Background: Rheumatologic and geriatric scholarly organisations recommendations for the management of hip and knee osteoarthritis, which emphasise the usefulness of non-pharmacological therapies, are not scaled according to patient's age and physical condition. We conducted a systematic review of clinical trials on exercise and weight loss in hip and knee osteoarthritis in very old patients. Methods: Electronic search in MEDLINE, EMBASE, PASCAL database, systematic search of the Cochrane Reviews, manual search in guidelines, meta-analyses and identified relevant articles. Results: We identified 83 trials, with only 2 on patients aged ≥ 75 years; we therefore lowered the mean age threshold to 70 years and found 15 trials, mainly performed in knee osteoarthritis and outpatients. Physical exercise 8 trials: was effective on pain and function (4 controlled trials), with a persistent effect only in case of self-rehabilitation. Aquatic exercise 5 trials: was as effective as land-based exercise. Weight loss 2 trials: only patients under diet + exercise had significant improvement on symptoms. Conclusion: Our systematic review confirms that international recommendations on exercise for knee osteoarthritis also apply to subjects aged 70-80 years. Long-term effectiveness requires a maintenance strategy. Specific trials on very old patients with various comorbidities are mandatory, given that these subjects are more exposed to drug-related iatrogenesis.