How does testosterone replacement therapy (TRT) affect joint pain?

Testosterone Replacement Therapy and Joint Pain

Testosterone replacement therapy (TRT) does not appear to improve joint pain and may actually increase the risk of certain tendon injuries, particularly in the quadriceps tendon.

Effects of TRT on Joint Pain and Musculoskeletal System

General Effects

• TRT has not been shown to improve joint pain in clinical studies and is not recommended specifically for joint pain management 1
• TRT is primarily indicated for hypogonadal symptoms including decreased libido, erectile dysfunction, depressed mood, anemia, and loss of muscle and bone mass 2
• The American Urological Association guidelines do not list joint pain improvement among the expected benefits of TRT 1

Potential Negative Effects on Tendons and Joints

• TRT is associated with a significantly increased risk of quadriceps tendon injury, with patients on TRT having 5.4 times higher odds of experiencing quadriceps injury compared to matched controls 3
• Male patients on TRT specifically showed 5.8 times higher odds of quadriceps injury within one year of starting therapy 3
• Patients on TRT who experienced quadriceps injury were 4.7 times more likely to require surgical repair than matched controls 3
• Recent research in orthopedic surgery is beginning to investigate the complex relationship between TRT and musculotendinous pathology 4

Effects on Muscle Function and Bone Health

• While TRT increases lean body mass, studies have not demonstrated corresponding improvements in muscle function or gait performance in men with chronic pain 5
• TRT has been shown to improve bone mineral density, with increases of 7% in lumbar spine trabecular volumetric BMD after 1 year of treatment 1
• Testosterone therapy can provide bone micro-architectural benefits, with significant increases in cortical volumetric BMD (3%) after 2 years 1

Considerations for TRT in Patients with Joint Concerns

Patient Selection

• TRT should only be prescribed for confirmed hypogonadism with total testosterone levels below 230 ng/dL, or potentially for symptomatic men with levels between 231-346 ng/dL after careful discussion of risks and benefits 1
• TRT should not be used in eugonadal men for any purpose, including joint pain management 1
• Patients with existing joint problems should be counseled about the potential increased risk of tendon injuries with TRT 3

Monitoring Recommendations

• Baseline and follow-up monitoring should include assessment of:
  • PSA and hematocrit/hemoglobin levels 1
  • Digital rectal examination 1
  • Voiding symptoms 1
  • Sleep apnea history 1
• First follow-up should occur at 1-2 months to assess efficacy, with subsequent monitoring every 3-6 months for the first year, then annually 1

Contraindications and Cautions

• TRT is contraindicated in men trying to conceive due to effects on spermatogenesis 1
• TRT should be used cautiously in men with congestive heart failure due to potential fluid retention 6, 7
• TRT is contraindicated in men with active or treated breast cancer 1
• TRT should be used with caution in men with severe LUTS 1

Potential Protective Effects of Testosterone on Pain

• Animal studies suggest testosterone may have a protective role against the development of temporomandibular joint pain, with male rats showing lower risk for TMJ pain development compared to females 8
• At supraphysiological levels, testosterone demonstrated antinociceptive effects in male rats but not female rats in experimental TMJ pain models 8
• These protective effects observed in animal studies have not been consistently demonstrated in human clinical trials for joint pain 5

Clinical Recommendations

• For patients with joint pain, TRT should not be prescribed solely for pain management as there is insufficient evidence supporting its efficacy for this indication 1, 5
• Patients already on TRT should be monitored for potential tendon injuries, particularly of the quadriceps tendon 3
• For hypogonadal men with osteoporosis and joint pain, established anti-osteoporosis medications should be considered as the primary treatment, regardless of whether TRT is instituted 1
• Lifestyle modifications, including weight loss and increased physical activity, should be recommended as first-line approaches for both hypogonadism and joint pain management 1
• Target testosterone levels during therapy should be in the mid-range (350-600 ng/dL) rather than high-normal range to minimize potential adverse effects 1, 7