Sexual activity rarely enters the consultation room in rheumatology. Patients describe pain patterns, functional limitations, or beliefs about symptom causation, yet almost never the mechanics of intimacy. Clinicians seldom ask about it. Sexual activity is largely absent from musculoskeletal (MSK) assessments, despite involving the same principles of posture, joint loading, leverage, and repetition that govern the periarticular soft tissue syndromes we diagnose routinely,1 whether as isolated mechanical complaints in otherwise healthy individuals or as comorbid manifestations in patients with systemic rheumatic disease.
MSK complaints arise from every posture the human body adopts. We teach residents that overuse-related soft tissue syndromes arise from repetitive mechanical loading that produces microtrauma and irritation in tendons, bursae, and adjacent structures. Tendinopathies result from repetitive strain, bursitis arises from focal compression, and mechanical low back pain reflects postural mechanics. We routinely attribute lateral epicondylitis to tennis, prepatellar bursitis to kneeling, ischial bursitis to prolonged sitting, and de Quervain tenosynovitis to violin playing or heavy smartphone use. If this logic applies to tennis, sewing, and texting, it is reasonable to ask whether it might also apply to sexual activity.
This question became unavoidable after a personal experience. One of us developed prepatellar bursitis during an entirely ordinary moment of intimacy while traveling. There was no trauma and no unusual maneuvering—only an unfortunate angle and pressure. A few hours later, kneeling had become impossible. The following 2 days required the use of crutches while sightseeing with family, accompanied by a mix of discomfort and embarrassment. No imaging was performed, and no structural lesion was suspected; the episode resolved spontaneously. The experience raised an important question: If symptoms arise this easily under ordinary circumstances, how many similar episodes go unreported in clinical practice?
Rheumatologists, sports physicians, and physiatrists have studied the biomechanics of work, exercise, and daily activities for decades. Yet, the biomechanics of sexual activity, a universal human behavior, remain almost completely unexamined. No formal study has mapped MSK symptoms to specific sexual positions, evaluated joint loading or positional mechanics during intimacy, or explored whether sexual activity contributes to the global burden of mechanical low back pain, tendinopathy, or bursitis.
Our exploratory project began with the bursitis episode. Three clinicians, including 2 rheumatologists (CRR and JAN) and a specialist in physical medicine and rehabilitation (MHH), reviewed common sexual positions and identified anatomical regions under predictable mechanical stress. From this process, we selected 11 periarticular soft tissue syndromes that could plausibly arise from position-specific load. We constructed a catalogue of 11 common sexual positions,2,3 illustrated with neutral schematic diagrams. Two participant roles were defined, partner A and partner B, without gendered and sex-based assumptions. We then built an anonymous online survey. (The position catalogue, survey instrument, and complete results table are available upon request.)
Ninety-two adults completed the anonymous survey after providing consent. Each respondent selected 1 position they had personally experienced, identified their typical role, and answered only the symptom-based items relevant to that configuration. Participants were not selected based on health status, and no information regarding rheumatic diagnoses or comorbid conditions was collected. Respondents therefore represented a heterogeneous adult sample, including individuals with and without known rheumatic disease.
Symptoms were not rare. We recorded 108 reports of MSK symptoms consistent with the 11 predefined periarticular soft tissue syndromes. Mechanical low back pain was the most frequent, followed by hip flexor strain, prepatellar bursitis, trochanteric bursitis, pes anserine bursitis, piriformis syndrome, and gluteal tendinopathy. Cervical radiculopathy, subacromial bursitis, and olecranon bursitis were less common, and no cases of bicipitoradial bursitis were described.
Symptoms were reported in both partner roles and across all age groups represented in the survey, from early adulthood to individuals aged ≥ 70 years. A visual summary of the age distribution of these reports is presented in the Figure, illustrating that symptoms occurred throughout the adult lifespan.
Distribution of symptom-based MSK syndromes by age group, across all positions and partner roles. BB: bicipitoradial bursitis; CR: cervical radiculopathy; GT: gluteal tendinopathy; HFS: hip flexor strain; LBP: low back pain; OB: olecranon bursitis; PAB: pes anserine bursitis; PPB: prepatellar bursitis; PS: piriformis syndrome; SAB: subacromial bursitis; TB: trochanteric bursitis.
Every study is shaped by its methods, and ours was intentionally modest. Convenience sampling limits representativeness, and respondents were drawn from our extended networks. Symptom identification relied on self-report without clinical examination or imaging. Screening items were clinically grounded but were not adapted from validated diagnostic instruments. Because each respondent answered only items relevant to a specific position-role configuration, denominators varied across syndromes.
However, the overall approach parallels routine rheumatology practice. Most diagnoses of mechanical low back pain, tendinopathy, or bursitis rely on clinical hypotheses derived from symptom patterns and mechanical context rather than on demonstration of structural abnormalities.4 Contemporary models of tendon and soft tissue pathology emphasize load-response relationships rather than discrete imaging lesions. Within this framework, the symptom patterns we observed are familiar and clinically coherent.
The observed symptoms should be understood as position-related MSK complaints occurring across a general adult population, rather than as manifestations specific to systemic rheumatic disease.
Despite its limitations, this study offers several strengths. To our knowledge, it represents the first systematic attempt within rheumatology to examine MSK symptoms associated with specific sexual positions. The biomechanical mapping was performed independently by clinicians experienced in load-related periarticular syndromes, providing a structured and reproducible framework. The fully anonymous survey format likely encouraged candid reporting in a domain where underreporting is almost inevitable. Together, these characteristics position the study as a pragmatic foundation for further inquiry into an area that has been essentially absent from rheumatologic research.
Future work in this area could include prospective studies that capture symptoms in real time, validation efforts to refine symptom-based questionnaires, imaging studies examining load-induced soft tissue changes, or interventions exploring whether biomechanical guidance or targeted conditioning exercises reduce symptom onset. Equally important are questions that extend beyond mechanics. We do not know whether these symptoms meaningfully influence sexual satisfaction or broader quality of life. We do not know how couples interpret a partner’s pain, whether with concern, humor, embarrassment, or as a sign of aging. We do not know whether such symptoms tend to be isolated and self-limited or whether they recur under similar mechanical conditions. It also remains unclear whether individuals would modify positions or adopt preventive measures if provided with guidance. These questions invite rheumatologists to consider sexual activity as a form of human movement subject to the same mechanical principles that govern all periarticular function.
The observation that an ordinary sexual position can produce periarticular symptoms reinforces a basic principle: sexual activity is also a mechanical activity. It loads joints, stresses tendons, and compresses bursae. It requires coordination, leverage, strength, flexibility, and balance. It is part of the lived human experience. Perhaps the barrier is not patient reluctance to volunteer the information but our own hesitation to ask about it. As authors, we recognize this hesitation firsthand; even we needed an unexpected bout of prepatellar bursitis to realize how selectively we apply our biomechanical curiosity. As rheumatologists, we are at our best when we understand the whole human experience, not just the comfortable parts.
Footnotes
CONTRIBUTIONS
IGM: conceptualization, data curation, investigation, methodology, visualization, validation, writing - original draft, writing - review & editing; MHH: conceptualization, formal analysis, investigation, resources, supervision, validation, writing - original draft, writing - review & editing; ABO: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, writing - original draft; JAN: conceptualization, formal analysis, investigation, methodology, supervision, validation, writing - review & editing; PGM, MNM: data curation, investigation, visualization, writing - original draft; CRR: conceptualization, investigation, methodology, project administration, supervision, visualization, validation, writing - original draft, writing - review & editing.
FUNDING
The authors declare no funding or support for this research.
COMPETING INTERESTS
The authors declare no conflicts of interest relevant to this article.
ETHICS AND PATIENT CONSENT
This study involved an anonymous, voluntary online survey of adults and did not collect any identifiable personal or health information. The study was considered exempt from formal institutional review board approval because it posed minimal risk to participants. Electronic informed consent was obtained from all participants prior to survey completion.
- Copyright © 2026 by the Journal of Rheumatology
