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Bones, Joints, and TRT: How testosterone promotes bone and joint health

Joint pain like arthritis is common among aging men, and there’s a clear cause and effect between low testosterone and the risk of developing arthritis. Testosterone has a protective effect on the cartilage in the body so, naturally, as men begin to reach the age of 60 the risk of osteoporosis is much higher. TRT can help with joint pain caused by arthritis, previous injuries, or simply the wear and tear from getting older.

The body uses testosterone to create bones so as T levels decrease, so does the development of healthy bone formation. So many studies confirm that older men that are treating low T with testosterone replacement therapy (TRT) see impressive bone density scores alleviating joint pain and damage. Keeping BMD or bone mineral density high is important in older men as brittle bones lead to the risk of major injury. No one wants to look like the hunchback of Notre Dame at 55 years old.

A majority of men over 50 years old go undergo knee or back surgery and probably have several nagging injuries from their 20s and 30s they would rather ride out rather than correcting the issue…

Over time, aging steps in, and these injuries begin to wore down the body affecting joint health. This is where testosterone replacement therapy could improve general well-being for those men at risk of, or suffering from, some sort of joint issue or arthritis condition like osteoarthritis (most common), rheumatoid arthritis, osteoporosis, or Crohn’s disease.

Low levels of testosterone lead to stiffness and lack of flexibility or mobility. The natural thing to do with painful or stiff joints is to take it easy or sit around and do nothing at all but this can actually make the joint issues worse. By becoming a couch potato, men will begin to gain weight putting more strain and pressure on the joints as they try to carry a heavier body (plus the 15 Arby’s roast beef sandwiches carefully balanced into a meaty pyramid on the belly). All jokes aside, painful joints can become problematic without some sort of medical help.

There are two very common types of arthritis among men. Inflammatory arthritis like rheumatoid arthritis (RA), and noninflammatory arthritis is known as osteoarthritis (OA).

OA is your “run of the mill” arthritis when joint cartilage breaks down. Cartilage is the slick tissue that covers the ends of the bones in a joint but due to injury or aging, the slick tissue wears away.

OA usually occurs in the knees, hips, spine, or hands.

RA is an autoimmune disease and believed to be triggered by genetics or hormonal issues. When men or women suffer from RA, the body’s immune system attacks healthy tissue.

Let’s break down how testosterone helps the body create bones.

Osteoblast is the formation of bones and osteoclast is the breaking down of bones. Osteo means “bones” in Greek. Many studies confirm that testosterone replacement therapy can be helpful because of its stimulation of osteoblast creation and osteoclast dampening.

Once again, the brain and pituitary gland plays a critical role in bone production. As we speak about in our TBI and PTSD article, testosterone fills up androgen (testosterone) receptors asking to body to create bones (osteoblast) and remove the old bones (osteoclast). These androgen receptors feed off of the testosterone to stimulate the action of creation. If testosterone levels are low, then these receptors have nothing to gas them up. Low levels of testosterone for an extended period of time could have a negative impact on bone structure and lead to the possibility of broken bones.

  • These studies share that TRT increased men’s bone mineral density by 7.5% in the spine (lumber L2-L4).
  • Over a 6-month period, several people saw a 2% increase in bone density.
  • Another study shared that using testosterone replacement therapy for more than 1 year showed a 3.1% increase in bone mineral density in aging men.

Reference, Reference, Reference

A bone mineral density (BMD) test provides a picture of your bone health. The test is used to identify osteoporosis, identifies the risk of broken bones, and measure the effectiveness of osteoporosis treatment. BMD uses what’s called a T-score showing how much bone density is higher or lower than the bone density of a healthy 30-year old adult.

According to the World Health Organization (WHO):

  • A T-score of -1.0 or above is normal BMD. Examples are 0.9, 0 and -0.9.
  • A T-score between -1.0 and -2.5 means low bone density.
  • A T-score of -2.5 or below is an osteoporosis diagnosis.

The lower a person’s T-score, the lower the bone density.

As scientists find new anti-aging techniques, skeletal diseases like osteoporosis become much more prevalent due to the natural aging of the body as well as day-to-day wear and tear.

Like cells and skin, bones are constantly regenerating and replacing old with a new/healthy bone.

For many men, bone mass peaks between ages 30-35, and at this point, the density of bones in the body’s skeletal frame begins to slowly decrease as removal of old bone mass exceeds formation of new bone. With age brings men more osteoclast over osteoblast.

  • Roughly 1 in 4 men over the age of 50 will break a bone due to osteoporosis.
  • Almost two million American men have osteoporosis with close to 12 million at risk.
  • Most men over 50 years old are more at risk to break a bone due to osteoporosis than they are to get prostate cancer.
  • Close to 100,000 men break a hip each year.

Men are more likely to die within a year after breaking a hip than women due to complexations with the injury.


Many studies show that while females are at a higher risk of osteoporosis there is a very clear cause and effect in men when it comes to aging and healthy bone density. These studies point to low testosterone and hormonal imbalance as one of the main culprits.

Aging men with low testosterone are more likely to break a bone than men on TRT.

Interestingly, estrogen plays the largest role in decreasing bone loss and broken bones in men, however too much can cause some serious issues throughout the body. This is why it’s important to balance estrogen and testosterone levels during testosterone replacement therapy. These same studies also show that these men with low testosterone levels have much

While testosterone replacement therapy can help improve cartilage, bone density, and joint health, bisphosphonates (medication) are considered a first-line treatment method for men with osteoporosis.


“Important cause of osteoporosis in men is reduced serum testosterone. The incidence of osteoporosis in men is indirectly correlated to the reduction in circulating testosterone. Because androgens may promote the proliferation and differentiation of osteoblasts, as well as inhibit osteoclast activity (recruitment and signaling), decreased bone density may ensue.” – Kendall Dupree, MD out of Johns Hopkins University School of Medicine.

How the body maintains healthy bones

The skeletal system maintains bone health and density through remodeling which is controlled by three types of bone cells: bone-forming osteoblasts, bone-resorbing osteoclasts, and post bone-creation osteocytes.

All of these cells are hypersensitive to hormone signals like testosterone and estrogen, minerals like zinc, and cytokines, which are cell-signaling proteins.

Some of these cells thrive off androgen while others love estrogen. If testosterone or estrogen is imbalanced, these cells begin to mess up the bone remodeling process.

Osteoblasts cells are directly responsible for osteogenesis in the building process of bones.

After testosterone fires off the androgen receptors, the osteoblasts synthesize organic bone osteoid proteins starting the development of the body’s skeleton. Without the osteoblast process, bones will continually reduce overtime.

The bone-forming osteoblast cells not only remodel bones but also fills these bones with calcium, which is called bone mineralization. Bone mineralization converts calcium into rigid bones.

Looking back at bone androgen receptors, testosterone feeds bone categories like bone marrow and growth plates.

Estrogen receptors fire off bone metabolism, which helps pump calcium through the skeletal frame. Bone metabolism keeps joint fluid at normal levels.

Reference, Reference, Reference, Reference, Reference, Reference, Reference, Reference

Another important hormone in the bone creation and removal process is calcitonin, which helps reduce osteoclast (bone removal) and continuing bone loss in aging men.

Calcitonin is a hormone produced by the thyroid gland. Calcitonin increases the flow of calcium and phosphate into the bone and lowers blood flow to allow the calcium deposit to safely bind to bones throughout the body.

In older men with low testosterone or high estrogen, bone creation will have a tough time compensating for the increase in bone removal (osteoclast), which will lead to bone loss.

To reference more studies of low testosterone and bone loss, the data shows that low T has a clear connection to the reduction of osteoclast bone removal and a positive effect on bone production.

Give us a call at 817-900-0304 or sign-up through our online intake process if you would like to get started with treatment!

Cartilage and testosterone

Cartilage is the tissue between joints keeping bones from rubbing on each other.

Testosterone helps with the regeneration of cartilage while estrogen helps in the production and growth of cartilage. Men on TRT sometimes need an estrogen blocker like anastrozole (AI) to keep estrogen levels under control due to the aromatization that occurs when the body converts testosterone to estrogen. There are times when estrogen drops below a normal level, which can lead to aches and joint paint. Without proper estrogen and testosterone levels, cartilage production could be impacted.

The knee joints intersection is where the thighbone, shinbone, and kneecap (patella) meet. In between the knee includes cartilage, ligaments, menisci, and tendons.

Cartilage is a slippery substance on the ends of the bones. The slippery mess allows bones to rub or pass smoothly over one another as the joint bends and straightens.

  • The menisci act as cushions between the femur and tibia that also act as shock absorbers.
  • Ligaments hold the bones together and give the joints stability. Damage and pain to the ligaments can result from overuse.
  • Tendons are the connective tissues that attach the muscles to the bones they control throughout the body.

When all these pieces work together, the joint functions to its full potential and the body can move around freely. The creation of cartilage is a complex mix of tissue consisting of proteins. Just like bone health and age cartilage begins to change as men age, which leads to osteoarthritis.

Aging does not cause osteoarthritis, but aging impacts how the body produces cartilage thus increasing the risk of arthritis and decreasing the ability for joints to stop the degeneration of healthy tissue.

Stress and Cartilage degeneration

Most impactful changes that come with age involves the change in cells inside cartilage called chondrocyte. The synthesis of proteoglycans, which is a binding protein found in connective tissue and chondrocytes is important for new cartilage development. Excessive stress on joints commonly found in former athletes and men with past injuries plays a role in the oxidative damage in chondrocytes ultimately leading to arthritis. Many studies point to excessive or abnormal stresses playing a central role in the development of OA. In men with low testosterone, the lack of tissue regeneration compounds on the joint causing serious discomfort.

The term senescence comes from the Latin word “senescere” which means to grow old or to wane.

In cartilage health, chondrocyte senescence is a decline in chondrocyte cell creation and testosterone response to growth stimulation.

As we talk about in our sermorelin article, IGF-1 can decline with age leading to a laundry list of issues. Researchers confirm that IGF-1 stimulates cartilage creation and there is a ton of evidence that shows how proteoglycan cells, connective tissue and collagen production are impacted when IGF-1 levels are low.

Aside from low testosterone response, some studies show that declining protein synthesis and IGF-1 production changes force cells to drift toward senescence during the aging process.

Reference, Reference, Reference

And aside from the above factors, oxidative stress that comes with age results in ROS or reactive oxygen species in the chondrocytes cells. This increase in ROS impacts testosterone and estrogen signals creating a reduction in new cell synthesis leading to arthritis.

Aging also increases fatigue failure of cartilage when stress is continually applied to the joint. This fatigue is called advanced glycation end-products (AGEs).

That takes this a step further into the science of aging and cartilage, DNA sequences can impact joint health through erosion of the chromosome decrease the health of cells critical in the production of new cartilage.

The effects of testosterone on chondrocytes cells have been studied for many years. In one study, researchers confirmed that testosterone aids in the production of chondrocyte cells in joints and increases collagen production, which are both important components in the healing process of joint cartilage.

Cytokines and testosterone

Cytokines are cell-signaling proteins affecting nearly every biological process in the body.

Cytokine signals play a role in embryo development to infection or disease response to cognitive function. They are important pieces to maintain healthy aging.

Cytokines are considered the hormones of immune and inflammatory responses but they are far more powerful than hormones. Cytokines orchestrate immune defenses throughout the body to protect the body against inflammation and attacks on the immune system. Sometimes these cytokines can negatively impact tissue and end up damaging cartilage due to excessive response. This is the onset of autoimmune diseases like RA.

Cytokines can wreak havoc on the immune system turning against itself in autoimmune diseases. During the attack, the cytokines launch a powerful storm to stop any infection, but once that infection has been destroyed, the signals that typically ask cytokines to fail, the infection attack continues although there is no infection. Chronic activation of these cells now dominates an otherwise resting immune system.


Myokines, Cytokines, and testosterone

Myokines are cytokines that signal muscles to flex or contract.

Maintaining skeletal muscle mass is considered an essential factor of muscle strength and function. Testosterone and these cytokines keep connective tissue found in the joints in tip-top shape.

Muscles are of course responsible for maintaining and changing body position and the movement of internal organs.

The internal skeletal muscle plays a part in the endocrine axis where the flex/contraction of the muscles starts the production and release of cytokines, which plays a role in the metabolism and production of cartilage and bones.

Areas of the body that rely on androgen receptors and healthy testosterone levels increase the secretion of bone myokines that improve bone strength.


Rheumatoid Arthritis (RA) and testosterone

During an RA account bone destruction occurs through a complex inflammatory cytokines attacks resulting in the chronic inflammation of the synovium membrane between joints.

Studies show a connection between low testosterone sufferers and RA as it relates to an inflammatory reaction. There appears to be a protective effect on RA in middle-aged men with normal-to-high levels of testosterone. It is well documented that men with RA and taking glucocorticoid medications have lower levels of testosterone. When men continually take glucocorticoid medications, bone mass often decreases quickly which can be problematic. Some studies point to inflammation caused by RA to decrease and suppress the production of testosterone. Reference

Body fat, bones, and testosterone

Adipose tissue is body fat found throughout the body. This tissue is commonly referred to as “adipokines” that play a positive role in bone creation and bone removal.

As we talk about above, despite the fact that muscle is the largest internal organ, muscle also helps fire off cytokine cells and growth factors that we learned are called myokines.

As it relates to bone health, myokines that are a part of the muscle-bone interface and are known to play a role in bone creation.

Muscle is a source of secreted factors (myokines) that significantly influence bone repair and bone metabolism. At a deeper level, without proper testosterone levels, aging men can suffer from impaired bone repair. Reference

Estrogen, bone health, and testosterone

Estrogen and bones have a very positive relationship but for men, it is important to keep levels in control to avoid joint pain. As we touch on earlier in this high estrogen low testosterone article, testosterone converts to estrogen in men (aromatase). Too much or too little is problematic as it can lead to joint pain due to poor cartilage production. The aromatization of testosterone to estrogen has a significant impact on bone structure in men.

Estrogen makes bones thick and helps to maintain bone mineral density.

Estrogen helps sustain bone mass as young men mature and more importantly slows bone loss in aging men.

As men age, the chances of low testosterone increase, which directly impacts the aromatization of estrogen in turn impacting bone health. Studies have found that low testosterone contributes to osteoporosis in older men. Studies have also found that testosterone replacement therapy can help prevent or slow down bone loss.

Other factors that impact bone health

  • Excessive alcohol consumption can decrease bone density over time. Loads of evidence shows that alcohol abuse may decrease bone density and increase the risk of broken bones.
  • Obesity is not only a risk factor for low testosterone, but also for fragile bones. The extra pounds add up to more load on the knees. Combining extra load with age adds extra pressure on the knees. The heavier load leads to the development of arthritis over time.
  • Muscle mass and structure begin to decrease starting at age 30. Muscles may shrink in size by roughly 40% over the course of 1-2 decades. The loss of muscle mass leads to loss of muscle strength. Muscles in the hips and knees take up a lot of force on your legs during basic activates like walking. These simple activates can wear down joints over time as muscle strength drops.

Most treatments for treatment plan start with a balanced diet with calcium and vitamin D rich foods combined with exercise. It’s also important to stop smoking.

Chronic joint pain presents itself through swelling, redness, pain, loss of function, and ongoing inflammation of joints.

According to the CDC, approximately 22.7% of adults in the United States have some form of arthritis each year. Combining these figures with the prevalence of obesity in the USA brings up another compelling reason for joint pain which centers around metabolism and inflammation. Low testosterone levels can lead to weight gain which increases the risk of developing arthritis due to aggravated wear and tear changes in the joints.

Is joint pain treatable?

Joint pain like osteoarthritis is treatable. While treatments like TRT may not lead to a completely pain-free life, managing the condition is certainly doable as the goal is to keep symptoms under control.

There are several obvious causes of joint pain. Most of the pain is caused by trauma directly to the joint. Events like falling, receiving a direct blow to the joint, making a sudden change in direction, or making repetitive movements during training are all causes of traumatic joint injuries.

As it relates to the knee could be:

  • Dislocation of the kneecap
  • A fracture of the kneecap, femur, or tibia
  • Torn ligament
  • Meniscus tear

Injuries can also happen:

  • Due to the lack of a warm-up before exercise or working too hard during any activity.
  • Playing sports without using protective equipment.
  • When involved in a traffic accident.

Medical conditions more serious knee issues include:

  • Degenerative tissue disorders, such as osteoarthritis
  • Infections
  • Obesity
  • Auto-inflammatory disease, such as rheumatoid arthritis
  • Tendinitis, an inflammation of a tendon, leading to pain when walking upstairs
  • Bursitis, an inflammation resulting from overuse
  • Chondromalacia patella, or damage to the cartilage below the kneecap
  • Gout
  • A Baker’s cyst, when fluid builds up behind the knee
  • A tumor, either benign or malignant in the knee


Gout is a metabolic disorder and some people may experience knee pain because gout causes acidic crystals to build up in the joints leading to painful inflammation.


Bacterial infections like cellulitis can cause sudden knee pain. Cellulitis occurs when bacteria that normally sit on top of the skin make their way underneath causing serious pain. Cellulitis around the knee can cause infection in the joint.

Connective tissue disorders:

Risk factors for RA include a family history of RA, being over 40, smoking, and obesity.


Tips for reducing the risk of chronic knee pain and improving the outlook for existing knee problems include:

  • Reducing alcohol intake
  • Stop smoking
  • Weight loss
  • Exercise
  • Warming up before activity

Smoking and bone loss goes hand in hand. While it’s not entirely clear the case behind the loss of density, tobacco, nicotine, and other chemicals found in cigarettes are toxic to bone, or they may stop the absorption of calcium and other nutrients needed for bone health.

Quitting is suggested approach to reduce rates of bone loss or an increase in bone density.

Gastrointestinal disorders and lack of nutrients can impair bone health. Vitamins and minerals like amino acids, calcium, magnesium, zinc, phosphorous, and vitamins D and K, are great for bone health. Diseases of the stomach and intestines can lead to bone issues due to poor absorption of key nutrients.

Hypercalciuria is a disorder that causes too much calcium to be flushed through the urine, which makes the calcium unavailable for building bone leading to bone loss. Reference

Exercise is important for any male over 40 years old

Exercise decreases the risk of many diseases in men like heart disease, cancer, diabetes, high blood pressure, depression, obesity, and osteoporosis.

There are several low-stress exercises that may help improve or prevent knee pain include:

  • Cycling
  • Swimming
  • Walking

Depending on the cause of the knee pain and the health status of the individual, our providers can help provide guidance on what type of exercise will help reduce pain and how much intensity to push for during the exercise.

Sleeping and joint pain

Research shows that between 50 to 90% of people with chronic joint pain have trouble sleeping. Stiffness generally occurs during the night as the body is at rest for many hours.

  • It’s important to find a comfortable position to avoid joint pain. Keeping a pillow between the legs is suggested for those with knee pain.
  • Using a long-lasting anti-inflammatory can impact sleep so consult with your doctor on the best practice to find rest.
  • Avoiding alcohol and caffeine.
  • Maintaining good sleep hygiene with a schedule to rest for 7-8 hours per night.
  • Using a firm mattress with a foam pad on top can help distribute body weight to avoid laying awkwardly during sleep.

Some easy first pass treatment options for joint pain:

  • RICE: Rest, Ice, Compression, and Elevation can help reduce swelling and pain.
  • Anti-inflammatory medications like aspirin or ibuprofen. If you are considering acetaminophen, it is a good pain reliever but does not reduce inflammation.
  • Physical therapy is a good option for chronic joint pain. Like our in-clinic PT preaches, using exercises that strengthen the quads and hamstrings may help relieve the pressure around the knees.
  • Knee braces can take the pressure off the problem area.
  • Cortisone injections are a good short-term option that may lessen the swelling and achy pain.
  • Lubricant injections are another short-term option that can help the knee move more smoothly.

Reference, Reference, Reference, Reference

Joint supplements and testosterone

Outside of diet, TRT, and hormonal balance, there are several supplements that can help reduce joint pain.


Glucosamine and chondroitin protect cells called the chondrocytes cells to help maintain cartilage structure. Some studies claim that this supplement slows cartilage degeneration in the joints and reduces pain as it slows the damage.

These same studies show glucosamine as an effective treatment option for arthritis. Glucosamine is an amino acid that is essential for the synthesis of glycosylated proteins and lipids. Without getting too technical, there are proteins and lipids within cartilage that thrives on glucosamine especially in the intervertebral disc and synovial fluid.


Turmeric is an anti-inflammatory herb that has been used for many years to ease joint stiffness, pain, swelling, and discomfort along with supporting overall health in many ways. While not fully backed by medical researchers, the alternative world stands behind the herb as a viable treatment option.


MSM aids in the assembly of tissue and shown to reduce symptoms of joint pain as well as reducing inflammation. Many fitness supplements include MSM as it speeds up recovery and keeps joints health.

Inside the body, MSM controls the immune response between oxidative stress and inflammation.

Cissus Quadrangularis:

Cissus is a plant from southeast Asia widely used for alternative medical treatments. Some studies claim Cissus reduces joint pain and enhance recovery following exercise. Cissus quadrangularis is part of the grape family and also called veldt grape, adamant creeper, or devil’s backbone.

Cissus quadrangularis L. reportedly contain 3-ketosteroids and have bone rebuilding benefits.

The plant is rich in vitamin C, antioxidants, calcium, and phosphorus. Across India, the extracts from the stem of this plant have been used widely for the early repair of fractures, gout, and back pain for centuries. The studies we reviewed seemed to have an agenda behind them so we are unsure if Cissus quadrangularis is actually beneficial but the herb isn’t harmful so give it a go!

Vitamin C:

Adequate amounts of vitamin C can relieve and prevent pain in your joints. The body uses Vitamin C for the synthesis of collagen.

As we talk about early on, collagen is a crucial component of tendons, ligaments, and cartilage. Many multi-vitamins include Vitamin C. When taken daily, the C can help your body produce collagen thus strengthening your cartilage.


Collagen is the largest fibrous protein in the body and underpins healthy connective tissue. There are at least 16 types of collagen, but 80 to 90% of the collagen in the body consists of types I, II, and III.


Many websites call bromelain a wonder cure for joints. Bromelain is found in pineapple and usually execrated to create a potent pill. Bromelain has anti-inflammatory properties. Research shows that bromelain has been found useful in joint healing and reduction of swelling. Bromelains anti-inflammatory and analgesic properties make a good supplement to help reduce pain, soft-tissue swelling, and stiffness common with osteoarthritis.

According to research among moderate-to-severe arthritis of the knee sufferers:

  • There was a reduction in soft tissue swelling in 72.4%.
  • A reduction in pain indices by 80% sustained at 4 weeks post-treatment.

Hyaluronic Acid:

One of the more common joint supplements. Like glucosamine, HA improves the quality of the synovial fluid that surrounds joints.

Hyaluronic acid exists in every tissue of the body. HA helps remove the waste from the cells that do not have a direct blood supply such as cartilage cells. HA also helps keep your joint cavities healthy and functions as a joint lubricant.

HA helps with keeping appropriate moisture within joints as well.

With low levels of hyaluronic acid, nutrients have a hard time moving into these cells and waste cannot be removed from the cells.

All joints are surrounded by a substance called the synovial membrane, which forms a capsule around the ends of the bones.

The membrane has many functions like used as a lubricant or shock absorber between joints and a nutrient carrier helping joints thrive and survive. Cartilage is avascular, which means there are no blood vessels.

This makes synovial fluid is important. Synovial fluid is the only way in which nutrients can be carried into the cartilage and waste can be removed.

Reference, Reference, Reference, Reference

Medically peer reviewed by Dr. Kenneth Lecroy, MD. Written by Our Editorial Team.

Give us a call at 817-900-0304 or sign-up through our online intake process if you would like to get started with treatment!

If you do have low testosterone it can be easily treated and monitored via telehealth with the same level of care as you would receive in our traditional clinic setting in Roanoke, Texas. Give us a call if you have any questions!

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