As therapy for osteoporosis, exercise has come of age. Previously considered to evoke only modest benefit for BMD, recent examination of higher intensity loading has produced more positive results. In fact, from an ancillary therapy playing a distant second fiddle to medications, there is now strong evidence that exercise should be first line therapy for osteoporosis for all who are physically capable. Not only can exercise improve bone density but bone morphology in strategic locations likely to improve the resistance of a bone to fracture. Furthermore, the vital role of exercise to promote neuromuscular adaptations in the lower extremity that reduce the propensity to fall cannot be overstated. Several clinical cases will be presented demonstrating the effects of high intensity exercise under a variety of conditions of low bone mass, including a ‘standard’ postmenopausal response, pre-menopause, breast cancer recovery, and cessation of bone medications. The principles behind effective exercise loading for bone will be discussed as the rationale for high intensity exercise prescription. A successful model of translation of high intensity exercise into clinical practice for osteoporosis will be described. Recognised challenges to high intensity exercise arising from prevalent comorbidities in the osteoporotic demographic will be addressed and practical solutions presented.