Supplements for osteoarthritis

Executive Summary
Here are the supplements recommended for osteoarthritis.

Necessary:
Glucosamine HCl (1,500 mg a day);
Omega-3 fish oil (3,000 mg day);
Boswellia (250 mg a day).

Optional:
Chondroitin (1,200 mg a day);
Bromelain (1,000 mg a day);
Collagen (20 mg a day);
SAMe (600 mg a day).

Osteoarthritis is a disease of the joints. Osteo– means bones, arthro– refers to a joint, and –itis is a suffix indicating inflammation or swelling. So osteoarthritis means inflammation of a bone joint.

In this article, I will specifically talk about knee osteoarthritis, which is the joint most commonly affected by arthritis. However, the discussion will also be applicable to hip-, spine-, and shoulder osteoarthritis.

Rheumatoid arthritis is a completely different condition. While it also affects and damages the joints, its cause is altogether different. So the supplementation strategy for it will be different. I will cover that condition in a separate article in the future.

Disclaimer

This article is not medical advice. You should consult your doctor and if you prefer the procedures advised, you should undergo them. This article will tell you what your supplementation options are. You can consider them along with your treatment.

In case you have already undergone surgical procedures for your joints, you may still look at supplementation. After all, you have two knees and many other joints. The supplements don’t work selectively on any specific joint; they are meant to keep all your joints healthy.

Introduction

Our bones have a rubbery tissue called cartilage at their ends. This healthy tissue allows the bones to glide against one another without causing much friction.

In osteoarthritis (OA), the cartilage wears out, causing bones to rub against each other leading to swelling and pain. The osteoarthritic joints may develop stiffness and their range of movement may reduce.

Osteoarthritis is the most common type of arthritis. It is usually a condition that starts in one’s 50s or 60s and progresses with age.

Osteoarthritis is long considered a problem of wear and tear of the joint cartilage. But we now know that it is not caused by just an overuse of the joint.

People are wrongly cautioned from overusing their knees as if the knee cartilage has a certain usage life. So there is a misconception that if your cartilage is damaged—which happens in osteoarthritis—the story is over for that joint.

In this article, I will tell you some interesting scientific facts about your knee and its cartilage. I will not spend time on how a normal knee works. For that, there are many wonderful articles and videos on the internet.

I will cover how the cartilage functions—gets better or worsens under various conditions. I will tell you how knee osteoarthritis develops. That will give you some ideas on how you can control further damage and even fix some damage with supplementation.

For starters, you can also get osteoarthritis at a younger age if your joint gets an injury. This should give you a hint that osteoarthritis is not a condition of worn cartilage but of damaged cartilage—age is just one factor that can damage the cartilage.

How Osteoarthritis Develops

In this section, I will briefly explain how osteoarthritis develops. The insight is meant to help you understand the prevailing thinking behind where, when, and why to intervene with supplements. However, if you prefer to skip this part, you can go to the section on Principles of Supplementation for Osteoarthritis.

Your joint cartilage is living tissue. It is meant to grow, degrade, or change like most other body tissues do. That means it has an inherent capability to repair itself. But for that to happen, certain conditions need to prevail.

The purpose of supplementation is to help restore those conditions so that the body repairs the cartilage. Therefore, let us first learn how osteoarthritis develops, which can happen only if the body cartilage cannot repair itself.

Inside A Healthy Joint

A joint has two or more bones coming together. For example, the knee joint is formed by two bones, viz. femur, and tibia. To allow smooth, frictionless movement between them, those bone ends are covered with a rubber-like elastic tissue. This tissue is smooth, flexible, and firm.

Many people think that cartilage is some kind of inert appendages like your hair or nails. But, your cartilage is as much living tissue as your bones are. You must be knowing that bones are continuously changing shape and size inside your body. New bone is formed and old bone is removed from your body based on the stress at that location.

The cartilage absorbs the shock of any impact by compressing. It distributes loads evenly on the joint to avoid very high pressure at any single point of contact between the two bones. It glides smoothly against the cartilage of the opposing bone in that knee joint.

The cartilage is made up of proteins called collagens. Collagen fibers are strong and rope-like. They form a matrix inside the cartilage. When saturated with water, this collagen matrix turns into a tough gel.

Here is pretty much everything you would ever want to know about cartilage: The Basic Science of Articular Cartilage.

Inside Healthy Cartilage

Inside the cartilage matrix, there are certain cells called chondrocytes. Chondro– means cartilage; –cytes means cells. The part of cartilage other than these cells is called, well, extracellular matrix or ECM. Extracellular means outside of the cells.

The ECM is made up of water, collagens, and certain large molecules called proteoglycans. Don’t worry if you find the word to be a mouthful; just know that it is something important for the health of the cartilage. Besides, there are a few other things that don’t matter as much for our discussion.

The water obviously brings nutrients and removes waste products from the chondrocytes. It also provides lubrication.

Collagens offer tensile and shear properties to the ECM, stabilising it. We use the plural for collagen because there are various types of collagen fibres present in the cartilage. They are slightly different in structure and functionality.

Proteoglycans give enough water-retention ability to the cartilage that it can withstand large compressive loads such as your weight. In another article on this website, I have shown that knee cartilage can handle at least six times your body weight, in normal conditions.

The chondrocytes are sparsely populated within the ECM. They are just about 1-2% of the weight of the cartilage. Water constitutes 75% and the solids mentioned are about 25% by weight.

The chondrocytes are responsible for developing, maintaining, and repairing the ECM. For example, they make collagens and proteoglycans in the ECM. So, if your cartilage is damaged, who ensures its repair? Your chondrocytes. But that needs some more things.

The functioning of chondrocytes is altered by the mechanical and chemical conditions around them.

Cartilage Restructing

As mentioned earlier, your cartilage is not a car’s brake lining that just thins out with usage. Cartilage keeps strengthening or weakening depending on the forces applied to it. It keeps remodeling itself—remodeling is a fancy medical word that means “changing the shape, structure, or form of something”.

Mechanical Stress on the Joint

The chondrocytes can sense the movement and pressure on the joint. When the load on the joint is within limits (less than six times the body weight, for normal knee cartilage), the chondrocytes are stimulated to form more collagens and proteoglycans, strengthening the cartilage. In fact, inactivity worsens the cartilage. This is vital because it tells us that as long as your chondrocytes are alive, healthy physical activity will repair and strengthen the joint.

Chemical Stress on the Cartilage

Certain chemicals produced inside our joints—called inflammatory cytokines or chemicals that cause inflammation—have a negative effect on the cartilage. They lead to the breakdown of the cartilage structure.

What produces these inflammatory chemicals? Many things, including damage to your joint. If your joint somehow gets injured, even at a young age, these inflammatory chemicals are produced in your cartilage. They can destruct the ECM of the cartilage.

Damage to Cartilage Proteins

Chondrocytes live a lonely life. They are in a way stuck inside the ECM grid for life–their life. They sit there sensing mechanical stress. If it is more, they increase the production of proteins to strengthen the ECM.

The chondrocytes also sit there sensing chemical stress. If it is more, they reduce the production of proteins to weaken the ECM. But why would they reduce the production and deliberately weaken the cartilage?

In normal times, the proteoglycans and collagens are sturdy lots. Their protein molecules take 25 and 100 years, respectively, to degrade and be replaced. So chondrocytes need to function very slowly in the production of those proteins.

But, when there is some damage to the ECM, either due to an injury or old age, the collagens and proteoglycans need to be rebuilt quickly. But the law of nature is “destroy the old, to make space for new and better”. So the chondrocytes start destroying the damaged cartilage proteins and making new ones to rebuild stronger cartilage.

This happens in normal times. However, with age or injury, this mechanism suffers.

What Happens with Age?

Chondrocytes not only are immobile in the cartilage structure, but they also don’t replicate easily. So they are there almost for life–your life.

As we age, the outer region of cartilage (the one farther from the bone inside) starts thinning out. This can dry out that part of cartilage, which starts cracking with excess mechanical loading or weight. Once the cartilage ECM cracks, it can lead to the release of inflammatory chemicals, which causes further degradation of the cartilage ECM. Unless the ECM regeneration by the chondrocytes is at a faster rate than its breakdown, the cartilage keeps degrading further.

What Happens with an Injury?

When the cartilage is injured due to a fall, accident, or a sport-related cause, the cartilage gets inflamed and sometimes torn. This causes the release of a lot of inflammatory chemicals in the cartilage. If the injury is significant, the degradation of the cartilage ECM is faster than the speed at which chondrocytes can repair it, leading to further damage.

Chondrocyte Damage

The damaged cartilage due to age or injury is much weaker than normal. Any mechanical stress that healthy cartilage can handle, cannot be handled by such weak and unhealthy cartilage easily. The biomechanical stress now starts affecting the functioning of the chondrocytes, destroying them slowly.

Unfortunately, chondrocytes are very limited in their ability to replicate. So once they are destroyed, due to ageing or an injury, it is very difficult to get their replacement. Without chondrocytes, you cannot get new proteoglycans and collagens.

This vicious cycle leads to progressive cartilage destruction.

Bone Spurs

The unstable joint with the degraded cartilage goes into protective mode. Since the cartilage over the bones is eroded, the bone ends develop small calcified bone spurs, which is the body’s way of stabilising that joint structure. Unfortunately, these small bony protuberances are not designed for joint movement. Trying to move such joint causes further pain and damage.

Synovial Inflammation

The cartilage does not have any blood supply. So its chondrocytes don’t get nutrients directly supplied through blood. As a result, the healing process in that region is very slow.

The cartilage gets its nutrient supply through a liquid named synovial fluid that surrounds the joint. Around a damaged joint, the synovial fluid accumulates the inflammatory chemicals. That can cause swelling to the membrane—called the synovium—surrounding the joint and the synovial fluid. This causes further pain and swelling in the region.

Summary of How Osteoarthritis Develops

1. In a normal joint, mechanical pressure and movement keep the chondrocyte cells healthy. They produce the required amount of collagens and proteoglycans to repair, or occasionally strengthen, the natural degradation of those proteins.
2. With age, the chondrocytes in the surfaces of cartilage regions thin out, making the cartilage dry and cracking. This triggers the release of excess inflammatory chemicals in the cartilage, more than what the chondrocytes can handle safely for making new collagens and proteoglycans.
3. Instead, with an injury, the damaged cartilage structure releases excess inflammatory chemicals in the cartilage, once again more than what the chondrocytes can handle safely to make new collagens and proteoglycans.
4. The damaged cartilage in both cases allows too much biomechanical stress on the chondrocytes than what they can handle, even with the normal level of physical activity.
5. The chondrocytes start dying or getting damaged, restricting their cartilage repairing ability further.
6. The thinned-out cartilage triggers the newly exposed bones to develop bone spurs—small bony fragments jutting out of the bone—to give more scaffolding to the joint and stabilising it.
7. Bone spurs are useful for supporting the joint when it is stationary but not helpful when the joint is moved. Such action causes more pain and inflammation in the joint.
8. The inflammatory chemicals from the cartilage degeneration accumulate in the synovial fluid that surrounds the joint. It leads to swelling of the synovial membrane that encapsulates the joint. This causes further pain and a swollen joint.

Principles of Supplementation for Osteoarthritis

So when and how do you intervene with supplements in the above degenerative process? Well, as early as possible. Don’t wait for the condition to worsen. It becomes progressively difficult to manage the damaged joint. Remember that once the chondrocytes are gone, it is very hard to get back to normalcy.

Intervene quickly; intervene aggressively. Here are the three pillars of supplementation strategy for osteoarthritis:

1. Reducing inflammation:
   We must stop or control the inflammation fast. That would involve reducing inflammatory chemicals in the cartilage as well as in the synovial fluid.
2. Rebuilding cartilage:
   We should provide nutrients to the chondrocytes to rebuild the collagens and proteoglycans.
3. Strengthening the bone ends:
   We have to keep the bone ends healthy enough to withstand the mechanical stress of the body weight and normal activity levels.

Supplements for Reducing Inflammation

There are many options here and each of them helps in one way or the other. You don’t need to take them all. Do consider a few that are specifically known to act as anti-inflammatories for the joints.

Remember that there is no blood supply to the cartilage. So removal of inflammatory chemicals in the joint space is a slow process. The anti-inflammatory supplements that specifically help the joints are better choices, in general.

1. Omega-3 fish oils: One of the inflammatory chemicals in cartilage degration is Leukotriene-B₄. Omega-3 oils are known to reduce their levels. This helps in arthritic pain relief. 1,000-3,000 mg a day depending on the severity of pain. For detailed coverage of this nutrient, read on this website: Omega–3 oils: A complete guide.
2. Bromelain: This is an extract from pineapple leaves. It is a good anti-inflammatory for joint pain. As per Ayurveda, the Indian medicinal science, an extract taken from the stem of a pineapple is considered anti-inflammatory for joints. Take 1 g a day.
3. Boswellia or Guggul: Boswellia is an extract from an ayurvedic herb, salakki guggul, or the frankincense tree. As per the latest research, Boswellia is excellent for reducing arthritic joint pain and stiffness and improving function. Take 250 mg a day.
4. Curcumin: This is an extract from turmeric. Anti-inflammatory effect in the body. 500 mg three times a day.
5. Ginger: Anti-inflammatory. 2 g a day.
6. Garlic: Anti-inflammatory. 2 g a day.
7. Resveratrol: Anti-inflammatory. Gives better pain relief if taken with a pain-killer. 500 mg a day.
8. Methylsulfonylmethane (MSM): Has anti-inflammatory and pain-killing effects.
9. Devil’s Claw: An extract from a plant called Grapple Plant has anti-inflammatory properties. It can also prevent free radical damage to the cartilage. 600 mg a day. I am a bit cautious about this because of its side effects. Make sure you learn about them before using this supplement.

As I mentioned earlier, you don’t need all of these. The first two or three anti-inflammatory supplements are enough. I have mentioned the rest just to tell you that if you are taking them for some other reason, they will help with your osteoarthritis, too.

Supplements for Rebuilding Cartilage

These supplements constitute the raw material for cartilage production and so are thought to help in cartilage rebuilding.

1. Glucosamine: The primary building block of cartilage proteoglycans. Stimulates chondrocytes to produce proteoglycans. Also, reduces inflammatory chemicals.
   Available in two varieties: Hydrochloride and Sulphate. The latter needs salt stabilisers and so can only be 74% pure. The former can be 99% pure and needs a lesser dose: 1,500 mg a day of Glucosamine Hydrochloride versus 2,600 mg a day of Glucosamine Sulphate.
   Be prepared to continue the treatment for three to six months before seeing any noticeable difference. As I have already mentioned, there is no blood supply to your cartilage and so the rate at which these nutrients can reach there is abysmally low.
2. Chondroitin: A building block of cartilage ECM. Helps cartilage retain water. Anti-inflammatory and reduces joint breakdown. Made from cow trachea; so may not be acceptable to all. 1,200 mg a day.
3. Collagen: Since collagens are part of cartilage, ingestion of collagen supplements is thought to help in osteoarthritis. There is some evidence that taking collagen supplements improves the overall function of the joint. 20 mg a day as a tablet or 10 g a day as gelatin.
4. S-adenosylmethionine (SAMe): It is normally produced in our liver. SAMe appears to increase cartilage thickness. Prevents damage to chondrocytes. 600 mg a day.

Supplements for Bone Strengthening

Inflammation can also cause bone density loss. Since osteoarthritis is an inflammatory condition, excess bone loss is expected. People with arthritis reduce their weight-bearing activities due to pain, which can reduce new bone formation.

1. Calcium: 1200 mg a day through food as well as supplements. Read on this website: Are you consuming enough calcium?
2. Vitamin D: Low vitamin D levels are associated with loss of cartilage and degenerative bony spur formation. 2,000-4,000 IU a day, with vitamin K₂.

Long-Term Complications

Osteoarthritis causes debilitating pain. If untreated, it restricts mobility causing its own problems such as weight gain, depression, and sleep disorders. Limping with a painful knee can cause falls and fractures. Here are some possible medical complications:

• Stress fractures;
• Bone death or necrosis; and
• Joint infections.

My Views

1. I have a family history of osteoarthritis and I am a marathon runner. So I am more worried about developing knee pain than most of you. The human need for self-preservation!
   So I have gone through a lot of medical literature about knee osteoarthritis. This article is the culmination of what I have learned over three decades about my own knee health.
2. When my mother was detected with knee osteoarthritis in the year 2000, she was advised a total knee replacement surgery. At that time, I did not know much about supplementation for knee osteoarthritis. But since my mother was very reluctant to undergo knee surgery, I evaluated supplementation options available at that time. I started my mother on glucosamine, boswellia, bromelain, and fish oil supplementation, purely on a trial basis.
   Within six weeks, her knee pain disappeared and within three years, her knee x-rays started showing the increased spacing between the two knee bones (meaning, the cartilage had regrown in thickness—an exciting improvement). We and our orthopedic surgeon did not know how that could have happened.
   However, now we understand that most likely, the fish oil, boswellia, and bromelain reduced inflammation in my mother’s knee joints, which prevented further degradation and relieved her of knee pain. Then, she resumed normal activity, thinking her knee had become normal (which I do not think it had, though the pain had subsided making her feel that her problem had resolved). That perhaps triggered the remaining chondrocytes in her knee cartilage to increase their metabolism.
   Glucosamine HCl then helped the chondrocytes to make more proteoglycans and collagens, resulting in improved cartilage thickness.
   Of course, I didn’t want to do any experiments on my mother. So we will never know. Today, twenty-two years later, her knees are still holding without surgery. Not bad for an 85-year-old arthritic knee!
3. Many people wait for supplement guidelines from various healthcare associations. If there are no guidelines, such people freeze into inaction.
   But try to understand how medical bodies come up with their recommendations: They need to evaluate the evidence, the side effects, and the cost of the treatment. Then, they have to weigh all these cost-benefits before deciding whether it is worth recommending a supplement to all.
   The healthcare associations have to look at probabilities; but if you have osteoarthritis and knee pain, you have to look at possibilities. So you have to ask three questions:
   A. Is there a ‘decent’ amount of belief in the supplement in the healthcare world? Are many mainstream healthcare companies offering the supplement? Do many preventive-health practitioners believe it would be useful? After all, a completely useless product will never reach such a level of acceptance.
   B. Are there any major side effects that I need to know?
   C. Can I afford the cost?
   If the answers to the three are Yes, No, and Yes, respectively, I think it is worth using that supplement.
4. In some clinical trials, there is no clear-cut’ statistically significant’ benefit seen from a supplement. But people take that result to mean that the supplement is not beneficial. I always say:
   “Absence of proof is not proof of absence.”
   Think about it. I have written a detailed article on this website about How to understand the evidence from clinical trials of nutrients.
5. If you need help with any of the points discussed, write to me at madhur.kotharay@gmail.com (Disclaimer: No medical advice from my side, please. But I will be happy to help with the supplement selection part). Kindly mention “Supplements for Osteoarthritis” in the subject of the email.

To Read More

• Cleveland Clinic: Osteoarthritis;
• Johns Hopkins Arthritis Center: Osteoarthritis: Pathophysiology;
• Healthline: Everything You Need to Know about Osteoarthritis (OA);
• WebMD: The Basics of Osteoarthritis;
• CDC: Osteoarthritis (OA);
• National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH: The Role of Inflammation in Osteoarthritis;
• On this website: Everything you want to know about running and knee osteoarthritis;
• On this website: Obesity worsens osteoarthritis in many ways;
• On this website: The real secret why knee arthritis is getting prevalent;
• On this website: Healthy diet for osteoarthritis.

First published on: 3rd April 2022
Image credit: Healthy man photo created by rawpixel.com – www.freepik.com
Last updated on: 12th July 2022