The evidence that cholesterol medication is sending you to knee replacement

Marion Hauser, MS, RD

High cholesterol, and its treatment with statins, has been a hallmark of cardiovascular disease management for decades. Many people worry about their cholesterol because they feel they have to, based on drug companies and the media bombarding us with the impression there is a one to one linkage between elevated blood fats and arteriosclerosis. The benefits, side-effects, and even the worthiness of taking statins have been under constant attack in recent years. One of the side-effects reports, statins negative influence on soft tissue, namely tendons and ligaments, will be the focus of this article.

Researchers writing in the medical journal Knee surgery, sports traumatology, arthroscopy, (1) discussed the accumulating clinical evidence indicating the risk of tendinopathy and spontaneous and/or simultaneous tendon ruptures associated with statin use.

In their experimental study, the researchers designed a plan to evaluate and compare the biomechanical and histopathological (tissue damaging) effects of the three most commonly prescribed statins (simvastatin, atorvastatin and rosuvastatin) on the Achilles tendon in rats.

Statins were given to the rats at daily doses of 20 and 40 mg/kg for 3 weeks. One week later, the Achilles tendons were dissected and their biomechanical properties, including ultimate tensile force, yield force and elastic modulus, were determined.

  • All the statins caused deterioration of the biomechanical parameters of the Achilles tendon. Histopathological (tissue damage) analysis demonstrated foci of dystrophic calcification (the calcification of dead and dying soft tissue) in the statin-treated groups.

Higher doses of either of these two statins are toxic for tendon fibroblasts

Researcher Pernilla Eliasson who is affiliated with the University of Copenhagen, Linköping University, Sweden, and the University of Rochester in New York lead a team of researchers looking at the complexity of Simvastatin and atorvastatin and its relationship with tendon damage.

The research appearing in the on-line medical journal PLOS (2) examined the theory that Simvastatin and atorvastatin may have different potential for negative effects on tendons. Atorvastatin has been pointed out as one of the most harmful statins for tendon tissue while simvastatin has appeared with mixed findings.

  • Some studies indicate that simvastatin has a negative impact on tendon tissue, while other studies suggest that simvastatin might even have a positive effect.
  • Both atorvastatin and simvastatin had a negative effect on the tendon constructs in our study, however, the effect of simvastatin was in fact stronger and more pronounced.
    • This indicates that simvastatin indeed is harmful for tendon tissue and its extracellular matrix. However, high dose atorvastatin treatment was the only treatment which had an effect on collagen content, and this was reduced by 22% compared to controls.
  • Simvastatin had no effect on the collagen content to the researcher’s surprise. This indicates that there might be some differences in the mechanism of action on human tendon cells and extracellular matrix between these two statins. The range of the dosage of the two statins in clinical settings is similar, though the average dose for atorvastatin is slightly lower than the average dose for simvastatin.

Higher doses of either of these two statins are toxic for tendon fibroblasts

The researchers concluded that normal statin treatment of just seven days  had such a detrimental effect upon tendon tissue indicates that also long term adaptations may occur. The more you take the statins, the worse the tendon damage.

Soon after taking these new cholesterol medications I felt a sharp and sudden pain in my knee

A patient comes in on a recommendation from a friend.

“I am here because I have very bad knee pain . . . here is my story:

I went to the doctor for my check up. My blood work revealed slightly elevated cholesterol and I was advised that I need to take and was given prescriptions for medications that would lower my cholesterol. I also told my doctor that my knee was hurting, could I get something for it? My doctor asked, when and how the knee pain started? I said I aggravated it with a new exercise program, one I would hope that would lower my weight and cholesterol. My doctor said, “go easy on my knee.”

Soon after taking these new cholesterol medications I felt a sharp and sudden pain in my knee as my wife and I were walking to our car. My wife drove us home and she got me to the chair and we elevated my leg and got plenty of ice on it.

We made an appointment at the doctor’s. Here I was given the reason why my knee hurt. 

  • It must be the exercise program. I should go slower or completely rest.

After a week of not exercising at all, my knee pain, now the pain was in both knees, became so much worse, I could not sleep. My wife began looking up things on the internet. She showed me some articles that said it was the statins, the cholesterol medication causing the knee pain. In fact, she showed me, it is a well-known side-effect.

We made an appointment at the doctor’s where I was told to reduce the cholesterol medication and slowly work my way back up to tolerating it, if in fact that was causing the knee pain. My doctor was skeptical. 

Even after lowering the cholesterol medication dosage I still had the same pain. My doctor told me to stop taking the statins. After a few days, maybe a week or two, my knee pain reduced significantly but they were still painful.I returned to the doctor and told him that I would try to manage my cholesterol without medications and we will see how I do. I am here because I cannot exercise with my knees like this.

Statins create pain

An international team of university researchers and various national councils published these findings in the journal Arthritis care and research (3) in August 2019.

These are key learning points:

  • The research surrounding the possible relationship between statins use and outcomes in knee osteoarthritis is limited.
  • This study examined 1,127 adults for 4 years who took statins.
  • What the researchers were looking for was how did statin use influence:
    • Radiographic osteoarthritis, (how did the knee look in MRI and scans over the 4 year period. Did the MRI/scans look worse?)
    • Symptomatic knee osteoarthritis (did the person in the study have new knee pain symptoms and was this matched by eroding conditions in the knee on MRI and scans?)
    • Overall, did the person’s knee pain get worse?

The BIG RESULTS and CONCLUSIONS: Statins were not good pain medications

  • No matter what statin was used: Statin use was not associated with lower risk of worsening pain. In other words, statins were not good pain medications.
  • Atorvastatin (Lipitor) use was associated with a reduced risk of developing pain, whilst rosuvastatin (Crestor) lead to a higher risk of developing pain.

From the researchers: “The effect of statins use on knee osteoarthritis outcomes remains unclear, although in our study those using statins for over five years and those using atorvastatin reported a significantly lower risk of developing knee pain.”

Confusing right?

  • First, the Atorvastatin (Lipitor) user was associated with a reduced risk of developing pain AS COMPARED to (Crestor) which lead to a higher risk of developing pain. So the Atorvastatin produced less knee pain risk, but still a risk.
  • Either way, if you already have knee pain, cholesterol lowering medicine will not help make it less painful or from it getting worse.

So again, all these research universities and national resources and a long-term study of over 1000 patients came to this conclusion: “The effect of statins use on knee osteoarthritis outcomes remains unclear.”

The story of cholesterol-lowering medications and joint pain surround the impact of these medications on inflammation. Are statins an anti-inflammatory or do they create more inflammation?

Study: “The only significant finding indicated that increased duration of statin use was associated with worsening in knee pain and osteoarthritis.”

There is no general consensus that statins help or statins make things worse. I highlighted the study above because these were findings presented in print in August 2019. They are built on other research that took counter viewpoints.

A study from the Netherlands and a team of Dutch university researchers published in the Annals of the rheumatic diseases (4) found that Statin use is associated with more than a 50% reduction in overall progression of osteoarthritis of the knee.

Yet, Virginia Commonwealth University researchers published in the same journal the Annals of the rheumatic diseases, these findings:

  • Statin use was not associated with improvements in knee pain, function or structural progression trajectories.
  • The only significant finding indicated that increased duration of statin use was associated with worsening in knee pain and osteoarthritis. (5)

The doctors from the Netherlands responded in print a few months later in proper scientific debate. In this response in the Annals of the Rheumatic Diseases, it was suggested that parts of their study should be re-evaluated to find the benefits of statins. They point out

  • “Considering the theoretical effects of statins on osteoarthritis (lowering of serum lipid levels lowering local and systemic inflammation, and prevention of atherosclerosis), it is more plausible that statins could be useful in the early stages of osteoarthritis or even before initiation of the disease process.”(6)

If I control my cholesterol with diet and exercise, instead of medications, my knee pain can be helped without the medication’s side-effects.

Here medical and university researchers published their finding in the influential Scientific reports (7) from the Nature Publish group in London.

  • In the present study of nearly 14,000 participants, the research team identified a positive association between hyperlipidemia (high cholesterol) and elevated risks of knee pain and clinical knee osteoarthritis in middle-aged or older adults.
  • There is a relationship between triglycerides and knee osteoarthritis.
  • Study results indicate that the influence of lipid-lowering drugs on knee pain and clinical knee osteoarthritis is limited.
  • These findings have notable implications for public health because the relatively high prevalence of knee osteoarthritis seriously affects the quality of life for older adults, and hyperlipidemia may be prevented through diet and physical exercise.

The researchers then sought to clarify the contradicting research presented in the two studies above.

  • The first study above from the Netherlands demonstrated that lipid-lowering drugs were associated with slower knee osteoarthritis progression.
  • The second study from Virginia did not find the same results
  • In this study from China, the researchers:
    • did not observe an increased risk of knee pain or clinical knee osteoarthritis among the group of participants without high cholesterol but taking lipid-lowering drugs for prevention of other diseases.
    • However, among participants with high cholesterol, risks for knee pain and clinical knee osteoarthritis were higher among those taking lipid-lowering drugs than among those not taking such drugs.
    • Possible explanations for this finding may be that the participants with hyperlipidemia and use of lipid-lowering drugs had higher serum lipids before pharmacotherapy and longer course of hyperlipidemia. Our results suggest that hyperlipidemia may be an independent risk factor for knee osteoarthritis and that the effect of lipid-lowering drugs on this association is limited.

They concluded that their results indicate that hyperlipidemia may be an independent risk factor for knee pain and clinical knee osteoarthritis among middle-aged or older adults. These findings have substantial implications for the prevention of knee osteoarthritis through the reduction of blood lipid levels.

Do Statin use in healthy individuals lead to knee replacement?

In an October 2018 study led by the VA North Texas Health Care System, (8) doctors questioned the use of statin prescriptions as a preventative medicine in healthy individuals because

  • Statins are among the most commonly prescribed medications and their use for primary prevention in many otherwise healthy individuals, including those who are physically active, is increasing.
  • There is conflicting evidence regarding the relationship of statin use and musculoskeletal conditions. Given the rising disability associated with musculoskeletal conditions, understanding predisposing factors, including medication-related exposures, deserves further attention.

Medication-related exposures means that there is a question that the medication is causing joint pain problems.

  • Patients enrolled in a regional military healthcare system between 2003 and 2012 were evaluated in this retrospective cohort study.
  • A propensity score was generated to match statin-users and nonusers using 115 baseline characteristics. Outcomes included ICD-9 diagnoses codes for Agency for Healthcare Research and Quality disease categories of: non-traumatic arthropathies, use-related injury and undergoing rehabilitation. Primary analysis examined the outcomes in statin-users and nonusers after propensity score matching using conditional logistic regression analysis.

What were the findings of this study? “Statin use was associated with a significant increased risk of non-traumatic arthropathies (wear and tear related joint replacement) and use-related injury.”

The statins were sending healthy, people who exercise to joint replacement.

Our results provide additional data that can inform patient and clinician conversations about the benefits and risks of statin use.

The subnote, of course, is through diet and exercise. Please see my article on The evidence that your diet is destroying your joints and will send you to a nursing home.

If you have questions about your knee pain, you can get help and information from our Caring Medical Staff

1 Kaleağasıoğlu F, Olcay E, Olgaç V. Statin-induced calcific Achilles tendinopathy in rats: comparison of biomechanical and histopathological effects of simvastatin, atorvastatin and rosuvastatin. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jun 1;25(6):1884-91. [Google Scholar]
2 Eliasson P, Svensson RB, Giannopoulos A, Eismark C, Kjær M, Schjerling P, Heinemeier KM. Simvastatin and atorvastatin reduce the mechanical properties of tendon constructs in vitro and introduce catabolic changes in the gene expression pattern. PloS one. 2017 Mar 6;12(3):e0172797. [Google Scholar]
3 Veronese N, Koyanagi A, Stubbs B, Cooper C, Guglielmi G, Rizzoli R, Schofield P, Punzi L, Al‐Daghri N, Smith L, Maggi S. Statin use and knee osteoarthritis outcomes: A longitudinal cohort study. Arthritis care & research. 2018 Aug 20. [Google Scholar]
4 Clockaerts S, Van Osch GJ, Bastiaansen-Jenniskens YM, Verhaar JA, Van Glabbeek F, Van Meurs JB, Kerkhof HJ, Hofman A, Stricker BC, Bierma-Zeinstra SM. Statin use is associated with reduced incidence and progression of knee osteoarthritis in the Rotterdam study. Annals of the rheumatic diseases. 2011 Oct 1:annrheumdis-2011. [Google Scholar]
5 Riddle DL, Moxley G, Dumenci L. Associations between statin use and changes in pain, function and structural progression: a longitudinal study of persons with knee osteoarthritis. Annals of the rheumatic diseases. 2013 Feb 1;72(2):196-203. [Google Scholar]
6 Clockaerts S, Van Osch GJ, Bierma-Zeinstra SM. Comment on ‘Associations between statin use and changes in pain, function and structural progression: a longitudinal study of persons with knee osteoarthritis’. Annals of the rheumatic diseases. 2013 May 1;72(5):e9-. [Google Scholar]
7 Zhou M, Guo Y, Wang D, Shi D, Li W, Liu Y, Yuan J, He M, Zhang X, Guo H, Wu T. The cross-sectional and longitudinal effect of hyperlipidemia on knee osteoarthritis: Results from the Dongfeng-Tongji cohort in China. Scientific Reports. 2017 Aug 29;7(1):9739.  [Google Scholar]
8 Makris UE, Alvarez CA, Mortensen EM, Mansi IA. Association of statin use with increased risk of musculoskeletal conditions: a retrospective cohort study. Drug safety. 2018 Oct 1;41(10):939-50. [Google Scholar]


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