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Nutritional Supplements for Musculoskeletal Health

Evidence on dietary supplements for joint, muscle and bone health — protein and amino acids, creatine, collagen peptides, glucosamine and chondroitin, and omega-3 — including perioperative recovery and osteoarthritis.

37 citationsUpdated Oct 2026
Illustration: Nutritional Supplements for Musculoskeletal Health

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Nutritional supplements currently lack robust efficacy and safety data to serve as replacements or adjuncts to standard orthopaedic care [1]. While specific supplementation may benefit geriatric patients, particularly those unable to exercise [2], and intravenous peri-operative protein or amino acid supplementation offers benefits for total joint arthroplasty with mixed effects on muscle strength [3], the broader clinical landscape remains nuanced. In spine surgery, substantial barriers to nutritional optimization include inconsistent protocols and patient nonadherence, highlighting the need for multifactorial assessment and standardization of multidisciplinary protocols [32].

For osteoarthritis, glucosamine and chondroitin sulfate possess an excellent safety profile and may serve as initial treatment modalities [4]. Glucosamine sulfate specifically shows potential to relieve pain and improve function with low side effects, though long-term effects and dosage remain unresolved [11]. Evidence supports the efficacy of non-steroidal anti-inflammatory drugs and glucosamine sulfate in reducing pain, improving function, and possibly regulating joint damage in knee osteoarthritis [7]. In symptomatic primary hand osteoarthritis, glucosamine and chondroitin sulfate may be considered reasonable options within a multimodal approach if costs are not prohibitive [15].

In post-operative and athletic contexts, adjuvant oral supplementation containing collagen, hyaluronic acid, chondroitin sulfate, and plasma proteins may increase physical therapy efficacy after anterior cruciate ligament reconstruction by shortening return-to-activity time and reducing analgesic consumption [5]. Omega-3 polyunsaturated fatty acid supplementation for 3-4 months reduces patient-reported joint pain intensity, morning stiffness, painful or tender joints, and NSAID consumption [8]. Conditionally essential amino acid supplementation protects against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures [9]. Nutritional supplementation has also been shown to markedly reduce hospital costs by lowering ICU admissions, hospital-associated complications, and hospital-acquired infections in orthopaedic surgery [14]. For athletes, appropriate dietary supplement use can be beneficial, whereas others may harm health, performance, or reputation if antidoping rule violations occur [12].

How It Works

Protein and Amino Acids

Intravenous protein or amino acid supplementation offers benefits for total joint arthroplasty, although effects on muscle strength and function remain mixed [3]. Protein supplementation serves as a low-cost intervention that is easy to incorporate into perioperative management; its beneficial effects on muscle strength could potentially reduce the risk of longer-term complications such as falls and periprosthetic fracture after total knee arthroplasty [18]. This supplementation appears to have beneficial effects on mitigating muscle atrophy in the postoperative period following ACL reconstruction, total hip arthroplasty, total knee arthroplasty, and surgical treatment of hip fracture [21]. In ACL patients, restoration of distal vasti muscle mass and knee extension muscle strength with resistance training is promoted further by protein-containing nutrient supplementation immediately after single exercise sessions [20]. However, in healthy adults, protein intakes at amounts greater than ~1.6 g/kg/day do not further contribute to resistance training-induced gains in fat-free mass [25].

Omega-3 Fatty Acids

Supplementation of n-3 polyunsaturated fatty acids is effective to relieve pain and improve joint function in patients with osteoarthritis [19]. Additionally, EPA supplementation could offer a promising strategy for preventing post-traumatic osteoarthritis progression following acute cartilage injuries by reducing the mechanical sensitivity of chondrocytes [35].

Glucosamine and Chondroitin Sulfate

The excellent safety profile of glucosamine and chondroitin sulfate should be discussed with patients, and they may serve a role as an initial treatment modality for many osteoarthritis patients [4]. If the cost is not prohibitive, these products may be considered reasonable treatment options as part of a multimodal approach for symptomatic primary hand osteoarthritis [15]. High levels of glucosamine–chondroitin sulfate can alter the cyclic preload and acute overload responses of chondral explants, demonstrating a biological action and effect on mechanical properties in an in vitro model [34]. Furthermore, glucosamine sulfate restrains the TNFα-mediated up-regulation of MMP-3 in bovine nucleus pulposus intervertebral disc cells, providing evidence for a protective role against early mediators of disc degeneration [39].

Collagen

An eight-week collagen-based supplement containing type I and type III collagen peptide and type II hydrolyzed collagen had a positive effect on pain, quality of life levels, and some functional test results in patients with meniscopathy [24].

Other Supplements

Calcium: Supplements may appear to improve fracture healing of osteoporotic bone but failed to improve strength in a rat osteoporotic model [16]. Creatine: Patients do not benefit from creatine supplementation during the first 12 weeks of rehabilitation after anterior cruciate ligament reconstruction [28]. Hyaluronic Acid: Intra-articular injections of hyaluronic acid supplemented with CCL25 attenuate cartilage degeneration in a guinea pig model of knee osteoarthritis [37]. Growth Factors: Supplementation with increasing concentrations of insulin-like growth factor-I enhances chondrocyte matrix synthesis and may provide a means to enhance chondrocyte phenotypic stability and function during transplantation grafting procedures [38]. The combination of anabolic growth factors (insulin-like growth factor-I) and catabolic blockers (interleukin-1 receptor antagonist protein) results in improved preservation of proteoglycan content of cartilage explants exposed to the depleting effects of IL-1 [40].

General Considerations

Because of the lack of robust efficacy and safety data, peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care [1]. The appropriate use of some supplements can benefit the athlete, but others may harm the athlete’s health, performance, and/or livelihood and reputation if an antidoping rule violation results [12].

What the Evidence Shows

Protein and Amino Acid Supplementation

Protein supplementation mitigates muscle atrophy in the postoperative period following ACL reconstruction, total hip arthroplasty, total knee arthroplasty, and surgical treatment of hip fracture [21]. As a low-cost intervention easily incorporated into perioperative management, protein supplementation improves muscle strength, potentially reducing the risk of longer-term complications such as falls and periprosthetic fracture [18]. Specific nutritional supplementation alone may benefit geriatric patients, particularly those unable to exercise [2]. While intravenous supplementation offers benefits for total joint arthroplasty, its effects on muscle strength and function remain mixed [3].

Resistance training combined with protein-containing nutrient supplementation immediately after single exercise sessions further promotes the restoration of distal vasti muscle mass and knee extension muscle strength [20]. However, protein intakes greater than ~1.6 g/kg/day do not further contribute to resistance training-induced gains in fat-free mass [25]. For malnourished patients, orthopaedic surgeons can select nutrition consultation and perioperative supplementation with amino acids and micronutrients as readily available interventions [22]. Integrating targeted nutrition into prehabilitation pathways may help reduce complications and support faster functional gains in total joint arthroplasty [29]. Perioperative nutritional optimization is associated with improved outcomes for patients undergoing spine surgery, though additional investigation is needed to determine effective protocols [47]. A low-cost commercially available amino acid supplement resulted in fewer overall postoperative complications and served as a low-risk intervention for the studied patient population [26].

Fracture and Hip Fracture Care

Oral nutritional supplementation and dietetic assistance represent low-risk interventions that may improve morbidity and mortality in older people with hip fractures [23]. A comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively in hip fracture patients [30]. In adults with traumatic peri-trochanteric femoral fracture, patients in the colostrum group had approximately 4 lower Oswestry Disability Index scores than the control group over the 90-day study period, indicating improved physical function [46].

Osteoarthritis and Joint Supplements

Oral chondroitin is more effective than placebo on relieving pain and improving physical function, while glucosamine showed an effect on stiffness outcome in osteoarthritis [43]. The evidence supports the efficacy of non-steroidal anti-inflammatory drugs and glucosamine sulfate in reducing pain, improving function, and possibly regulating joint damage in knee osteoarthritis [7]. Glucosamine sulfate has the potential to relieve pain and improve function with low side effects, but unanswered questions regarding long-term effects and dosage preclude a definitive endorsement [11]. The excellent safety profile of glucosamine and chondroitin sulfate should be discussed with patients, as they may serve a role as an initial treatment modality for many osteoarthritis patients [4].

Supplementation with omega-3 polyunsaturated fatty acids for 3-4 months reduces patient-reported joint pain intensity, minutes of morning stiffness, number of painful and/or tender joints, and NSAID consumption [8]. Supplementation of n-3 PUFAs is effective to relieve pain and improve joint function in patients with osteoarthritis [19]. Significant pain relief was demonstrated in patients with knee osteoarthritis who received collagen peptides compared to those who received placebo [45]. An eight-week collagen-based supplement had a positive effect on pain and quality of life levels and some functional test results in patients with meniscopathy [24].

Ligament and Tendon Recovery

Adjuvant oral supplementation containing collagen, hyaluronic acid, chondroitin sulfate, and plasma proteins may increase the efficacy of physical therapy by shortening the time needed to return to pre-injury activity and the analgesic consumption after ACL reconstruction [5]. Patients do not benefit from creatine supplementation during the first 12 weeks of rehabilitation after ACL reconstruction [28].

General and Safety Considerations

Peer-reviewed scientific research often fails to support the efficacy of amino acids marketed as ergogenics for enhancing athletic performance [49].

Practical Considerations

Perioperative and Postoperative Supplementation

Intravenous protein or amino acid supplementation provides benefits for total joint arthroplasty, although effects on muscle strength and function remain mixed [3]. For patients undergoing operative fixation of extremity and pelvic fractures, conditionally essential amino acid (CEAA) supplementation exerts a protective effect against common complications and early skeletal muscle wasting [9]. In the context of total knee arthroplasty, protein supplementation serves as a low-cost intervention that is easy to incorporate into perioperative management [18]. The beneficial effects of this supplementation on muscle strength could potentially reduce the risk of longer-term complications, such as falls and periprosthetic fracture, after total knee arthroplasty [18].

Orthopaedic surgeons can select readily available interventions, including nutrition consultation and perioperative supplementation with amino acids and micronutrients, for malnourished patients [22]. The use of a low-cost commercially available amino acid supplement resulted in fewer overall complications postoperatively and was a low-risk intervention for the patient population [26]. For hip fracture patients, a comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively [30]. Furthermore, oral nutritional supplementation and dietetic assistance represent low-risk interventions that may improve morbidity and mortality in older people after hip fracture [23].

Non-Operative and General Musculoskeletal Health

Evidence supports the efficacy of glucosamine sulfate in reducing pain, improving function, and possibly regulating joint damage in knee osteoarthritis [7]. Regarding fracture healing, calcium supplements may appear to improve fracture healing of osteoporotic bone but failed to improve strength in a rat model [16].

Key Evidence

  • [L5] Because of the lack of robust efficacy and safety data, peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care. [1] (10.1177/03635465261464420)
  • [L1] This study shows proof-of-principle that specific nutritional supplementation alone might benefit geriatric patients, especially relevant for those who are unable to exercise. [2] (10.1016/j.jamda.2015.05.021)
  • [L1] While effects on muscle strength and function are mixed, intravenous supplementation offers benefits. [3] (10.1186/s13018-025-05847-4)
  • [L2] The excellent safety profile of these supplements should be discussed with patients, and they may serve a role as an initial treatment modality for many OA patients. [4] (10.1016/j.arthro.2008.07.020)
  • [L1] Adjuvant oral supplementation may increase the efficacy of physical therapy by shortening the time needed to return to pre-injury activity and the analgesic consumption. [5] (10.1177/2325967118s00040)
  • [L4] The evidence supports efficacy in reducing pain, improving function, and possibly regulating joint damage. [7] (10.1186/s12891-022-06046-6)
  • [L1] Supplementation with omega-3 PUFAs for 3-4 months reduces patient reported joint pain intensity, minutes of morning stiffness, number of painful and/or tender joints, and NSAID consumption. [8] (10.1016/j.pain.2007.01.020)
  • [L1] CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. [9] (10.2106/jbjs.21.01014)
  • [L5] The authors conclude that while glucosamine sulfate has potential to relieve pain and improve function with low side effects, unanswered questions regarding long-term effects and dosage preclude a definitive endorsement, and the lack of substantial evidence currently prevents a ringing endorsement of these agents. [11] (10.5435/00124635-200109000-00009)
  • [Paper] The appropriate use of some supplements can benefit the athlete, but others may harm the athlete’s health, performance, and/or livelihood and reputation (if an antidoping rule violation results). [12] (10.1136/bjsports-2018-099027)
  • [L4] Nutritional supplementation has been shown to markedly reduce hospital costs by reducing rates of ICU admissions, hospital-associated complications, and hospital-acquired infections. [14] (10.5435/jaaos-d-23-00300)
  • [L4] If the cost is not prohibitive, these products may be considered reasonable treatment options as part of a multimodal approach for symptomatic primary osteoarthritis. [15] (10.1016/j.jhsa.2013.05.017)
  • [Paper] Therefore, calcium supplements may appear to improve fracture healing of osteoporotic bone but failed to improve strength. [16] (10.1002/jor.21180)
  • [L5] Protein supplementation is a low-cost intervention that is easy to incorporate into perioperative management, and the beneficial effects on muscle strength could potentially reduce the risk of longer-term complications, such as falls and periprosthetic fracture. [18] (10.2106/jbjs.22.01357)
  • [L1] Supplementation of n-3 PUFAs is effective to relieve pain and improve joint function in patients with OA. [19] (10.1186/s13018-023-03855-w)
  • [L1] The results from this study demonstrate that restoration of the distal vasti muscle mass and knee extension muscle strength with resistance training is promoted further by protein-containing nutrient supplementation immediately after single exercise sessions. [20] (10.1002/jor.20147)
  • [L1] Protein supplementation appears to have beneficial effects on mitigating muscle atrophy in the postoperative period following ACLR, THA, TKA, and surgical treatment of hip fracture. [21] (10.1177/2325967123s00326)
  • [L5] Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients. [22] (10.2106/jbjs.rvw.23.00242)
  • [L1] However, oral nutritional supplementation and dietetic assistance represent low-risk interventions that may improve morbidity and mortality. [23] (10.1097/corr.0000000000000658)
  • [L1] The results of the study showed that the eight-week collagen-based supplement had a positive effect on pain and quality of life levels and some functional test results in patients with meniscopathy. [24] (10.1186/s12891-024-08244-w)
  • [L1] With protein supplementation, protein intakes at amounts greater than ~1.6 g/kg/day do not further contribute RET-induced gains in FFM. [25] (10.1136/bjsports-2017-097608)
  • [L5] The use of the low-cost commercially available amino acid supplement resulted in fewer overall complications postoperatively and was a low-risk intervention for their patient population. [26] (10.2106/jbjs.22.00078)
  • [L1] The results demonstrate that patients do not benefit from creatine supplementation during the first 12 weeks of rehabilitation after ACL reconstruction. [28] (10.1177/0363546503261731)
  • [L4] Integrating targeted nutrition into prehabilitation pathways may help reduce complications and support faster functional gains. [29] (10.1016/j.arth.2026.03.088)
  • [L1] The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively. [30] (10.1097/01.blo.0000224054.86625.06)
  • [L4] Despite these benefits, substantial barriers like inconsistent protocols and patient nonadherence remain, highlighting the need for multifactorial assessment and standardization of multidisciplinary nutritional protocols. [32] (10.5435/jaaos-d-25-00757)
  • [Paper] These data show a biological action of high concentrations of this supplement and its effect on the mechanical properties in this in vitro model. [34] (10.1002/jor.20757)
  • [L5] The findings suggest that EPA supplementation could offer a promising strategy for preventing PTOA progression following acute cartilage injuries. [35] (10.1186/s13018-024-05081-4)
  • [Paper] These data suggest that intra-articular injections of HA supplemented with CCL25 attenuates OA. [37] (10.1002/jor.24312)
  • [Paper] Supplementation with increasing concentrations of insulin-like growth factor-I enhances chondrocyte matrix synthesis and may provide a means to enhance chondrocyte phenotypic stability and function during transplantation grafting procedures. [38] (10.1002/jor.1100170403)
  • [L5] This is the first report providing evidence for the protective role of glucosamine against this early mediator of disc degeneration that could support the potential usage of this molecule as a treatment for preventing disc degenerative disorders. [39] (10.1002/jor.22725)
  • [Paper] The beneficial effects of the combination of anabolic growth factors and catabolic blockers were evident in improved preservation of proteoglycan content of cartilage explants exposed to the depleting effects of IL-1. [40] (10.1016/j.orthres.2004.06.020)
  • [L1] Oral chondroitin is more effective than placebo on relieving pain and improving physical function, while glucosamine showed effect on stiffness outcome. [43] (10.1186/s13018-018-0871-5)
  • [L1] Our findings demonstrate significant pain relief in patients with knee osteoarthritis who received collagen peptides compared to those who received placebo. [45] (10.1186/s13018-023-04182-w)
  • [L1] Additionally, patients in the colostrum group had approximately 4 lower Oswestry Disability Index (ODI) scores than the control group over the 90-day study period, indicating improved physical function. [46] (10.1016/j.injury.2023.111253)
  • [L4] Perioperative nutritional optimization has been associated with improved outcomes for patients undergoing spine surgery, but additional investigation is needed to determine effective perioperative nutritional protocols. [47] (10.5435/jaaos-d-24-01101)
  • [Paper] The article highlights that while amino acids are marketed as ergogenics, peer-reviewed scientific research often fails to support their efficacy for enhancing athletic performance. [49] (10.1016/s0278-5919(05)70173-3)

See Also

  • Osteoarthritis

References

[1] Peptide Supplements and Their Therapeutic Applications in Sports Medicine. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261464420

[2] Effects of a Vitamin D and Leucine-Enriched Whey Protein Nutritional Supplement on Measures of Sarcopenia in Older Adults, the PROVIDE Study: A Randomized, Double-Blind, Placebo-Controlled Trial. Journal of the American Medical Directors Association. 2015. DOI: 10.1016/j.jamda.2015.05.021

[3] Peri-operative protein or amino acid supplementation for total joint arthroplasty: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05847-4

[4] A Review of Evidence‐Based Medicine for Glucosamine and Chondroitin Sulfate Use in Knee Osteoarthritis. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.07.020

[5] Efficacy and Tolerability of a Dietary Supplement Containing Collagen, Hyaluronic Acid, Chondroitin Sulfate and Plasma Proteins in the Recovery After Anterior Cruciate Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118s00040

[7] Possible synergic action of non-steroidal anti-inflammatory drugs and glucosamine sulfate for the treatment of knee osteoarthritis: a scoping review. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06046-6

[8] A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007. DOI: 10.1016/j.pain.2007.01.020

[9] Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.01014

[11] Use of Glucosamine and Chondroitin Sulfate in the Management of Osteoarthritis. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200109000-00009

[12] IOC consensus statement: dietary supplements and the high-performance athlete. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2018-099027

[14] The Role of Amino Acid Supplementation in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00300

[15] Glucosamine and Chondroitin Sulfate Treatment of Hand Osteoarthritis. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.05.017

[16] Effects of calcium supplements on fracture healing in a rat osteoporotic model. Journal of Orthopaedic Research. 2010. DOI: 10.1002/jor.21180

[18] Nutritional Optimization with Amino Acid Supplementation Aids Recovery After Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.01357

[19] Effect of omega-3 polyunsaturated fatty acids supplementation for patients with osteoarthritis: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03855-w

[20] The effect of protein and carbohydrate supplementation on strength training outcome of rehabilitation in ACL patients. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20147

[21] Poster 363: Post-Operative Protein Supplementation following Orthopaedic Surgery: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00326

[22] The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.23.00242

[23] Cochrane in CORR®: Nutritional Supplementation for Hip Fracture Aftercare in Older People. Clinical Orthopaedics & Related Research. 2019. DOI: 10.1097/corr.0000000000000658

[24] The effect of supplementation with type I and type III collagen peptide and type II hydrolyzed collagen on pain, quality of life and physical function in patients with meniscopathy: a randomized, double-blind, placebo-controlled study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08244-w

[25] A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2017-097608

[26] Essential Amino Acid Supplementation: Feed the Injured Patient. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00078

[28] The Effect of Creatine Supplementation on Strength Recovery after Anterior Cruciate Ligament (ACL) Reconstruction. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503261731

[29] Perioperative Nutritional Optimization in Total Joint Arthroplasty: From Screening to Supplementation. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.088

[30] Nutritional Supplementation Decreases Hip Fracture-related Complications. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000224054.86625.06

[32] Nutritional Optimization in Spine Surgery: A Review of Its Implications for Postoperative Recovery and Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-25-00757

[34] High levels of glucosamine–chondroitin sulfate can alter the cyclic preload and acute overload responses of chondral explants. Journal of Orthopaedic Research. 2009. DOI: 10.1002/jor.20757

[35] Omega-3 fatty acids protect cartilage from acute injurie by reducing the mechanical sensitivity of chondrocytes. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05081-4

[37] CCL25‐Supplemented Hyaluronic Acid Attenuates Cartilage Degeneration in a Guinea Pig Model of Knee Osteoarthritis. Journal of Orthopaedic Research. 2019. DOI: 10.1002/jor.24312

[38] Coordinate upregulation of cartilage matrix synthesis in fibrin cultures supplemented with exogenous insulin‐like growth factor‐I. Journal of Orthopaedic Research. 1999. DOI: 10.1002/jor.1100170403

[39] The catabolic effect of TNFα on bovine nucleus pulposus intervertebral disc cells and the restraining role of glucosamine sulfate in the TNFα-mediated up-regulation of MMP-3. Journal of Orthopaedic Research. 2014. DOI: 10.1002/jor.22725

[40] Dual transduction of insulin‐like growth factor‐I and interleukin‐l receptor antagonist protein controls cartilage degradation in an osteoarthritic culture model. Journal of Orthopaedic Research. 2005. DOI: 10.1016/j.orthres.2004.06.020

[43] Effectiveness and safety of glucosamine and chondroitin for the treatment of osteoarthritis: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0871-5

[45] Analgesic efficacy of collagen peptide in knee osteoarthritis: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04182-w

[46] Improved physical disability and nutritional status by bovine colostrum supplementation in adults with traumatic peri-trochanteric femoral fracture: A randomized, controlled, clinical trial. Injury. 2024. DOI: 10.1016/j.injury.2023.111253

[47] Perioperative Nutritional Optimization in Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01101

[49] FACTS AND FALLACIES OF PURPORTED ERGOGENIC AMINO ACID SUPPLEMENTS. Clinics in Sports Medicine. 1999. DOI: 10.1016/s0278-5919(05)70173-3

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.