Ever the poor cousin to pharmacological intervention, the clinical community has traditionally considered exercise to be, at best, an ancillary strategy for the management of osteoporosis.  The ostensible reasons for this scepticism are three-fold.  The first is that, in the past, generic exercise interventions have induced relatively unremarkable BMD effects in comparison to medications; serving mainly to arrest bone loss.  Second, the anticipated reluctance of patients to adopt regular exercise, particularly when the existing recommendations involve prolonged and frequent exposure, was a disincentive for clinicians to prescribe it.  Third, as GPs do not traditionally receive adequate training in exercise prescription, they rarely feel confident recommending exercise programs beyond simple walking regimes or generic gym memberships.  Recently however, the landscape has changed.  Novel evidence that brief, bone-targeted exercise can do more than simply maintain bone mass, and the arrival of exercise physiologists on the allied health scene, has provided a more feasible and efficacious strategy to apply exercise therapy for osteoporosis.  Bearing in mind the simultaneous benefit for sarcopenia and falls, neither of which are enhanced by bone medications, exercise can now be described as providing a more ‘broad spectrum’ management strategy for osteoporosis than pharmaceuticals.  The question of whether exercise can actually prevent osteoporotic fracture remains contentious, owing to a lack of direct evidence from large-scale, long-term interventions.  Nevertheless, considerable indirect evidence exists, as falls prevention translates to fracture prevention, and longitudinal observational data and meta-analyses reveal a strongly negative relationship between exercise and incident fracture.  Moreover, exercise has few serious side effects.  On the contrary, the benefits to multiple body systems are well known.  Exercise prescription is therefore ethical for prevention as well as treatment.  Growing evidence has moved exercise from an ancillary strategy in the management of osteoporosis to a front line therapy central to patient care.