Joint Health

Steve: Is there hope for them? And the answer to that from our three decades of work is yes, there is. You can lose weight. You can lose it in a healthy manner. You can lose it and you can keep it off. But it's a change in lifestyle, and a lot of people need help.

Brent: Welcome to Death Clock. I'm your host, Brent Franson. Today we speak with Dr. Steve Messier about joint health. Dr. Messier has spent his career studying joints and, in particular, osteoarthritis, which is the most common form of joint degradation and joint pain. We talk about what we can do to prevent it and what the key risk factors are. This was a really surprising discussion for me.

Brent: There are a lot of very counterintuitive learnings about how to take care of the knees and what we can be doing, so I hope you find it as enjoyable and informative as I did.

Brent: Dr. Steve Messier, welcome to the show.

Steve: Thank you. I'm glad to be here.

Brent: So the topic today is joint health. And this is going to hit particularly close to home for me. I'm 43 and I'm a trail runner. I'm in Boulder, Colorado, and I'm realizing my joints are bothering me a little bit more than normal. So I'm excited to dive into the topic and figure out what I need to do.

Brent: I'm hoping the answer is not "no more trail running." But before we get into all of that, could you give us a sense of your background? You've been studying joints and focusing on them for quite some time. Could you give us a quick overview of your career?

Steve: I'm at Wake Forest University in Winston-Salem, North Carolina. My undergraduate work is in civil engineering, and I have a PhD in biomechanics. What I do now is run large randomized clinical trials with older adults who experience joint pain, although right now we're looking at people who are at risk for joint pain but don't have it yet.

Steve: I've been at Wake Forest for 43 years, and over the past three decades we've been doing work on people with osteoarthritis of the knee.

Brent: Just to set the stage, when we use the term "osteoarthritis," is that a fancy term for wear and tear of the joints over time?

Steve: Osteoarthritis is a disease of the joints. It is not simple wear and tear, though key risk factors include being overweight and joint injury. Those are two primary things we'll talk about today.

Steve: Unfortunately, being female is a risk factor as well; about 70% of people with osteoarthritis are female. There are over 100 types of arthritis, and osteoarthritis is the most common, making it the leading cause of disability in adults worldwide.

Steve: Let's talk about the younger demographic that listens to your podcast—people who are really active like yourself. You live in Colorado and are outdoors all the time. Exercise is fantastic for you in so many ways, but occasionally you might injure a joint.

Steve: If you injure the knee joint—which is the most frequently affected weight-bearing joint—by tearing cartilage or a ligament, it starts an inflammatory process. Some excellent studies show that a major injury essentially ages your knees by about 30 years.

Steve: If you tear an ACL (anterior cruciate ligament), an MCL (medial collateral ligament), or your meniscus (which cushions the knee) at age 20, by the time you're 40, you effectively have the knees of a 70-year-old.

Steve: I have a daughter who was very active and tore her MCL three times, and a son who tore his ACL twice. I told them, "If I live long enough, you'll be in my studies," and they didn't find that funny at all! So that's the downside: staying active is the best thing you can do...

Steve: Exercise is medicine. But if you injure a joint, there's a heightened risk that you'll run into issues with it later in life.

Brent: So you disagree with the notion that osteoarthritis is just a fancy term for wear and tear. You're saying it's a disease driven by key factors like excess weight, joint injury, or biological sex. I assume that last factor relates to hormones?

Brent: Is it a misconception that as we age, degradation of the joint is inevitable and that's all osteoarthritis is? You're saying that's not true?

Steve: Some people assume it's inevitable that they'll get osteoarthritis of the knee as they get older. Let's talk about the mechanisms behind how it actually develops. Covering the ends of your bones, you have cartilage.

Steve: This is called articular cartilage, which helps create a better-fitting joint and reduces friction. In your knee, you also have an additional piece on top of that called the meniscus, which helps form an even better-fitting joint.

Steve: The knee is not a naturally well-designed joint. If you carry weight that isn't healthy for you, every step you take over days, months, and years exerts excess load on that joint and its cartilage.

Steve: Underneath that cartilage is cancellous bone, which has many tiny spaces in it. Think of it like air cushioning in a running shoe; when contained, it's a great shock absorber. There are these thin spicules of subchondral bone right beneath the cartilage.

Steve: Bone adapts and grows in response to stress. When there's excessive load, those thin spicules bulk up to handle the force. However, this reduces the porous spaces, making the bone less capable of absorbing shock effectively.

Steve: As a result, the overlying cartilage takes on that extra stress. It isn't designed to handle that level of force, which causes the cartilage to break down. So it isn't simple wear and tear, and osteoarthritis is not inevitable.

Brent: Is joint degradation or knee pain inevitable? Say I'm at a healthy weight, have no prior knee injuries, and am male—can I live to 90 with completely healthy joints?

Steve: Yes.

Brent: That's good to hear. I've had ACL surgery on my left knee, which is what's bothering me. Is an injury to one knee a risk factor for both? Does it disrupt the overall alignment and balance in a way that affects the uninjured knee?

Steve: That's a great question. If you have unilateral osteoarthritis (arthritis on one side), you are at higher risk for developing it on the other side. We published a paper comparing bilateral versus unilateral osteoarthritis, and interestingly, the biomechanics are largely the same.

Brent: I have a cadaver ACL, and for a long time the surgical knee actually felt more robust than the uninjured one. Now both give me issues. When you injure one side, does it throw off your gait balance during walking or running, leading to secondary issues?

Steve: The literature suggests there isn't a dramatic mechanical difference between people with unilateral versus bilateral osteoarthritis. There is a clear mechanical difference between people with osteoarthritis and those without, but not much difference between unilateral and bilateral cases.

Steve: You're still at risk for developing it on the other side. What you have is post-traumatic osteoarthritis, which differs from idiopathic osteoarthritis. Post-traumatic osteoarthritis usually afflicts younger, active individuals. For idiopathic osteoarthritis, the main risk factor...

Steve: ...is being overweight. If you have osteoarthritis on one side and are overweight, you're at risk of developing it on the other side as well.

Brent: So the key risk factors are excess weight, prior joint injury, and female sex. Does that third factor relate to hormones like estrogen?

Steve: It's fascinating because across virtually all 100 forms of arthritis, females are at higher risk. We don't have a definitive answer yet for why that is.

Brent: We had a bone health episode recently, and the expert mentioned that while osteoporosis is commonly thought to affect women predominantly, that might not be as clear-cut as believed. Is there a similar lack of consensus in your field regarding why it affects women more?

Brent: There's no firm conclusion on that yet.

Steve: No. We conducted a weight training study in people with knee arthritis. Initially, critics said, "You can't do strength training in people with bad knees." But we did, and because it was a strength training study, we ended up attracting more male participants than usual, resulting in about a 50/50 ratio.

Steve: When presenting at a conference with 16,000 attendees, someone asked if our sample was truly representative of the general osteoarthritis population. I explained that we enrolled qualifying applicants as they came in. Normally our studies see closer to a 70/30 female-to-male ratio.

Brent: What felt counterintuitive in reviewing your research is that exercise—and even strength training—can actually be beneficial for joint health and osteoarthritis. Coming in, I assumed athletic activities like running and skiing were great for cardiovascular health, but ultimately hard on the joints.

Brent: Your career research suggests the opposite: that exercise and strength training can actively benefit joints.

Brent: Specifically, exercise and strength training can be beneficial for joint health.

Steve: Absolutely. Studies suggesting exercise is bad for knees often look at career athletes in a single cross-sectional snapshot. That isn't robust science for determining risk factors over time.

Steve: Our studies clearly demonstrate that exercise is effective. The specific mechanism is another story, but simply staying active can reduce pain by about 25% over an 18-month period, regardless of the modality.

Steve: Whether it's strength training, walking, running, or tai chi, movement helps decrease joint pain overall.

Steve: If you want the biggest impact, combining diet and exercise for weight loss yields the most dramatic non-pharmacological benefit. Taking load off the joint produces pain reduction comparable to NSAIDs (non-steroidal anti-inflammatory drugs).

Brent: I assumed you might advise that trail running in my 40s applies too much load, and that low-impact activities like swimming or cycling would be better choices.

Brent: And I don't hear you saying that.

Steve: You will never hear me say that. Do you enjoy what you do?

Brent: Yes, but I have the ability to modify my activities if needed.

Steve: You enjoy it, and it's a key part of your lifestyle. You appear to be at a healthy weight as well.

Brent: I am at a healthy weight. At 6'4" and 195 lbs, it's appropriate for my height, though I'm a larger person overall.

Steve: Being taller exerts slightly more torque on the knees, so you want to be mindful of that. However, the benefits of your regular exercise far outweigh the risks. Just be careful on the trails and avoid reckless injuries.

Brent: Is joint cartilage more dynamic and living than people realize? I used to visualize cartilage as a fixed piece of rubber between bones that gradually wears down over a lifetime without regenerating.

Steve: That description fits the meniscus more closely.

Brent: I assumed that every trail run wears it down slightly, making it progressively thinner over time without any way to restore it.

Brent: You're saying that loading the joint through exercise is actually beneficial for it.

Steve: You have two main types of cartilage in the knee: the meniscus, and articular (hyaline) cartilage, which covers the ends of long bones to facilitate smooth movement.

Steve: Inside the joint, you have synovial fluid. While people often think synovial fluid is the primary shock absorber, most of the cushioning comes from fluid exchange within the cartilage matrix itself.

Steve: Cartilage consists of cells embedded in a water-rich matrix. Cyclic loading pushes fluid through the cartilage structure, providing significant shock absorption for the joint.

Steve: Loading the joint properly stimulates this mechanism and promotes healthy joint function. However, abnormal mechanical loading can cause issues. Underlying bone spicules normally align along natural lines of force.

Steve: If an injury causes you to alter your gait, the direction of force shifts to an unusual angle. Over time, the underlying bone restructures along that altered line of stress.

Steve: That altered bone alignment can increase localized stress on the cartilage, leading to breakdown over time.

Steve: Abnormal stress distribution also causes bone growth along joint margins, forming osteophytes (bone spurs).

Steve: Bone spurs can restrict joint range of motion. So normal physical loads are beneficial, whereas abnormal, misaligned loads are harmful.

Brent: So activities like running, skiing, or cycling are healthy for joint cartilage, provided you avoid acute injury. Higher-impact sports carry a greater risk of joint trauma, but the physical force itself is beneficial unless an injury alters joint mechanics.

Brent: Once an injury occurs, it can accelerate joint aging.

Steve: It increases the risk significantly. Following an injury, maintaining a healthy body weight, wearing supportive footwear, strengthening surrounding musculature, and continuing safe exercise are key protective strategies.

Steve: The alternative—becoming sedentary and gaining weight—is far worse for long-term health. Exercise also supports psychological well-being and allows you to maintain a healthy, enjoyable relationship with food.

Steve: Enjoying food and culinary experiences is an important aspect of life quality.

Steve: Sharing food and enjoying cuisine is a vital part of life.

Brent: We've discussed cardiovascular exercise, but your research also evaluates strength training. Resistance training—whether upper or lower body—provides healthy joint loading that helps preserve function.

Steve: Yep.

Brent: Did your research indicate whether high-intensity strength training yielded superior results compared to lower-intensity options?

Steve: Regarding pain reduction, both intensities performed similarly. However, high-intensity strength training led to greater improvements in muscle strength.

Brent: Is increased strength inherently better for protecting the joint?

Steve: They built more strength, but both exercise groups experienced similar pain reduction compared to controls.

Brent: So if someone experiences knee pain, effective non-pharmacological approaches include aerobic exercise and strength training...

Steve: ...along with maintaining a healthy body weight.

Brent: And staying active can actually help reduce joint pain over time?

Steve: Exercise doesn't worsen the condition. In our 18-month walking studies, participants often report a temporary slight increase in discomfort during the first 3 to 6 months as they adapt to walking faster and building endurance.

Steve: We encourage participants to persist through that initial adaptation phase. By months 3 to 4, discomfort typically drops well below baseline levels.

Steve: Participants adapt to improved movement mechanics as they gain strength and lose weight. Our clinical trials run for 18 months because lasting lifestyle changes take time to establish.

Brent: What is your perspective on dietary supplements marketed for joint health, such as glucosamine?

Steve: I evaluate them based on scientific evidence. If a supplement feels helpful to you and fits your budget, there's no harm in taking it.

Brent: It sounds like placebo effects can still provide real perceived relief for individuals.

Steve: My wife used to take glucosamine and felt it helped. When trials showed limited objective benefit, I mentioned it to her, but she noted she felt better while taking it.

Steve: Major clinical trials, such as a large study published in the New England Journal of Medicine, showed no significant overall difference between glucosamine and placebo.

Brent: So rigorously speaking, high-level scientific consensus doesn't show significant joint health benefits from popular supplements?

Steve: There is no conclusive evidence from large-scale, high-quality clinical trials published in major journals like JAMA or NEJM showing meaningful efficacy.

Brent: You mentioned diet earlier. I assume systemic inflammation is harmful to joints, meaning pro-inflammatory diets could aggravate joint conditions?

Steve: My colleague Dr. Gary Miller and I discuss this often. From an engineering standpoint, caloric balance is key for weight management. For mechanical joint load, total weight is the primary driver.

Steve: Emphasizing anti-inflammatory foods is great overall, but strictly regarding osteoarthritis, reducing mechanical joint load via weight management is paramount.

Steve: A balanced diet that manages caloric intake while remaining sustainable and enjoyable is ideal. We don't strictly forbid specific foods in our clinical trial programs.

Steve: Moderation allows people to stick with health goals long-term without feeling overly restricted.

Steve: Moderation in all things leads to better long-term adherence.

Brent: So at a healthy body weight, dietary patterns like Mediterranean versus high-sugar diets show little direct differential impact on osteoarthritis outside of their effect on body weight?

Steve: Exactly.

Brent: That's surprising. I would have expected a stronger direct inflammatory link.

Steve: Inflammation is certainly important. Osteoarthritis progresses along two main pathways: mechanical load and local joint inflammation. Following joint injury, local pro-inflammatory cytokines break down cartilage tissue.

Steve: So consuming a nutrient-dense, anti-inflammatory diet is a healthy supportive habit for overall joint and body health.

Steve: An anti-inflammatory diet is beneficial across many systems, not just the joints.

Brent: Is trauma-induced joint inflammation distinct from systemic low-grade inflammation (like high-sensitivity hs-CRP)?

Steve: The primary triggers differ, though some overlapping inflammatory cytokines are involved.

Brent: My father needed knee replacements after a severe college pole-vaulting injury in his 20s. Before surgery, he experienced painful bone-on-bone friction when walking.

Brent: Does post-traumatic inflammation degrade joint space over time to the point where replacement surgery becomes necessary?

Steve: That high-impact landing likely triggered both significant acute inflammation and abnormal high-magnitude mechanical stress simultaneously.

Steve: That dual impact led to accelerated post-traumatic osteoarthritis over time.

Brent: And it worsened progressively until he had it replaced in his 70s.

Steve: Some individuals experience steady progression, while others plateau with stable symptoms for long periods. Research trials actively seek to identify predictors of disease progression.

Steve: Our current preventive trials study individuals at risk before onset to evaluate whether early interventions can prevent osteoarthritis from developing.

Brent: That makes sense. Two individuals can have similar initial presentations, yet one remains stable while the other progresses, and predicting those trajectories remains challenging.

Steve: Predicting progressors is difficult. In clinical trials, having non-progressing participants in control groups can make intervention effects harder to isolate.

Steve: Non-progressors in a control group can mask intervention effects.

Brent: Is genetic variation assumed to play a significant role?

Steve: That remains an open scientific question.

Brent: How is osteoarthritis severity measured clinically? Through imaging like MRI versus self-reported pain scales?

Steve: It includes clinical pain reports and structural imaging. Standard weight-bearing X-rays remain the primary structural benchmark.

Brent: Doesn't standard X-ray imaging miss soft tissue detail?

Steve: X-rays visualize bone and joint space narrowing. As articular cartilage thins, the distance between the femur and tibia decreases.

Steve: Joint space narrowing occurs most commonly on the medial (inner) side of the knee, alongside osteophytes visible on X-rays.

Brent: I had a full-body scan that noted mild osteoarthritis in my sacroiliac joint. Is MRI superior to X-ray for soft tissue evaluation?

Steve: Standard X-ray remains the conventional reference standard in clinical practice.

Brent: And pain assessment uses standard visual analog scales?

Steve: Yes, standardized validated scales are used.

Brent: A standard 0 to 10 numerical rating scale?

Steve: We utilize standardized pain scales (such as 0-10 or 0-20 WOMAC subscales). Interestingly, the correlation between structural X-ray findings and reported pain is modest (~0.3). Someone can have significant joint narrowing on X-ray with minimal pain, or vice versa.

Brent: What is your perspective on surgical options like total knee arthroplasty?

Steve: It is an end-stage option, but yields remarkable outcomes for suitable candidates.

Brent: A major surgical procedure, but highly effective for advanced cases.

Steve: It involves surgical recovery and inherent risks, but for end-stage joint damage, outcomes and satisfaction rates are very high.

Steve: Overall, the vast majority of patients achieve significant relief and are satisfied with joint replacement results.

Brent: What about minor procedures like joint debridement or lavage?

Steve: Landmark sham-controlled clinical trials evaluated arthroscopic lavage and debridement for knee osteoarthritis.

Steve: In these rigorously controlled studies, sham surgeries (skin incisions without joint intervention) were compared directly against true arthroscopic debridement.

Steve: At two-year follow-ups, there was no statistically significant difference in pain outcomes between the sham group and the surgical group.

Steve: Subsequent Canadian replication trials confirmed the same outcome: arthroscopic lavage/debridement offers no significant benefit over conservative management for general osteoarthritis.

Brent: To summarize key evidence-based takeaways: maintain a healthy body weight and avoid acute joint injuries.

Brent: Women experience higher incidence rates. Core prevention focuses on regular exercise, weight management, and avoiding injury. Over-the-counter supplements show limited high-level evidence, and arthroscopic cleaning surgeries show no advantage over placebo.

Brent: Lifestyle fundamentals—balanced nutrition for weight control and consistent, safe physical activity—remain the primary interventions. For advanced end-stage joint disease, total joint replacement remains a proven surgical solution.

Brent: Total knee replacement requires significant recovery, but delivers reliable long-term outcomes.

Steve: For individuals in mid-to-later life who are currently sedentary, carrying excess weight, and experiencing joint pain, can meaningful improvement still be achieved?

Steve: Three decades of research show clear proof: yes. Sustainable weight loss and improved physical function are entirely achievable with structured support and guided lifestyle modification.

Steve: Brief clinical advice to "lose weight" without structured behavioral support rarely leads to successful outcomes. Patients need practical guidance and accessible community resources.

Steve: Integrating skilled exercise specialists, dietitians, and community health programs with physician follow-up creates an effective ecosystem for patient success.

Steve: Studies show primary care physicians spend under one minute discussing lifestyle modifications per visit, largely due to systemic time constraints and lack of specialized exercise counseling training.

Steve: Physicians often lack the referral networks or time required. Establishing interdisciplinary community programs fills that gap effectively.

Steve: Community-based exercise and dietary interventions are highly cost-effective strategies for managing osteoarthritis public health burdens.

Steve: Economic analyses confirm structured diet and exercise programs are extremely cost-effective solutions for health systems.

Brent: Preventive medicine and comprehensive lifestyle interventions are central to the mission of Death Clock. Proactive care significantly influences healthspan and longevity.

Brent: Proactive healthcare models allow practitioners to allocate adequate time to guide diet, physical activity, and preventive habits.

Brent: Insurance-driven fee-for-service models force high volume, leaving clinicians little time to address foundational lifestyle habits thoroughly.

Brent: Clinicians want to help, but brief encounters restrict care to immediate pharmacological or surgical referrals.

Steve: When orthopedists see high daily patient volumes, comprehensive lifestyle counseling is constrained by time.

Brent: Empowering individuals with evidence-based lifestyle information fills a critical gap in preventive health.

Brent: Are there emerging therapies, protocols, or pharmaceutical developments in joint care that you find promising?

Steve: GLP-1 receptor agonists are a major area of current investigation for weight management within our multi-year clinical trials.

Steve: We view GLP-1 medications as an adjunct tool when participants hit weight loss plateaus, alongside behavioral, dietary, and psychological support strategies.

Steve: GLP-1 therapy can assist short-term momentum before tapering, while core nutrition and exercise habits remain the cornerstone.

Steve: GLP-1s serve as an adjunct tool in our clinical framework, but long-term success still rests on regular exercise and healthy nutrition.

Brent: Dr. Steve Messier, thank you so much for sharing your expertise and research with us today.

Steve: Thank you, Brent. It was a pleasure to join you.

Brent: Death Clock is recorded in Boulder, Colorado, produced by Patrick Gudino, with music by Patrick Lee. Hosted by Brent Franson, founder and CEO of Death Clock.