You don’t have to be a baby boomer to suffer from knee pain. Plenty of younger people have pain that they can trace to overuse or to a specific injury. Older people also may be afflicted with arthritis that can cause knee or hip pain. But as increasing numbers of boomers move into their 60s and 70s, knee arthritis is becoming a common complaint. Moreover, the pain it produces can interfere with people being able to run or even walk as they would wish. Understandably, many people are looking for the best medication to ease the pain. Here, the research has failed us all.
No Clarity on Long-Term Pain Control for Knee Arthritis:
An article in JAMA (Dec. 25, 2018) reviewed 47 randomized controlled trials of medications or supplements for knee pain. In all of them, the pharmacological intervention was compared to placebo or to another treatment. Importantly, all of the studies lasted for at least a year. (Short-term pain relief studies may not tell us enough about how well the treatment works in the long run.) This is exactly the type of study that should reveal how well medications work over the long term for controlling knee pain.
The Envelope Is Nearly Empty:
As a result, we are disappointed that this meta-analysis that included more than 22,000 patients did not demonstrate a clear winner. Two of the interventions did show a decrease in pain attributed to knee arthritis. They were celecoxib (Celebrex), a specialized COX-2 inhibitor in the NSAID category and crystalline glucosamine sulfate. (This product is available by prescription in Europe, where the authors are based, but not in the US.) Glucosamine sulfate had the best showing but the effect was small to moderate.
As the investigators state:
“Among the high-quality trials, glucosamine sulfate had the highest probability of being the best long-term treatment…”
In addition, the scientists found that glucosamine sulfate was most likely to be associated with improvements in joint structure. However, the authors noted significant uncertainty regarding how much this product is likely to help. Importantly, they found even more uncertainty with respect to celecoxib, the only NSAID (nonsteroidal anti-inflammatory drug) to do well in this set of long-term clinical trials. NSAIDs like ibuprofen and naproxen are far and away the most popular medications used to treat knee arthritis despite a lack of evidence that they help over the long term.
Consequently, the researchers conclude:
“Larger RCTs are needed to resolve the uncertainty around efficacy of medications for knee osteoarthritis.”
What Can You Do About Knee Arthritis?
Given this research, a person suffering the pain of osteoarthritis of the knee might well decide to explore glucosamine sulfate as a treatment option. People in the US might have trouble finding crystalline glucosamine sulfate, however, and other forms of glucosamine do not appear to be useful.
Fish Oil Offered Surprising Relief for Knee Arthritis:
One reader started taking fish oil for a different purpose. Relief from knee pain was a pleasant surprise.
Q. I started taking fish oil about seven years ago for dry eyes. To my surprise, I noticed about a month later that my arthritic knees went away. It’s dramatic because I have stage 4 arthritis in my right knee! My eyes only improved slightly, but I’ll take this supplement as long as I can.
A. We are not surprised that your arthritis improved thanks to fish oil. There is some scientific evidence that the omega-3 fatty acids found in fish oil have significant anti-inflammatory activity. A meta-analysis of nine randomized controlled trials involving more than 2,000 patients was published in the Journal of Orthopaedic Surgery and Research (May 24, 2023). It concluded that such supplementation with omega-3 fatty acids “could significantly relieve arthritis pain and improve joint function in patients with OA [osteoarthritis].”
There is one caution, however. A recent review of omega-3 supplements found substantial variability in “freshness” when it comes to fish oil quality (Journal of Dietary Supplements, Sept. 15, 2023). The researchers analyzed 72 omega-3 supplements for rancidity (oxidation). Almost two-thirds of the flavored supplements that were tested produced disappointing results. Over one-tenth of the unflavored omega-3 products tested also failed tests for rancidity.
To find out which fish oil supplements are highly rated, we recommend the subscription-based website ConsumerLab.com. Two of our favorite products include Costco’s Kirkland brand 1,000 mg Fish oil and Life Extension’s Super Omega-3.
Will Fish Oil or Herbs Help?
Q. Although I’m a retired physician, I am not much of a medicine man. I’ve seen too many problems with drugs and their side effects. Alternative treatments have helped a lot of people, and I prefer them when possible.
My wife has arthritic knees. NSAIDS like ibuprofen and naproxen have not provided relief. Can you offer any guidance on fish oil or anti-inflammatory herbs?
A. The research is somewhat confusing. As you’ve just read, a meta-analysis concluded omega-3 fats can help. On the other hand, a large randomized controlled trial of vitamin D and fish oil (VITAL) found no benefit for knee arthritis (Arthritis & Rheumatology, Nov. 2020). The study lasted over five years and included nearly 1,400 volunteers. Since we have no scientific way to resolve these differing results, we can only suggest that your wife try a good brand of fish oil to see if it helps her.
What About Krill Oil?
Another source of omega-3 fatty acids is the tiny crustaceans in Antarctica called krill or Euphausia superba. Krill oil is a popular dietary supplement rich in both EPA and DHA, just as fish oil is.
A randomized controlled trial from Australia evaluated whether krill oil could ease knee pain (American Journal of Clinical Nutrition, Sept. 2, 2022). The scientists recruited 235 middle-aged volunteers with mild to moderate osteoarthritis of the knee. After six months, those taking 4 grams krill oil daily reported less knee pain compared to people taking placebo. They also reported modest improvement in joint stiffness and better physical function, without significant safety concerns. We do not know if krill oil, like fish oil, can trigger atrial fibrillation in some people, but it did not show up in this study.
Herbs Hold Promise:
Other natural options worth consideration include turmeric, boswellia, ashwagandha and ginger. There is research to support the anti-inflammatory activity of these botanicals. For example, a systematic review of controlled trials of turmeric extract found that curcumin relieved pain and joint stiffness with fewer side effects than NSAIDs (Bioscience Reports, June 25, 2021). However, scientists have not studied most herbs even as rigorously as medications.
NSAID pain relievers such as diclofenac or ibuprofen have some serious side effects when taken for chronic pain. Moreover, not everyone can tolerate fish oil or herbs. There are many other options included in our eGuide to Alternatives for Arthritis.
Home remedies are popular, but few scientists have studied their effects on knee arthritis. If you would like to learn more about them, you may be interested in our Guide to Alternatives for Arthritis. It is available as a printed book or as an online resource (not a pdf). In addition, you may wish to listen to our interview with Dr. Beth Jonas. It is Show 1140: How Can You Manage Arthritis Pain?