Can low testosterone cause joint pain?

Low testosterone may contribute to joint pain by weakening the muscle and bone that support joints, and possibly by favoring low-grade inflammation, but direct evidence in men is limited. If aching knees or stiff shoulders come with fatigue, lower libido, or loss of strength, it’s worth checking hormones as part of the workup.

Key takeaways

• Low testosterone may contribute to joint pain, usually alongside wear and tear, injuries, and body weight rather than as the only cause. Studies linking low testosterone to osteoarthritis in men are mainly observational.
• Testosterone influences cytokines, the signaling proteins that regulate inflammation. Low levels may favor persistent low-grade inflammation, but trials have not shown that this causes joint pain.
• A 2005 meta-analysis of 29 randomized trials found that testosterone treatment in middle-aged and older men increased lean mass, reduced body fat, and raised lumbar spine bone density. ^[1] Less muscle and more body fat increase the load on knees and hips.
• According to the European Academy of Andrology and American Urological Association guidelines, testosterone deficiency is diagnosed only when persistent symptoms are paired with low morning testosterone confirmed on repeat testing. ^{[2] [3]} LH and FSH should be measured alongside testosterone to tell primary from secondary hypogonadism.
• A practical plan is to get joint and hormone testing, prioritize resistance training 2 to 4 times per week, and aim for 5 to 10% weight loss to reduce knee and hip load. The EAA guideline recommends lifestyle change and weight loss as the first approach for overweight and obese men with functional hypogonadism. ^[2] Confirmed deficiency should be classified with LH and FSH before any medication is chosen.

The relationship

Testosterone is the main male sex hormone. It helps regulate sex drive, muscle mass, bone strength, and energy. It also affects tissues that matter for joints: it helps maintain bone and muscle, and laboratory research suggests it influences inflammation and the cells that maintain cartilage.

Joint pain in men usually has several causes at once: wear and tear, past injuries, body weight, activity level, and genetics. Low testosterone can add to that mix, mainly through loss of muscle and bone and possibly through more inflammation, but it is rarely the only cause.

The research on a direct link is thin. Studies connecting low testosterone with osteoarthritis are mostly observational, so they can show an association but not that low testosterone causes joint disease. Low testosterone is common in men with obesity and other chronic conditions, which also put extra strain on joints. The European Academy of Andrology’s 2020 guideline on functional hypogonadism recommends lifestyle change and weight loss as the first approach for all overweight and obese men with the condition. ^[2]

If you have nagging joint pain and also notice classic low testosterone symptoms like low libido, fatigue, and muscle loss, hormones deserve a closer look. You may still have arthritis or an overuse injury, but low testosterone can make recovery slower.

How it works

Testosterone and inflammation control

Inflammation is the immune system’s response to injury or irritation. Short bursts of inflammation help healing. Chronic low-grade inflammation that persists for years can damage joints and speed arthritis.

Testosterone influences cytokines, the signaling proteins that tell immune cells when to switch inflammation on or off. Laboratory and small clinical studies suggest that normal testosterone levels dampen pro-inflammatory cytokines in men, so low levels may shift the balance toward more inflammation, including in the joint lining. This has not been shown to cause joint disease directly.

Low testosterone does not mean a man will develop an autoimmune disease. In a man who already has early osteoarthritis, old sports injuries, or inflammatory arthritis, it may be one more factor that makes joint pain more frequent or more intense.

Cartilage health and protection

Cartilage is the smooth, rubbery tissue that covers the ends of bones in a joint so they glide easily. It has no blood supply of its own, so it depends on its surrounding biochemical environment to stay healthy.

Cartilage cells, called chondrocytes, maintain and repair the cartilage matrix, and laboratory studies show they respond to sex hormones. Whether low testosterone makes human cartilage thin faster has not been established. Thinning cartilage and more bone-on-bone contact are the hallmark of osteoarthritis whatever the cause.

The synovial membrane lines the joint and produces joint fluid. When it becomes inflamed, the joint swells and stiffens, especially after activity.

Bone density and joint stability

Bone mineral density is a measure of how solid and strong your bones are. In men, testosterone helps maintain bone both directly and after conversion to estradiol. A 2005 meta-analysis in Clinical Endocrinology, pooling 29 randomized trials in 1,083 middle-aged and older men, found that testosterone treatment raised lumbar spine bone mineral density by 3.7% compared with placebo, but not femoral neck density, and lowered markers of bone breakdown. ^[1]

Weaker bone around a joint may change how load is distributed across it. That matters most in weight-bearing joints such as the hips, knees, and lower spine.

Muscle strength, body weight, and joint load

Testosterone is a major driver of muscle mass in men. In the same meta-analysis, testosterone treatment increased fat-free mass by 1.6 kg and reduced total body fat by 1.6 kg, while effects on muscle strength were inconsistent, with only a trend toward better leg extension and grip strength. ^[1] Less muscle means less support for joints, and extra body weight increases the load on the knees, hips, and spine.

Even moderate weight gain adds noticeable pressure on the knee with each step. Weaker stabilizing muscles combined with a heavier load make joints more vulnerable to strain, overuse injuries, and osteoarthritis flare-ups. This is the most plausible route by which low testosterone adds to joint pain over time.

Conditions linked to it

Several joint-related conditions are reported more often in men with low testosterone. These associations do not show that testosterone is the cause.

• Osteoarthritis (OA): OA is the most common joint disease in men. Studies linking low testosterone to OA in men are observational and their results are not consistent, so testosterone’s role remains uncertain.
• Rheumatoid arthritis (RA): RA is an autoimmune disease in which the immune system attacks joint linings. Several studies report that men with RA have lower testosterone than healthy men, and levels may fall further during active disease. Chronic inflammation can itself suppress testosterone, so the direction of the link is unclear.
• Cartilage injuries and degeneration: Whether low testosterone slows recovery from meniscus tears or articular cartilage damage has not been well studied in men.
• Weight gain and metabolic issues: Low testosterone is closely tied to obesity, and the EAA guideline recommends weight reduction as the first approach for overweight and obese men with functional hypogonadism. ^[2] Extra weight and metabolic inflammation are strong, independent risk factors for knee and hip osteoarthritis and low back pain.

Most of these links come from observational studies, which can show association but cannot prove that low testosterone alone causes these conditions. Genetics, lifestyle, injuries, and other illnesses all play roles.

Symptoms and signals

Symptoms alone cannot diagnose low testosterone, but certain patterns should raise suspicion. Pay attention if you notice joint pain along with several of these signs:

• Persistent joint stiffness in the morning that improves slowly as the day goes on
• Aches in multiple joints (knees, hips, shoulders, hands) rather than just one injured area
• Joint pain that worsens as you gain weight or lose muscle strength
• Reduced sex drive or fewer morning erections compared with your past baseline
• Low energy, mental fog, or feeling “flat” most days
• Noticeable loss of muscle mass or strength, even if you still work out
• Increased body fat, especially around the waist
• Lower mood, irritability, or less motivation to train or be active
• Slower recovery after lifting, running, or weekend sports, with more lingering soreness

None of these prove that low testosterone is causing your joint pain, and some men with healthy testosterone have similar complaints. If you recognize both joint problems and classic low testosterone symptoms, ask your clinician to evaluate hormones as part of the workup.

What to do about it

A structured evaluation separates hormone problems from joint problems and guides treatment.

1. Get evaluated and tested

Start with your primary care clinician or a urologist or endocrinologist who is comfortable managing male hormone issues.

• Describe your joint pain clearly: which joints, how long, what makes it better or worse, morning stiffness, swelling, or warmth.
• Mention all other symptoms: libido changes, energy levels, mood, sleep, strength, and weight changes.
• Ask for a focused joint exam to look for signs of osteoarthritis or inflammatory arthritis.

The 2018 American Urological Association guideline uses total testosterone below 300 ng/dL on two separate morning draws, together with symptoms or signs, to diagnose testosterone deficiency. ^[3] The EAA guideline likewise requires symptoms plus repeatedly low morning fasting testosterone measured with a well-validated assay, after other causes have been excluded. ^[2] The AUA guideline also recommends measuring LH in men with low testosterone. ^[3] LH and FSH together classify the pattern as primary or secondary/functional hypogonadism, which determines the treatment options. Free testosterone, measured directly by equilibrium dialysis with LC-MS/MS or calculated from total testosterone, SHBG, and albumin, helps when total testosterone is borderline or SHBG is high.

Your clinician may also order basic labs for inflammation, blood counts, and metabolic health, and imaging such as X-rays if osteoarthritis or another structural joint problem is suspected.

2. Address root causes with lifestyle and classification-based hormone treatment

Treatment starts with lifestyle and joint mechanics, which help joints directly and can modestly raise testosterone:

• Strength training: Prioritize resistance training for major muscle groups 2 to 4 times per week to rebuild the muscle that supports your joints.
• Weight management: A 5 to 10% weight loss can reduce load on your knees and hips and improve pain, especially when combined with muscle-building exercise.
• Sleep and stress: Poor sleep and chronic stress can lower testosterone and increase inflammation. Aim for consistent sleep and stress-management habits.
• Joint-focused care: Physical therapy, sensible gym programming, and targeted mobility work can offload painful joints while you rebuild strength.

According to the EAA guideline, lifestyle changes and weight loss should come first for overweight and obese men with functional hypogonadism, and medicines that interfere with testosterone production should be stopped or changed where possible. ^[2] The rise in testosterone from lifestyle change alone is usually modest.

When medication is considered for confirmed deficiency, the type of hypogonadism guides the choice. Testosterone replacement therapy (TRT) is the standard treatment for primary hypogonadism, where the testes cannot respond to hormonal signals. For secondary or functional hypogonadism, enclomiphene is one alternative: it blocks estrogen feedback at the hypothalamus so the pituitary releases more LH and FSH, and the testes make more testosterone while sperm production continues. Enclomiphene does not work in primary hypogonadism.

Evidence that hormone treatment relieves osteoarthritis pain is limited. A 2015 randomized controlled trial in Pain, in 84 men aged 18 to 64 with opioid-induced androgen deficiency and chronic noncancer pain, found that 14 weeks of testosterone gel improved measured pain sensitivity, sexual desire, and body composition compared with placebo, but did not change self-reported pain. ^[4] According to the EAA guideline, testosterone therapy reliably improves sexual function in hypogonadal men, while its other benefits remain uncertain. ^[2] Hormone therapy should not be used as a stand-alone treatment for joint pain.

TRT suppresses sperm production, and the AUA guideline advises that men who want to preserve fertility should not be prescribed testosterone therapy. ^[3] Before TRT, the EAA guideline recommends a PSA test and prostate exam in men over 40 and treats a hematocrit above 48% to 50% as a relative contraindication. ^[2] With any hormone treatment, symptoms, blood counts, and follow-up labs should be checked during treatment.

Veedma offers testing that includes total and free testosterone measured by LC-MS/MS with LH and FSH, or a review of labs you already have, interpreted by licensed providers. In Veedma’s protocol, treatment is considered when free testosterone is below 100 pg/mL with persistent symptoms, using enclomiphene or the enclomiphene plus tadalafil tablet when appropriate. Enclomiphene is not an FDA-approved drug; it is prescribed after a provider confirms the diagnosis and is compounded by a licensed U.S. pharmacy.

Myth vs fact

Myth: Any joint pain in a man with low testosterone must be caused by hormones.

Fact: Most joint pain still comes from wear and tear, injuries, or arthritis. Low testosterone is usually a contributing factor, not the sole cause.

Myth: Testosterone therapy cures arthritis.

Fact: In middle-aged and older men, testosterone treatment can increase lean mass and lumbar spine bone density. ^[1] No treatment for low testosterone has been shown to reverse established cartilage damage, and none replaces standard arthritis care.

Myth: If your testosterone is “in the normal range,” hormones cannot be affecting your joints.

Fact: The lab “normal range” is wide, and symptoms can overlap with other conditions. According to the EAA and AUA guidelines, prescription treatment is considered only when persistent symptoms are paired with low testosterone on repeated morning testing. ^{[2] [3]} “Low-normal” results can still prompt a closer look for contributing factors such as sleep problems, medications, obesity, or thyroid issues.

Myth: Only very old men need to worry about low testosterone and joint pain.

Fact: Men in their 30s and 40s with obesity, metabolic issues, or prior testicular problems can have low testosterone and joint symptoms too.

Bottom line

Low testosterone can contribute to joint pain in men, usually as one factor among several, mainly by weakening the muscle and bone that support joints. If joint pain comes with low libido, fatigue, fewer morning erections, or declining strength, ask a clinician about an evaluation. Guidelines require persistent symptoms plus repeatedly low morning testosterone for a diagnosis. ^{[2] [3]} LH and FSH then show whether the problem is primary or secondary, which guides the choice of treatment.

References

1. Isidori AM, Giannetta E, Greco EA, et al. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: a meta-analysis. Clin Endocrinol (Oxf). 2005;63:280-93. PMID: 16117815
2. Corona G, Goulis DG, Huhtaniemi I, et al. European Academy of Andrology (EAA) guidelines on investigation, treatment and monitoring of functional hypogonadism in males: Endorsing organization: European Society of Endocrinology. Andrology. 2020;8:970-987. PMID: 32026626
3. Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200:423-432. PMID: 29601923
4. Basaria S, Travison TG, Alford D, et al. Effects of testosterone replacement in men with opioid-induced androgen deficiency: a randomized controlled trial. Pain. 2015;156:280-288. PMID: 25599449