Influence of different playing surfaces on bone mass accretion in male adolescent football players: A one-season study	Compare bone mass growth between football players and controls, and assess the influence of two different playing surfaces	LON	42 adolescent boys; football players (n = 27, 13.17 ± 0.52 y) and controls (n = 15, 12.58 ± 1.11 y). Two sub-groups: artificial turf with elastic layer (n = 14, 13.01 ± 0.61 y) and without elastic layer (n = 13, 13.35 ± 0.35 years)	9 months	Elastic turf group averaged 2.6 ± 0.2 h/week; non-elastic turf group 2.3 ± 0.3 h/week. Sessions included 5 min warm-up, 5–10 min low-intensity games, 60 min football drills, and 5–10 min cooldown stretches	All groups, including controls, showed BMD and BMC increases in all measured areas (p < 0.05). Leg BMD increased in all groups, with a greater improvement observed in both football groups (p < 0.05). Lumbar spine BMD showed a greater increase in players training on non-elastic turf (p < 0.05).
Gómez-Bruton et al. [47]	Longitudinal effects of swimming on bone in adolescents: a pQCT and DXA study	Evaluate BMD, bone strength, and structure over a swimming season and compare with a normally active control group	LON	62 adolescents; swimming group (n = 23, 15.0 ± 2.2 y; 15 boys, 9 girls), swimming + impact/strength group (n = 11, 15.1 ± 2.8 years; 8 boys, 3 girls), control group (n = 28, 14.1 ± 2.3 years; 16 boys, 12 girls)	8 months	Both swimming groups trained ≥6 h/week, including 1 h/week dry-land training. In the swimming + sport group, 6 participants did team sports and 5 performed resistance training	The swimming + impact/strength group showed greater arm BMD compared to the other groups (p < 0.05) The only differences found among the 3 groups for DXA and pQCT variables were for the DXA aBMD arm values as SWI-SPORT pre sented higher pre- and post-evaluation than CG
Murphy et al. [48]	Physical activity for bone health in inactive teenage girls: is a supervised, teacher-led program or self-led program best?	Evaluate the effect of a 6-month supervised physical activity program versus a self-directed program on bone structure in inactive adolescent girls	RCT	85 adolescent girls. Supervised group (n = 30, 16.3 ± 0.4 years), self-directed group (n = 29, 16.6 ± 0.6 years), and control (n = 26, 16.3 ± 0.8 years)	6 months	The supervised group performed 60 min strength sessions 2 times/week with an instructor and was advised to add two autonomous impact sessions. The self-directed group received guidelines for 3–4 similar sessions per week.	Both intervention groups showed significant improvements in bone parameters (broadband ultrasound attenuation, speed of sound, calcaneal stiffness index) versus baseline and the control group (except speed of sound) (p < 0.05). Gains in ultrasound attenuation were slightly greater in the supervised group
Nichols et al. [49]	Resistance training and bone mineral density in adolescent females	Examine the effects of a 15-month strength training program on BMD in adolescent girls	RCT	16 adolescent girls. Exercise group (n = 5, 16.01 ± 0.3 years) and control group (n = 11, 15.5 ± 0.2 years)	15 months	Strength training, 30–45 min, 3 times/week, including 15 exercises combining free weights and machines	Femoral neck BMD increased significantly in the training group (p < 0.01), with no change in the control group. No significant differences were observed in total or lumbar BMD in either group
Vlachopoulos et al. [50]	The effect of 12-month participation in osteogenic and non-osteogenic sports on bone development in adolescent male athletes. The PRO-BONE study	Investigate the effects of 12 months of participation in osteogenic versus non-osteogenic sports on bone development.	LON	116 adolescent boys—football players (n = 37, 12.9 ± 0.9 years), swimmers (n = 37, 13.5 ± 1.0 years), cyclists (n = 28, 13.2 ± 1.0 years), and controls (n = 14, 12.3 ± 0.5 years)	12 months	Each sports group trained up to 3 h/week in their discipline.	Football players showed significantly greater BMC gains for the whole body and specific regions (6.3–8.0%) and versus swimmers (5.4–5.6%). No significant differences were found between swimmers, cyclists, or controls
Zribi et al. [53]	Volleyball practice increases bone mass in prepubescent boys during growth: A 1-yr longitudinal study	Examine the effects of one year of volleyball practice on bone development in prepubertal children.	LON	39 volunteer boys (11 ± 1 years) were divided into a volleyball group (n = 19, 11 ± 1 years) and a control group (n = 20, 11 ± 1 years).	12 months	4–6 h of volleyball per week, in addition to competition.	Volleyball players showed greater increases in BMD than the control group in almost all analyzed regions: whole body (4.5% vs. 1.7%), non-dominant arm (5.8% vs. 1.1%), dominant arm (6.0% vs. 2.1%), non-dominant leg (9.0% vs. 4.8%), dominant leg (10.7% vs. 6.0%), dominant ultradistal radius (10.4% vs. 0.9%), dominant one-third distal radius (9.6% vs. 3.7%), dominant total radius (7.4% vs. 3.1%), lumbar spine L2–L4 (9.9% vs. 2.8%), femoral neck (4.7% vs. 1.6%), trochanter (6.0% vs. 1.5%), and total hip (6.1% vs. 2.6%), all p < 0.005.

Note. BMC = Bone Mineral Content; BMD = Bone Mineral Density; h = hour; HIIT = High Intensity Interval Training; LON = Longitudinal design; MICT = Moderate Intensity Continuous Training; min = minutes; s = seconds; RCT = Randomized Controlled Trial; QES = Quasi experimental Study.

Table 2. Assessment of the Certainty of Evidence Using the GRADE Approach.

Certainty Assessment—GRADE Profile							Sample Size	Certainty
Nº of Studies	Study Desing	Methodological Limitations	Inconsistency	Indirectness	Imprecision	Publication Bias	Participants
Exercise Modality
Strength Training
5	QES (4) and RCT (1)	Very serious	Not serious	Not serious	Very Serious	Not serious	201	Very Low
Plyometric Training
2	QES (1) and RCT (1)	Serious	Not serious	Not serious	Serious	Not serious	141	Low
Football
4	LON	Very serious	Not serious	Not serious	Serious	Not serious	320 (risk of sample overlap)	Very low
Volleyball
1	LON	Very serious	Serious	Not serious	Serious	Serious	29	Very low
Gymnastic
1	LON	Very serious	Serious	Not serious	Serious	Serious	35	Very low
Cycling
2	LON	Very serious	Not serious	Not serious	Very serious	Not serious	220 (high risk of sample overlap)	Very low
Swimming
5	LON (4) and RCT (1)	Very serious	Not serious	Not serious	Serious	Not serious	403 (risk of sample overlap)	Low
Strength + Plyometric Training
1	RCT	Not serious	Serious	Not serious	Not serious	Serious	85	Moderate
Strength/Impact + Swimming/Cycling (Osteogenic + Non-Osteogenic)
2	LON (1) and RCT (1)	Serious	Not serious	Not serious	Serious	Serious	123	Low

Note. LON = Longitudinal design; RCT = Randomized Controlled Trial; QES = Quasi experimental Study.

4. Discussion

4.1. Type of Activity

Among the 17 studies included in this review, ten incorporated resistance training in their interventions [37,38,40,44,45,47,48,49,51,52,53]. In the studies by Dowthwaite et al., Bernardoni et al., and Thein-Nissenbaum et al., a similar program was implemented consisting of three weekly sessions of 8–12 min each, with multi-joint exercises in addition to regular physical education classes. In all three cases, the experimental group demonstrated superior outcomes compared to controls in both BMD and BMC [37,38,52]. A program with a higher weekly volume, such as that of Nichols et al., which included 30–45 min sessions at the same weekly frequency, also produced significant improvements compared to the control group [49]. Conversely, the study by Blimkie et al., which implemented a high-volume resistance training program over 26 weeks with 13 exercises per session, did not yield superior results in the experimental group [51]. Compared with other studies, these findings suggest that a higher training volume alone does not appear to be a decisive factor for enhancing bone outcomes.

Other researchers have investigated the effectiveness of resistance training in combination with other types of activity. Julian et al. examined the effects of combining cardiovascular exercise with strength training, comparing moderate- and high-intensity groups [40]. Only the high-intensity group showed significant changes after 16 weeks of intervention. Additionally, the studies by Gómez-Bruton et al. and Álvarez-San Emeterio et al. were considered. In the former, strength training was combined with swimming, and in the latter with alpine skiing; in both cases, significant improvements were observed [44,47].

However, regarding studies that examined the effectiveness of resistance training combined with another activity, none analyzed the additional influence of the secondary sport. In all cases, the comparison was made against a control group, but not against a group performing only resistance training without the additional activity [40,43,47]. Therefore, it cannot be concluded that adding other activities generates greater adaptations than resistance training alone. Resistance training produces positive bone adaptations in adolescents, consistent with the theoretical framework [1,2]. A weekly volume of three sessions of 8–12 min each may be sufficient.

Regarding plyometric exercises, two of the included studies examined their effects [45,48]. Murphy et al. [48] examined its responses combined with strength training. In this study, both experimental groups showed improvements in various bone indicators compared to the control group and baseline measurements, with slightly greater gains observed in the supervised group. In Witzke & Snow [45], both the control and experimental groups improved certain parameters, although improvements at the greater trochanter were greater in the experimental group. Plyometric exercise could be effective compared to control groups for improving BMD, particularly when combined with strength training, but the scientific evidence remains limited. This type of activity should be performed at least three times per week for 30 min.

Team sports, and more specifically football, generate joint impact due to the nature of their demands [54], suggesting that their effects on bone may be similar to those of plyometric exercises. Four of the included studies examined football [39,43,46,50]. In the studies by Ubago-Guisado et al. and Vlachopoulos et al., football players were compared with cyclists and swimmers, with significantly better outcomes observed for BMC in footballers [43,50]. In Ferry et al., the comparison was made between footballers, swimmers, and a control group, without including cyclists; footballers still exhibited superior results for the analyzed bone parameters [39]. Finally, Lozano-Berges et al. compared two groups of footballers training on different types of turf with a control group. Both experimental groups improved significantly more than the control group, with the highest bone mineral density (BMD) observed in those training on third-generation turf without elastic layers [46]. Therefore, football training appears effective in improving bone quality and is superior to other sports such as cycling and swimming. A total weekly volume of 3 h, spread over three sessions, may be adequate.

Another sport with relatively similar characteristics is volleyball, which also appears to be effective, as suggested by the results [53]. Given its high frequency of jumping and impact actions, volleyball can likewise be considered an osteogenic activity. However, only one study has examined its effects.

Regarding the previously discussed strength and impact sports, it is important to note that one of the included studies grouped both strength activities and impact sports (running, basketball, and football) into a single experimental group [47], compared with a group of swimmers and a control group. However, the results were not disaggregated by activity type or specific discipline, preventing a differentiated assessment of the effects of each modality on bone parameters. This lack of specificity limits the possibility of rigorously comparing the individual effects of impact sports versus strength activities. Nevertheless, another study included in the review, focusing on adolescent gymnasts [41], showed greater improvements in bone development compared with the control group, although these differences were not statistically significant, consistent with gymnastics’ profile as a discipline combining impact and strength demands. This suggests that such a combination may represent a particularly effective strategy to optimize bone health during adolescence. However, it should be noted that only one study has examined this combination, and given the lack of statistically significant results, there is insufficient evidence to draw firm conclusions.

On the other hand, the included studies examined sports considered non-osteogenic by the scientific literature [2,25,26]. Five of these studies included swimmers in their samples [39,42,43,47,50]. As previously discussed in the studies by Ferry et al., Vlachopoulos et al., and Ubago-Guisado et al., swimmers showed poorer outcomes compared to groups participating in football [39,43,50]. When analyzing the swimming groups in Vlachopoulos et al. and Ferry et al., which included a normoactive control group, it was observed that swimming did not provide additional benefits for bone development [39,50]. Swimming does not appear to stimulate bone development in adolescents, as hypothesized based on prior literature [2,25,26], neither in isolation nor in combination with whole-body vibration platforms [42].

Cycling is another sport considered non-osteogenic according to the scientific literature [26]. Three of the studies included in the present review examined the effects of this activity [40,43,50]. Similarly to swimming, the results from Vlachopoulos et al. and Ubago-Guisado et al. indicate that cycling provides lower osteogenic stimulation compared to impact sports [43,50]. Specifically, Vlachopoulos et al. showed that cyclists did not exhibit significant improvements in bone parameters compared to the control group, reinforcing the limited osteogenic potential of this discipline [50].

In one of the reviewed studies [40], two groups combining strength training with cycling exercise were compared, differing in protocol intensity (high-intensity intermittent vs. moderate continuous). Results indicated that only the high-intensity group experienced significant bone adaptations alongside strength training, whereas the moderate-intensity group did not show comparable improvements. This suggests that while cycling alone is not strongly osteogenic, its combination with high-intensity strength exercise may enhance bone tissue adaptations. Similarly, Gómez-Bruton et al. found that swimmers who combined their regular activity with resistance and impact training showed greater improvements compared with the control group [47]. These effects were not observed in the group that performed swimming alone, indicating that the improvements cannot be attributed to swimming itself but rather to the combined program, primarily due to the additional resistance and impact training.

These types of disciplines do not appear to be effective on their own, although their effects are likely low or uncertain. They may be beneficial when combined with activities that primarily involve resistance, and to a lesser extent, impact training. In any case, they do not appear to produce a negative effect.

Alpine skiing is another sport that, due to its specific demands, generally does not involve high-impact loading compared with other activities analyzed (e.g., football, volleyball, plyometric training). However, since the only study examining this discipline did not include a group performing skiing without resistance training, no definitive conclusions can be drawn regarding this modality [44].

4.2. Sex

Regarding the sex of participants, nine of the included studies [37,38,39,41,45,48,49,51,52] comprised exclusively of females, in three studies exclusively of males [43,46,50] and in the remaining four, both male and female adolescents were included [40,42,44,47].

Concerning strength training, both females and males appear to respond positively to this type of exercise, whether analyzed separately or together [37,44,47,49,52], with stronger evidence for females due to the higher number of studies including them. However, no study has directly compared adaptations between males and females, so there is currently no scientific evidence indicating that one sex responds better than the other.

Regarding plyometric exercise, the two included studies consisted of female adolescent samples, so the efficacy of this type of exercise, whether performed analytically or as a standalone program, is only supported for females in the present systematic review [45,48].

Concerning football, only one investigation was conducted with females [39] while the other three included studies involved males [43,46,50]. Nevertheless, based on the available data, it can be inferred that this type of sport is effective for both male and female adolescents in improving bone quality.

Regarding artistic gymnastics, only one study included in the review analyzed this sport [41], and it involved a female sample. Therefore, the evidence gathered in the present systematic review only supports its efficacy as an osteogenic activity for adolescent girls.

Finally, regarding non-osteogenic sports, namely cycling and swimming, the samples included in the analyzed studies indicate that these sports are not effective in adolescents—both girls and boys—for producing significant bone adaptations [25,39,40,42,43,44,50].

Overall, there is currently no consistent evidence indicating that biological sex significantly influences the bone adaptations resulting from different types of physical activity programs. However, this conclusion is limited by the fact that most available studies were conducted separately in male and female populations or included mixed samples without reliable sex-based comparisons.

4.3. Age

Seven of the included studies [37,38,41,43,46,50,52] focused on participants in early adolescence [31]. Eight studies [39,42,44,45,47,48,49,51] included participants in mid-adolescence [31]. The study by Julian et al. involved adolescents from both early and mid-adolescence [40]. No study included participants in late adolescence. Therefore, the evidence from this review supports the efficacy of interventions only during early and mid-adolescence.

Concerning strength training and football approaches, the available evidence suggests that both modalities are effective in improving bone health during early and mid-adolescence. Specifically, regarding plyometric training, only one study [45] examined it in isolation, with a sample of early adolescents, so the evidence is robust only for this developmental stage. Regarding gymnastics [41], the sole study analyzed participants in mid-adolescence.

As stated in the theoretical framework, the most favorable period for bone mass accrual is puberty [1,7,14,15], occurring primarily during early adolescence (ages 10–13/14) and extending into middle adolescence (ages 14–17) [31]. This underscores the importance of engaging in resistance and impact-based physical activity during these stages.

The available evidence should be interpreted with caution, as no studies directly compared early and mid-adolescent groups. Therefore, conclusions regarding differences between developmental stages remain limited.

4.4. Program Duration

The duration of the program is a key factor for determining the total training volume required to achieve significant changes. Regarding studies consisting solely of resistance training, the reviewed literature [37,38,49,52], suggests that a total program length of approximately 7 months appears sufficient to produce additional benefits in bone quality and health. No studies have investigated the effects of the same program over longer or shorter periods, so there is no evidence to support that longer interventions yield superior results.

One of the studies, conducted by Julian et al., showed positive results in just 4 months [40]. However, this finding should be interpreted with caution, as the study population consisted of adolescents with obesity. This factor should be considered a potential confounding variable, since leptin, a hormone derived from adipose tissue, has been shown to positively influence bone cell activity and metabolism [11]. In this case, the strength training was combined with cycle ergometer exercise, which can be classified as a non-osteogenic activity, and therefore should not be considered a relevant factor.

Regarding other types of activities, the studies included in this review involving football, isolated plyometric training, or gymnastics show that all programs lasted between 8 and 12 months [39,41,45,46].

Finally, when examining studies that combined strength training with other activities generating mechanical impact, such as Murphy et al., which included plyometric exercises, it was observed that the minimum duration to achieve adaptations was 6 months [48]. Therefore, the intervention period required to elicit positive adaptations could be shorter when different osteogenic activities are combined [48], although the supporting evidence is limited, as only one study addresses this. In line with this observation, it is noteworthy that the only strength-based program that did not produce significant improvements compared with the control group was that of Blimkie et al., whose program also lasted six months [51]. As discussed, combining resistance training with impact-loading activities may therefore be more effective than resistance training alone.

4.5. Limitations, Implications, and Future Research Directions

The main limitation of this systematic review lies in the heterogeneity of the included studies. Alongside RCTs, quasi-experimental and longitudinal designs with lower control over the intervention were considered. This diversity may affect the overall quality of evidence. The evaluations performed using the RoB 2 and ROBINS-I tools support the notion of heterogeneity among the included studies, as all of them presented some level of bias, with none being rated as low risk. Consistently, the certainty of evidence assessed using the GRADE approach was generally low to very low across outcomes, further reinforcing the need to interpret the results of this systematic review with caution. Including studies with such designs slightly limits the scientific quality of the evidence, as these studies generally have less control over variables and lower internal validity. Nevertheless, their inclusion allowed us to increase the number of studies analyzed and to provide a broader overview of the available evidence. In some research contexts, especially in fields such as physical activity or education, conducting randomized controlled trials may not always be feasible due to logistical, practical, or ethical constraints.

Moreover, the review was not preregistered in any public platform, which may have increased the risk of bias in study selection, data handling, and decision-making processes, although the procedures followed adhered to PRISMA guidelines. Furthermore, the initial phase of the screening process, in which records were excluded based on title and abstract, was conducted by a single researcher (Y.A.). Nonetheless, the final selection and the application of the inclusion criteria were performed independently by two reviewers (Y.A. and M.R.F.). The fact that the first screening step was carried out by only one researcher may slightly increase the risk of bias.

Basing inclusion criteria on mean age alone may have allowed the inclusion of studies with participants outside the intended adolescent range (11–18 years), which could dilute the target population. However, this approach was adopted because some studies did not provide detailed age ranges or minimum/maximum ages. Restricting the review to studies with fully reported age distributions would have significantly limited the number of eligible studies, potentially reducing the comprehensiveness of the evidence base. Finally, a potential limitation relates to the possible overlap of participants in some studies, particularly those by Vlachapoulos et al. [50] and Ubago-Guisado et al. [43], in which athletes performed the same sports. The total sample sizes and group compositions differ, and ages are reported differently, so we cannot confirm exact overlap. This possible overlap should be considered when interpreting the results, although it likely affects only part of the samples.

This work may provide valuable insights for society due to its direct link with health and quality of life. Increasing bone quality in adolescents and improving BMD during a critical period such as puberty can promote better long-term health. This may enhance their ease or willingness to engage in physical activity, indirectly reducing the risk of musculoskeletal, cardiovascular, or metabolic disorders, and directly lowering the risk of osteoporosis in adulthood.

Contrary to the initial hypothesis, the findings of this review suggest that strength training doses of 8–12 min, much lower than those proposed, appear sufficient to elicit significant adaptations when performed 2–3 times per week. The combination of strength and impact training may reduce the time needed to achieve adaptations; however, evidence is limited, as only one study has addressed this. Furthermore, there is no evidence that adaptations are superior when disciplines are combined.

The control groups included in the interventions and follow-ups analyzed in the studies of this review were considered “normoactive” subjects, meaning that all of them engaged in physical activity within or outside the school context, in a non-systematic or non-prescribed manner, often considered as a covariate in the analyses. Therefore, all these types of physical activity programs should be implemented in addition to school physical education.

Including 2–3 sessions per week, with a total volume of 8–10 min of supplementary strength training in addition to school physical education (provided the curricular program incorporates various sports and impact activities), could offer significant social benefits and, in the long term, economic advantages. Implementation challenges include compliance with educational regulations and equipment costs, likely limiting feasibility to private schools.

As a future research direction, longitudinal intervention studies with long-term follow-up are needed. Current literature mostly comprises randomized controlled trials or quasi-experimental designs that assess BMD improvements during adolescence, but lack measurements in adulthood. Studies examining bone mass loss periods rely on correlations with childhood physical activity, limiting precise causal inference. Therefore, long-term longitudinal interventions with controlled physical activity (type, intensity, frequency, volume) and follow-up every 5–10 years are necessary to evaluate true long-term effects. It would also be useful to distinguish between individuals who continued physical activity after adolescence and those who did not.

Another relevant avenue is to examine bone adaptation during late adolescence. All included studies focus on early and middle adolescence, making interventions in this final stage particularly valuable.

Whereas earlier we discussed strength training performed in addition to regular school physical education, it would be important to test, within the standard school timetable, whether incorporating 2–3 weekly sessions of at least 10 min of strength training directly into all physical education classes is effective compared to controls.

Finally, no studies have examined whether combining strength and impact exercises is more effective than performing either modality independently when total training volume is held constant. To address this question, a possible study design would involve a randomized controlled trial with four groups: a strength training group (F), an impact exercise group (I), a combined strength and impact group (M), and a control group (C). All groups would follow the same intervention duration, and pre- and post-intervention assessments would be conducted, while controlling for key physical activity parameters such as intensity, volume, and frequency.

5. Conclusions

Physical activity programs involving strength training or impact activities, such as running, jumping, plyometrics, or football, appear to exert osteogenic effects in adolescents, regardless of sex, during early and middle adolescence. The results should be interpreted with caution, as the risk of bias in the included studies ranged from moderate to critical, and the certainty of the evidence, assessed using the GRADE approach, was generally moderate to very low. No meta-regression analysis was conducted, and the figures provided should be understood as approximate, context-dependent indications rather than prescriptive thresholds.

These activities should be performed alongside regular school physical education classes. The minimum effective volume for strength training may be 2–3 sessions per week, lasting 8–12 min each, with multi-joint exercises, for a minimum duration of 7 months.

For plyometric training, the minimum effective volume could be 3 sessions per week, 30–45 min per session, over a total of 9 months. For other impact activities, such as football, the minimum period required to achieve additional adaptations is likely to be 9 months, with a weekly volume of 2 sessions of approximately 75–90 min each.

If strength training is combined with impact exercise, the intervention period required to achieve significant bone adaptations could be shorter, around six months, with four weekly sessions (two strength, two impact) lasting approximately 60 min each.

Activities such as swimming and cycling may have a low or uncertain effect on BMD, although there is no evidence that they cause harm to this parameter.

Author Contributions

Conceptualization, Y.A. and C.M.T.-G.; methodology, Y.A., C.M.T.-G. and M.R.F.; validation, Y.A., C.M.T.-G. and M.R.F.; investigation, Y.A.; resources, Y.A.; writing—original draft preparation, Y.A.; writing—review and editing, C.M.T.-G. and M.R.F.; visualization, Y.A.; supervision, M.R.F.; project administration, Y.A. and M.R.F. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Acknowledgments

We would like to thank the independent reviewers for their effort, interest, and rigor in evaluating the manuscript, which has greatly contributed to improving the quality of the work.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. Risk of Bias Assessment of Randomized Controlled Trials Using the RoB 2 Tool.

Author	Randomization Process	Intervention Adherence	Data—Outcomes	Measurement of Outcome	Reported Result	Risk of Bias
Julian et al. [40]						Some concerns
Gómez-Bruton et al. [42]						High risk
Murphy et al. [48]						Some concerns
Nichols et al. [49]						High risk

Note. Green = Low risk of bias; Yellow = Some concerns; Red = High risk of bias.

Table A2. Risk of Bias Assessment of Quasi-Experimental and Longitudinal Studies Using the ROBINS-I Tool.

Author	Confounding	Selection of Participants	Classification of the Intervention	Deviations from Intended Interventions	Missing Data	Measurement of Outcomes	Selection of the Reported Result	Risk of Bias
Dowthwaite et al. [52]								Serious risk
Bernardoni et al. [37]								Moderate risk
Thein-Nissenbaum et al. [38]								Serious risk
Ferry et al. [39]								Critical risk
Courteix et al. [41]								Serious risk
Ubago-Guisado et al. [43]								Moderate risk
Álvarez-San Emeterio et al. [44]								Moderate risk
Witzke & Snow (2000) [45]								Moderate risk
Blimkie et al. [51]								Serious risk
Lozano-Berges et al. [46]								Serious risk
Gómez-Bruton et al. [47]								Critical risk
Vlachopoulos et al. [50]								Serious risk
Zribi et al. [53]								Serious risk

Note. Green = Low risk of bias; Yellow = Moderate risk of bias; Orange = Serious risk of bias; Red = Critical risk of bias.

Table A3. Excluded studies and reasons for exclusion.

Title	Reason of Exclusion
A 1-year prospective study on the relationship between physical activity, markers of bone metabolism, and bone acquisition in peripubertal girls	The mean age of the sample is lower than required.
A school-based exercise intervention augments bone mineral accrual in early pubertal girls	The mean age of the sample is lower than required.
An investigation into the relationship between physical activity and bone health	The mean age of the sample is lower than required.
Impact of strength training on bone mineralization in under-15 soccer players from Cortuluá club	The method used to assess BMD is neither reliable nor precise; the full text is not available in English.
Daily school physical activity from before to after puberty improves bone mass and a musculoskeletal composite risk score for fracture	The mean age of the sample is lower than required.
Dancing for bone health: a 3-year longitudinal study of bone mineral accrual across puberty in female non-elite dancers and controls	The mean age of the sample is lower than required.
Effect of a general school-based physical activity intervention on bone mineral content and density: A cluster-randomized controlled trial	Results are not presented separately for the 11–12-year-old group compared to the age-matched control group
Basketball affects bone mineral density accrual in boys more than swimming and other impact sports:9-mo follow-up	The training program (weekly volume) for each intervention group is not specified.
Effect of resistance training on body composition of adolescents: abcd growth study	The training volume, intensity, and criteria used to assign participants to each training group are not specified.
Effects of 12 weeks of endurance training on bone mineral content and bone mineral density in obese, overweight and normal weight adolescent girls	There is no control group or different interventions; the same intervention is applied to all groups
Effects of cheerleading practice on advanced glycation end products, areal bone mineral density, and physical fitness in female adolescents	The mean age of the sample exceeds the inclusion criteria.
Effects of physical activity and muscle quality on bone development in girls	The mean age of the sample is lower than required
Effects of playing surfaces on volumetric bone mineral density in adolescent male soccer players	This is not a scientific article, but a poster.
Growth, body composition and bone mineral density among pubertal male athletes: intra-individual 12-month changes and comparisons between soccer players and swimmers	The training programs followed by each group are not specified in detail.
High femoral bone mineral density accretion in prepubertal soccer players	The mean age of the sample is lower than required.
Impact of a school-based physical activity intervention on fitness and bone in adolescent females	Calcium supplementation was included
Impact of artistic gymnastics on bone formation marker, density and geometry in female adolescents: abcd-growth study	The volume, frequency, and minimal details of the training performed are not specified.
Impact of martial arts (judo, karate, and kung fu) on bone mineral density gains in adolescents of both genders: 9-month follow-up	The volume, frequency, and minimal details of the training performed are not specified.
Resistance training presents beneficial effects on bone development of adolescents engaged in swimming but not in impact sports: ABCD Growth Study	The volume, frequency, and minimal details of the training performed are not specified.
Skeletal effects of nine months of physical activity in obese and healthy-weight children	The sample does not consist of adolescents.
Sports participation and muscle mass affect sex-related differences in bone mineral density between male and female adolescents: A longitudinal study	The volume, frequency, and minimal details of the training performed are not specified.
Effects of badminton and ice hockey on bone mass in young males: A 12-year follow-up	Specific results between the baseline measurement and the second measurement, corresponding to the age indicated in this review as an inclusion criterion, are not provided.
Effect of physical training on bone mineral density in prepubertal girls: a comparative study between impact-loading and non-impact- loading sports	No baseline measurement was conducted prior to the 3-year training period
The impact of different loading sports and a jumping intervention on bone health in adolescent males: the PRO-BONE study	This is not a scientific article, but an excerpt from a thesis.
Lumbar spine bone mineral adaptation: cricket fast bowlers versus controls	Results are not presented separately for each age group, nor can they be extracted for comparison purposes.
Changes in bone mineral density in response to 24 weeks of resistance training in college-age men and women	The mean age of the sample exceeds the inclusion criteria.
Effects of aerobic training, resistance training, or both on cardiorespiratory and musculoskeletal fitness in adolescents with obesity: the HEARTY trial	Bone parameter measurements are not included, and a nutritional intervention was also conducted.
Effects of manual resistance versus weight resistance training on body composition and strength in young adults after a 14-week intervention	The mean age of the sample exceeds the inclusion criteria.
effects of resistance training on bone mineral density and resting serum hormones in female collegiate distance runners: a randomized controlled pilot trial	The mean age of the sample exceeds the inclusion criteria.

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Figure 1. Flow diagram of study identification.

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Antoranz, Y.; Ruiz Freire, M.; Tejero-González, C.M. Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review. Physiologia 2025, 5, 51. https://doi.org/10.3390/physiologia5040051

AMA Style

Antoranz Y, Ruiz Freire M, Tejero-González CM. Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review. Physiologia. 2025; 5(4):51. https://doi.org/10.3390/physiologia5040051

Chicago/Turabian Style

Antoranz, Yoel, Manuel Ruiz Freire, and Carlos Mª Tejero-González. 2025. "Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review" Physiologia 5, no. 4: 51. https://doi.org/10.3390/physiologia5040051

APA Style

Antoranz, Y., Ruiz Freire, M., & Tejero-González, C. M. (2025). Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review. Physiologia, 5(4), 51. https://doi.org/10.3390/physiologia5040051

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Physical Activity and the Optimization of Bone Mineral Density in Adolescents: A Systematic Review

Abstract

1. Introduction

2. Materials and Methods

2.1. Study Design and Search Strategy

2.2. Inclusion Criteria

2.3. Quality Assessment and Risk of Bias

2.4. Assessment of Certainty of Evidence (GRADE)

2.5. Data, Variables, and Reviewed Measures

2.6. Eligibility for Synthesis

2.7. Data Extraction and Reliability

3. Results

3.1. Search Results

3.2. Main Outcomes

3.3. Study Quality Assessment

3.4. Certainty of Evidence (GRADE)

4. Discussion

4.1. Type of Activity

4.2. Sex

4.3. Age

4.4. Program Duration

4.5. Limitations, Implications, and Future Research Directions

5. Conclusions

Author Contributions

Funding

Acknowledgments

Conflicts of Interest

Appendix A

References

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