At present, when resources allow, the main issue in preventing arthropathy in patients with haemophilia is determining the 'optimal' prophylaxis regimen rather than the choice between primary prophylaxis and on-demand treatment. Barriers to prophylaxis implementation are still relevant and include difficulties with venous access, adherence to treatment regimens and costs. Prospective studies with different prophylactic regimens and objective outcome measures are still needed to determine the best cost-benefit ratio. The results from large retrospective cohorts followed up for decades in several European countries have shown that regular prophylaxis started at an early age is able to reduce physical impairment from haemophilic arthropathy. The efficacy of primary prophylaxis was finally demonstrated also in the setting of a randomized clinical trial.