BACKGROUND Musculoskeletal conditions are the leading cause of years lived with disability globally, with pain and disability being two of the most important patient-reported outcomes. Exercise is a commonly recommended treatment for musculoskeletal conditions, though it is unclear whether exercise outperforms sham for improving pain and disability. AIM: To determine if exercise improves pain and disability more than sham for people with musculoskeletal conditions. METHODS We searched 5 databases and 3 clinical trial registers for randomised controlled trials comparing exercise against sham in people with a musculoskeletal condition. The co-primary outcomes were pain and disability. Data were analysed using random effects meta-analysis or narrative synthesis if < 5 studies were available to be pooled. The certainty of findings was assessed using the Grading of Recommendations, Assessment, Development and Evaluations tool. Data are presented as mean difference [95% CI], with a difference of >10/100 for pain and >14.5/68 for disability (WOMAC physical function sub-scale) considered clinically meaningful. RESULTS Within the 15 included studies, all reported pain intensity and 13 reported disability. There was low certainty evidence that exercise was more efficacious than sham for lowering low back pain (-5.94 [-7.74, -4.15], n=1091), osteoarthritis pain (-6.19 [-14.36, 1.97], n=447) and osteoarthritis disability (-7.95 [-11.45, -4.46], n=211). Narrative synthesis showed varied effects of exercise versus sham on pain and disability in neck pain, as well as on disability in low back pain and other measures of disability in osteoarthritis. No studies were located for rheumatoid arthritis. CONCLUSION Based on low certainty evidence from a limited number of studies, exercise may not cause clinically significant differences for pain and disability compared to sham in adults with osteoarthritis and back pain. Further research is needed to confirm this for low back pain and osteoarthritis and to extend the findings other musculoskeletal conditions.