Sunday, October 27, 2013

Which Supplements Work Best for Osteoarthritis?

The October issue of Nutrition Action Newsletter looked at pills that claim to reduce pain associated with osteoarthritis. As I’ve said before, I like Nutrition Action Newsletter for its level-headed, science-based analysis (its bias, if it has one, is for sensible eating and exercise and weight reduction -- and what’s not to like there?)

First, obesity was identified by an assistant research professor at University of Michigan’s School of Public Health as “the number-one risk factor for osteoarthritis.”

What’s so bad about excess weight, according to this article:

(1) Each extra pound increases the load across the joint “three to five times,” says an arthritis expert.

(2) The heavier you are, the higher your risk of injuring your joints, which can lead to osteoarthritis.

(3) Heavier people have higher levels of inflammatory chemicals circulating in their body, which can break down cartilage.

Now, what about their verdict on those “pills for pain”?

* Glucosamine

“Glucosamine doesn’t work, period,” David Felson of the Boston University School of Medicine says. Nine trials that found a benefit for glucosamine were run by the supplement industry. Still, despite the lack of evidence, Felson says if patients “think something is working and it’s not dangerous, I don’t discourage its use.”

That’s a wise stance for a doctor to take, I think.

* Chondroitin

Like glucosamine, chondroitin is an essential element in cartilage. Taken as a supplement, however, it is no more effective at relieving pain than a placebo, rigorous trials have found.

* Glucosamine and chondroitin

The combination didn’t work better than a placebo in the National Institute of Health’s large GAIT trial. At first it appeared to benefit a subset of subjects with moderate to severe pain. But, as I wrote in Saving My Knees, “this may just be a statistical anomaly.”

Yup. That’s exactly what it was. When researchers monitored the patients for two more years, they saw no benefit.

* MSM (methylsulfonylmethane)

MSM is sometimes substituted for chondroitin (which is more expensive) in supplements. In three trials, researchers question whether MSM would make much of a difference, if any, for treating arthritis.

* Avocado and soybean unsaponifiables (ASU)

The one good study from the last 11 years found no benefits for pain, stiffness or joint function.

* Vitamin D

A two-year study showed vitamin D was no better at reducing pain and slowing cartilage loss than a placebo.

* SAM-e

In half a dozen trials, 1,200 mg of SAM-e (S-adenosylmethionine) provided as much pain relief as anti-inflammatory drugs such as Celebrex or ibuprofen. However, a rheumatology professor cautions that the trials were small and characterizes the results as showing only a “small pain relieving effect.”

Then there’s the price: $80 to $110 for a month’s supply of 1,200 mg a day. That’ll put a dent in your household budget.

So, all in all, a fairly dismal showing for supplements that aim to reduce knee pain. SAM-e looks the most promising. Of course, if something seems to work for you, even if medical science says it’s useless, you might as well keep taking it.


  1. Very interesting, Richard.

    I've been reading about PFPS for quite a while (wanting to get to the bottom of what was happening was almost more important than sorting my problems out). Have you read this thesis?

    It is a very interesting read!

  2. My knees have improved dramatically over the past month or so - to the point where I am now easing back into cycling and running (well, you could not really call it running).

    Unlike Richard, my experiment was not well controlled at all, but I really do think I had a mild form of CRPS (my GP & physio tend to agree). I also think Richard may have had the same, triggered by underlying damage to his cartilage. Mine was triggered by a knee arthroscopy most likely. My physio admits the medical profession have under-estimated the occurrence of CRPS, and mild cases like mine are very easy to miss.

    So what seems to have worked for me?

    1. Following a SavingMyKnees-type schedule of avoiding things which aggravate, and going back to a gentler form of movement (walking 15 to 50 minutes per day) and then re-introducing some light jogging (5 mins shuffling on grass in 30-60sec intervals on a 2 min cycle, walking in-between), and now cycling (20-30mins only, not too hard). Interestingly, this is also in-line with what they now recommend in the treatment of CRPS (movement).
    2. Glucosamine-Chondriton-MSM powder. My GP recommended this, and the rapid improvement in my knees co-incided with starting this, but that could just be coincidence.
    3. UCII cartilage supplement (had to import from the UK, can't get it in Oz). Been on this 2 mths, maybe this helped, maybe again just coincidence.
    4. Started very shallow (no pain) supported single-leg squats (on GP advice). These place very little stress on the joint & muscles.

    Like I said, no controls in this experiment, but I do think the 12+ months of gentle movement was the key as my knees were very slowly moving in the right direction before I started the other 3 things. I now seem to be emerging from knee-pain Hell.

    Only problem now is I'm now in back-pain Hell - possibly due to having my legs elevated at work all the time (which I no longer have to do)! I think Richard has this problem too?

    cheers TriAgain

    1. TriAgain,
      I'm happy for you that you are getting better and emer

    2. TriAgain,
      Sorry my full comment didn't get included. What I was trying to say is that I'm glad to hear you are doing better! I was worried for you and the single leg knee squats!

      Thanks for keep us posted.

      My main form of therapy right now is walking. I was able to walk 3 miles in three 1-mile segments with rests between, so that's an improvement.

      Being able to walk without pain is such a gift.

      I'm reading Doug Kelsey's book although I have not taken action yet.

    3. It's not as good as I thought. I did a 45min ride, much of it into a strong headwind and started get the old symptoms back. Seems I still need to be careful. I think my problem is a combination of cartilage damage and CRPS. The single leg squats are OK as long as I'm very strict and have no pain, don't go too deep.

      So true, no pain is magic. I will be interested in getting an overview from you on Dougs book.

      Walking definitely helped me, though my GPs plan now is to be a bit more aggressive (to combat the CRPS I assume) and start light jogging again. Incredibly, that seems to do less damage than cycling.

      cheers, TriAgain

  3. Mayo Clinic cites Glucosamine as having grade A evidence for "mild to moderate knee osteoarthritis". In essence, the focus of this blog. So your strong conclusions that there is no evidence that glucosamine works is plain wrong.

    There may be conflicts of interest but until a large meta-analysis or every further study establishes as having no foundation, you're wrong.

    It MAY help, is a better more accurate conclusion with the literature.

  4. Other supplements you didn't mention: Flaxseed Oil, Fish Oil, Krill Oil, Curcermin (may be spelling it wrong...), comfrey (applied topically), Aloe Vera (applied topically)

    There are a lot more. Your conclusions that all this stuff has "no evidence' is plain wrong. Half of the studies basically show little to no effect, half show they help some. Might want to dedicate a whole post to each supplement panning out each study exhaustively searched on pubmed instead of making some generalistic post essentially saying no supplements work, period.

    Also some amino acids work for people like glutamine and arginine.

    1. I'm skeptical of supplements. My hunch is, at best, they help a bit around the margins. If you know of one that's helped you in particular, by all means, feel free to share your story. It's well known that the early positive studies on glucosamine tended to be funded by the very industry that makes the stuff. Clear conflict.

      Here's the latest from the New York Times blog, just this past week. More skepticism, so it's not just me:

      Above, I didn't say glucosamine doesn't work. Reread that. David Felson (who is a pretty well known researcher when it comes to knee pain and treatments for it) did. I think it may work for some people, probably because of the placebo effect.

      This is the problem with the glucosamine story (from my book):

      "When you swallow a glucosamine pill, it doesn’t make a beeline for your knee joints. Rather it heads off to the liver, an organ whose many functions include metabolism. The liver then rapidly breaks it down. After the industrious wrecking crew finishes, only a minuscule amount of glucosamine reaches the blood to wend its way to the joints. That’s what researchers discovered in a 2005 medical study where osteoarthritic patients took the recommended dose of 1,500 milligrams of the supplement, then had their blood tested."

    2. Thanks for the reply. You've probably read about more Glucosamine than I. I just find it difficult to calculate that Mayo Clinic is clueless. They're supposed to be one of the cutting-edge health organizations in the United States. I have taken some glucosamine (I take Animal Pak Flex, a bodybuilding joint supplement that contains flaxseed oil and a variety of other ingredients). I take it because I have a knee problem I am not addressing right now because of other injuries but I hope this stuff hedges my bet a little in effectiveness.

      I've read about people who it's been effective for. Some professor who had avascular necrosis of the hip took glucosamine, flaxseed oil and miacalcin and it helped him out some. I'm trying to form some meta-argument for glucosamine, I'm just saying sometimes it might work.

      I think Adequan and hydraulonic acid might be the equivalent of liquid glycosamigens. Adequan is used in animals only now and in Europe. HA is kind of popular right now.

      Basically your right, there is no proven great go-to supplement.

    3. You have a fair point about the Mayo Clinic. I don't think they are "clueless" -- not at all. But I do think Web pages can be out of date -- a lot of the thinking about glucosamine seems to have shifted dramatically in the last three or four years. When I first published "Saving My Knees," I definitely felt my opinion about glucosamine was more of a minority one. Now though I feel like I'm part of a skeptical majority.

      Might there be some efficacious cocktail of supplements, discovered or yet undiscovered, for knee pain sufferers? Sure. But I still think that the best approach is movement-based. My guess is that movement modifies the injured tissues a lot more effectively than anything that's ingested.

  5. That was a great article, I have tried chondroitin to no avail. I try a combo now with chondroitin and glucosamine. Wish me luck :)