Typical school provision of physical education, physical activity and sports may impact adolescent physical health. However, systematic literature reviews and meta-analysis have not yet considered this impact. The Web of Science, SPORTDiscus, PsychINFO, ERIC and MEDLINE databases were searched for relevant literature (2000–2023) pertaining to adolescents aged 12–18 years in secondary schools. Twenty-nine studies met the inclusion criteria, including twenty-three interventions, four cross-sectional and two longitudinal studies. Included studies contributed 268 reported effects on indicators of adolescent obesity, physical fitness, blood pressure and bone health. Fifteen studies were included in the meta-analysis and reported significantly positive effects on indicators of adiposity in experimental groups with minor modifications to typical school provision (g = − 0.11 [95% CI − 0.22, − 0.01], p < 0.04, I2 = 32.49%), in boys and girls. Subgroup analysis found significantly positive effects for body fat percentage (g = − 0.28 [95% CI − 0.49, − 0.06], p < 0.01). Robust examples of best practice in schools include extended days dedicated to physical education weekly (≥ 4 days), integration of theoretical components to physical education, sports field/gymnasium availability and a range of training modalities. Studies without the integration of a minor modification to typical school provision were deemed to have a limited impact on adolescent physical health. Further research that examines the additive impact of school physical activity and sports to supplement physical education is warranted.