International Journal of

Molecular Sciences

Review
Osteoarthritis Pain
Huan Yu 1,2 , Tianwen Huang 3 , William Weijia Lu 1,4 , Liping Tong 2, * and Di Chen 1,2, *

1 Faculty of Pharmaceutical Science, Shenzhen Institute of Advanced Technology, Chinese Academy of

Sciences, Shenzhen 518055, China; huan.yu@siat.ac.cn (H.Y.); ; wwlu@hku.hk (W.W.L.)
2 Research Center for Computer-Aided Drug Discovery, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen 518055, China
3 CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen-Hong Kong Institute of Brain
Science-Shenzhen Fundamental Research Institutions, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen 518055, China; tw.huang@siat.ac.cn
4 Department of Orthopaedics and Traumatology, The University of Hong Kong,
Hong Kong SAR 999077, China
* Correspondence: lp.tong@siat.ac.cn (L.T.); di.chen@siat.ac.cn (D.C.)

Abstract: Joint pain is the hallmark symptom of osteoarthritis (OA) and the main reason for patients
to seek medical assistance. OA pain greatly contributes to functional limitations of joints and reduced
quality of life. Although several pain-relieving medications are available for OA treatment, the
current intervention strategy for OA pain cannot provide satisfactory pain relief, and the chronic
use of the drugs for pain management is often associated with significant side effects and toxicities.
These observations suggest that the mechanisms of OA-related pain remain undefined. The current
review mainly focuses on the characteristics and mechanisms of OA pain. We evaluate pathways
associated with OA pain, such as nerve growth factor (NGF)/tropomyosin receptor kinase A (TrkA),
calcitonin gene-related peptide (CGRP), C–C motif chemokine ligands 2 (CCL2)/chemokine receptor
2 (CCR2) and tumor necrosis factor alpha (TNF-α), interleukin-1beta (IL-1β), the NOD-like receptor
(NLR) family, pyrin domain-containing protein 3 (NLRP3) inflammasome, and the Wnt/β-catenin
signaling pathway. In addition, animal models currently used for OA pain studies and emerging
preclinical studies are discussed. Understanding the multifactorial components contributing to OA
Citation: Yu, H.; Huang, T.; Lu, W.W.; pain could provide novel insights into the development of more specific and effective drugs for OA
Tong, L.; Chen, D. Osteoarthritis Pain. pain management.
Int. J. Mol. Sci. 2022, 23, 4642.
https://doi.org/10.3390/ Keywords: osteoarthritis; pain; NGF/TrkA; CGRP; CCL2/CCR2; TNF-α; IL-1β; NLRP3; β-catenin
ijms23094642

Academic Editor: Riko Nishimura

Received: 14 March 2022

1. Introduction
Accepted: 20 April 2022
Published: 22 April 2022
Osteoarthritis (OA) is one of the most common pain-evoking and disabling diseases
globally affecting about 250 million people [1]. It severely affects the patients’ quality
Publisher’s Note: MDPI stays neutral of life and imposes a great economic burden on individuals, families, and the entire
with regard to jurisdictional claims in
society. With the aging and increasing life expectancy of the population, OA poses a major
published maps and institutional affil-
challenge to social and public health [2]. OA is a whole-joint disease involving all joint
iations.
tissue types, namely, cartilage, menisci, synovial membrane, infrapatellar fat pads, and
subchondral bone caused by the combined actions of systemic-susceptibility and local
factors [3]. Varieties of factors, such as mechanical, inflammation, aging, and metabolic, are
Copyright: © 2022 by the authors.
involved in the pathogenesis of OA, and ultimately lead to articular structural destruction
Licensee MDPI, Basel, Switzerland.
and loss of functions of synovial joints, along with long-term chronic pain [4–6].
This article is an open access article Pain is the main symptom of OA and the main reason for patients to seek medical
distributed under the terms and help, and is defined by the International Association for the Study of Pain (IASP) as “an
conditions of the Creative Commons unpleasant sensory and emotional experience associated with, or resembling that associated
Attribution (CC BY) license (https:// with, actual or potential tissue damage” [7–9]. It is often regarded as an important warning
creativecommons.org/licenses/by/ signal that plays a protective role in the response to acute tissue injury and inflammation.
4.0/). When acute pain is not relieved and transitions into chronic pain, pain control becomes

Int. J. Mol. Sci. 2022, 23, 4642. https://doi.org/10.3390/ijms23094642 https://www.mdpi.com/journal/ijms

Int. J. Mol. Sci. 2022, 23, 4642 2 of 22

much more challenging [10,11]. OA patients often experience a dull, aching pain or
unpredicted intensity of intermittent pain that is initially activity-related and subsequently
more constant over time, representing one of the most prevalent and disabling chronic
conditions [12,13]. In addition to the pain itself, long-term chronic pain has negative
effects on mental health, sleep, and social participation [14,15]. Traditionally, NSAIDs,
acetaminophen, and opioid analgesics are the most common prescription drugs for the
management of OA pain. However, because the pathogenesis of OA pain is not well-
understood, the current strategy for the intervention of OA pain cannot provide satisfactory
pain relief, and the chronic use of the drugs for pain management is often associated
with significant side effects and toxicities [16,17]. Unravelling the mechanisms of these
multifactorial components contributing to the generation and maintenance of OA pain
offers critical new insights into the development of more effective and safer pain treatment.
In this review, we mainly focus on the characteristics and mechanisms of OA pain, and
important pathways associated with OA pain, such as nerve growth factor
(NGF)/tropomyosin receptor kinase A (TrkA), calcitonin gene-related peptide (CGRP),
C–C motif chemokine ligands 2 (CCL2)/chemokine receptor 2(CCR2) and tumor necrosis
factor alpha (TNF-α), interleukin-1beta (IL-1β), the NOD-like receptor (NLR) family, pyrin
domain–containing protein 3 (NLRP3) inflammasome, and the Wnt/β-catenin signaling
pathway. Animal models currently used for OA pain studies and emerging preclinical
studies are also discussed according to recent findings.

2. Materials and Methods

This narrative review search was conducted to describe the characteristics and mecha-
nisms of OA pain, and of a variety of critical signaling pathways associated with OA pain,
including NGF/TrkA, CGRP, CCL2/CCR2 and TNF-α, IL-1β, NLRP3 inflammasome, and
Wnt/β-catenin. We also included common animal models used for OA pain studies and
the results of emerging preclinical studies with limitations in terms of the English language.
Original papers and reviews that evaluated the mechanisms of OA pain, OA pain-related
animal models, and clinical efficacy for the treatment of OA pain were considered. In
March 2022, two electronic databases, PubMed and Google Scholar, were searched with
the terms osteoarthritis, pain, NGF/TrkA, CGRP, CCL2/CCR2, TNF-α, IL-1β, NLRP3,
and Wnt/β-catenin. In particular, the following terms were applied to the search: (os-
teoarthritis AND pain), (osteoarthritis AND (NGF OR TrkA)), (osteoarthritis AND CGRP),
(osteoarthritis AND CGRP), (osteoarthritis AND (CCL2 OR CCR2)), (osteoarthritis AND
TNF-α), (osteoarthritis AND IL-1β), (osteoarthritis AND NLRP3), (osteoarthritis AND
(Wnt OR β-catenin)), and (osteoarthritis AND animal model). Duplicates and nonrelevant
records were excluded. Other original articles, reviews, and important publications were
referred to in the references of the searched articles from database.

3. Characteristics and Structural Correlation of OA Pain

OA pain is the main symptom of the disease, but the true source of OA pain is
unclear. Although the hallmark pathology of OA is articular cartilage lesion, no nerves
and blood vessels exist in articular cartilage; thus, cartilage cannot directly generate OA
pain [18]. However, the surrounding tissue types of a joint, including the synovium, fat pad,
ligaments, joint capsule, and subchondral bone, are all highly innervated by rich sensory
and sympathetic nerves, and can be the source of nociceptive pain. Previous studies
showed that OA pain is linked with synovitis, and alterations in pain are related to changes
in synovitis [19]. Osteoclasts also induce sensory nerve innervation in subchondral bone,
which is the cause of OA pain [20,21]. In addition, abnormal infrapatellar fat pads, defects
in cartilage and subchondral bone microfractures, synovitis, osteophyte formation, and
intraosseous hypertension were all associated with OA pain [13,22–26]. Nociceptor nerve
terminals are key molecular transducers of these noxious stimuli that express varieties of
ion channels such as members of the transient receptor potential (TRP) ion channel family
including TRP vanilloid 1 (TRPV1), TRP melastatin 3 (TRPM3), TRP ankyrin 1 (TRPA1), and
Int. J. Mol. Sci. 2022, 23, 4642 3 of 22

voltage-gated sodium channel members, including Nav1.8 and Nav1.7 [27,28] (Figure 1A).
When detecting potential noxious stimuli such as mechanosensations and chemical or
thermal sensations, these terminals are activated to evoke pain transmission and release
neuropeptides including CGRP and substance P (SP) [29]. Subsequently, pain signals are
transmitted along the dorsal root ganglia (DRG), where the cell body of sensory neurons and
the dorsal horn of the spinal cord reside, leading to the upregulation of CCL2, NLRP3, and
Wnt/β-catenin (Figure 1B,C). Second-order neurons within the dorsal horn of the spinal
cord are activated through neurotransmitters including CGRP, SP, and glutamate [28,30]
(Figure 1C). Ultimately, ascending pathways activate the higher central nervous system,
leading to the conscious awareness of pain [31,32].
Int. J. Mol. Sci. 2022, 23, 4642 4 of 22

C Synapse

CGRP
NLRP3

A Noceptor terminal
Wnt/β-catenin Glutamate

CCL2
CGRP Substance P
Substance P

Macrophage
Wnt5a
TRPV1
CCL2

NGF TrkA
TNF-α Macrophage
1
and TRPA
IL-1β Nav1.7
B DRG

NLRP3
Wnt/β-catenin
Brain
CCL2

DRG

Sensory afferent fiber

Spinal cord

Knee

Figure 1. Overview of OA pain transmission and associated signaling pathways. (A). Peripheral
terminals of nociceptors contain a variety of transducing channels that convert harmful stimuli into
electrical activity, and thus action potentials in nociceptors that travel back to the central nervous
system. In the event of painful stimulatory factors such as NGF, TNFα, and IL-1β acting on their
receptors, ion channels such as TRPV1 and Nav1.7 are activated to transmit a pain signal and CCL2
expression, and are upregulated to recruit macrophage. (B). Cell bodies of nociceptors are located
in the dorsal root ganglion. Increased expression of NLRP3, Wnt/β-catenin, CCL2, Wnt5a in DRG
in chronic pain states. (C). Nociceptive signals are transmitted at a central synapse in the spinal
cord through the release of a variety of excitatory neurotransmitters, such as glutamate, CGRP, or
substance P, which could excite second-order nociceptive projection neurons. NLRP3, Wnt/β-catenin,
CCL2, and Wnt5a expression is upregulated in presynaptic neurons.

OA pain was long thought to be nociceptive pain triggered by damaged or inflamed

tissue. However, judging from the current evidence, OA pain is likely driven by both
nociceptive and neuropathic mechanisms [32]. First, the distribution of sensory nerve fibers
in various parts of the joint is the material basis for the body to perceive pain. OA pain is
usually located at the affected joint, which is related to exercise and weight bearing, and
relieved at rest, suggesting that OA pain can be caused by sensing structural damage [33].
Second, although OA is not typical inflammatory arthritis, inflammation mediators play
a key role in OA pathogenesis [34,35]. Various proinflammatory factors are produced
in OA pathological states and released into the joint fluid, driving a series of cascading
Int. J. Mol. Sci. 2022, 23, 4642 5 of 22

reactions. Cytokines such as IL-1β, IL-6, TNF-α, and NGF, and chemokines including CCL2
and fractalkine can participate in the generation of pain and peripheral sensitization by
interaction with sensory nerves [36]. The presence of persistent pain inputs in patients
with OA leads to the sensitization of the central and peripheral nervous systems, leading to
mechanical tenderness and hyperalgesia that are typical of neuropathic pain around the
OA joints, supporting the idea that neuropathic pain components exist in OA pain [30,31].
Central sensitization is likely involved in patients experiencing pain who suffered severe
OA pain despite the less severe joint pathology [37]. Other evidence showed that increased
synovial NGF expression, and higher cerebrospinal fluid levels of serotonin and dopamine
metabolites are positively correlated with pain severity and central sensitization in OA
patients [38]. Increased central sensitization is also associated with pain at rest, and affected
postoperative pain persistence and dissatisfaction following arthroplasty [39,40]. However,
the mechanisms of central sensitization underlying OA pain remain undefined.

4. Mechanisms of OA Pain
4.1. NGF/TrkA Signaling
NGF was first discovered approximately 60 years ago as an indispensable neurotrophic
factor that induces sensory and sympathetic nerve growth [41]. It is now known that
NGF is also a proinflammatory cytokine mediating pain signal transduction that leads to
the sensitization of the nervous system. NGF is upregulated by cytokines such as TNF
and can be produced by non-neural cells such as macrophages, mast cells, synoviocytes,
and neutrophils, found in the joint tissue of individuals with OA [42,43]. NGF acts on
its high-affinity receptor, TrkA, which is then taken up by endosomes and undergoes
long-distance retrograde transport from the distal axon to the cell body of DRG. The
activation of NGF/TrkA signaling results in the upregulation and release of inflammatory
mediators, and the increased activation of TRPV1 and Nav1.8, leading to a broad increase
in neuronal activity. Moreover, NGF upregulates the expression of neurotransmitters such
as CGRP, substance P, and brain-derived neurotrophic factor, which contribute to central
pain sensitivity [44].
McNamee and colleagues found that the induction of NGF expression following the
destabilization of medial meniscus (DMM)-induced OA was correlated with pain-related
behavioral changes during OA development in mice [45]. Ohashi et al. identified that a
subtype of macrophages, CD14 (high), in the synovium of hip OA patients expressed higher
levels of NGF, which contribute to joint pain and central sensitization [46]. Our previous
study demonstrated that DMM surgery increased NGF/TrkA expression and retrograded
transport of NGF in DRG in mice. Neurite outgrowth and NGF/TrkA signaling are critical
drivers for OA hyperalgesia in both experimental OA animal models and in OA patients
experiencing pain, which was unrelated with the severity of cartilage degeneration [47].
More recently, we demonstrated reduced OA pain, but worsened articular cartilage lesions
and osteophyte outgrowth in DMM-induced mice OA with CRISPR-mediated ablation of
NGF [48]. The results of rapidly progressive cartilage destruction were also observed when
anti-NGF antibodies were used to treat OA patients in a clinical trial. Thus, it is intriguing
how NGF function differentially induces joints pain and pathology. A more thorough
investigation for the role of NGF in OA would provide new insights into the development
of new medications with high efficacy for the treatment of OA pain while reducing toxicity.

4.2. CGRP
CGRP is a 37-amino acid neuropeptide that is widely expressed in the peripheral
and central nervous systems, with the most abundant in nociceptive neurons, e.g., in
the DRG and nerve fibers that project to the dorsal horn of the spinal cord [49,50]. As a
sensory neuropeptide, CGRP can dilate blood vessels, affect peripheral pain sensitization
and inflammation, and play a critical role in the process of neurogenic inflammation and
pain generation [51]. Many studies showed that CGRP specifically targets the pathologic
pain response associated with sensitization [52,53]. CGRP plays an important role in the
Int. J. Mol. Sci. 2022, 23, 4642 6 of 22

physiology of migraine, and CGRP receptor antagonists could block migraines and is the
most successful translational product for migraine treatment [54]. We found a critical
role of CGRP during bone fracture healing by mediating the interaction between nervous
and musculoskeletal systems [55]. Stockl and their colleagues analyzed the influence of
exogenous αCGRP and SP in vitro on the chondrocyte metabolism and modulation of
associated signaling pathways from OA patients receiving total knee arthroplasty and
non-OA cartilage donors. The study found that both αCGRP and SP treatment promoted
apoptosis and senescence, and decreased the expression of chondrogenic markers in OA
chondrocytes via the activation of ERK signaling, but αCGRP enhanced chondrocyte
anabolism and had protective effect on healthy chondrocytes; SP had minimal effects on
chondrocytes from healthy cartilage [29]. However, the precise role of CGRP in OA pain
remains unexplored.
Clinical evidence shows that serum CGRP levels and CGRP-positive nerve fiber
density are correlated with pain symptoms and disease severity in OA patients [56]. CGRP
receptor antagonists and CGRP neutralizing antibodies could alleviate pain in OA animal
models induced by different methods [57]. Recent studies also showed that blocking
the activity of CGRP through the administration of receptor antagonists or the deletion
of CGRP could prevent sensitization and mechanical allodynia caused by inflammation
and neuropathic pain [58,59]. These results indicate that CGRP is an effective target for
OA management. However, a recent Phase II clinical trial showed that CGRP antibodies
lack efficacy on moderate and severe OA pain (NCT02192190) [60]. The reason for these
negative results needs further investigation. A study analyzed CGRP and its receptor
expression in synovial tissue harvested from male and female patients receiving total knee
arthroplasty [61]. Synovial CGRP expression was positively correlated with pain severity
in women but not in men, whereas the expression of RAMP1 was not correlated with pain
scores in either men or women. These differential CGRP and RAMP1 expression levels by
sex suggest that different pain mechanisms exist in men and women with knee OA.

4.3. CCL2/CCR2
CCL2, also called monocyte chemo attractant protein (MCP)-1, was first identified
in 1989 and is described as a “tumor-derived chemotactic factor” [62]. It can be produced
by many activated cells, including macrophages, endothelial cells, fibroblasts, and lym-
phocytes, and functions as a potent chemoattractant for a variety of immune cells such as
monocytes, macrophages, dendritic cells, and memory T cells in multiple inflammatory
diseases [63,64]. The development and maintenance of OA pain behavior such as me-
chanical allodynia and movement-evoked pain involve molecular changes in the sensory
neurons of the DRG, including alterations of chemokines and their receptors in mRNA
and protein expression. CCL2/CCR2 signaling was recently found to be central to the
development of knee OA pain [65]. In that study, CCL2/CCR2 mRNA and protein ex-
pressions in L3–L5 DRG neurons were elevated at 8 weeks postsurgery, and returned to
normal levels at 16 weeks after DMM surgery. Mechanical allodynia in mice that lacked
CCR2 was resolved from 8 weeks onwards, while at 8 weeks, Ccr2-null mice did not dis-
play movement-provoked pain behaviors, and showed fewer macrophage infiltrations
in DRG. These results demonstrated that neuronal CCL2 and CCR2 from DRG play vi-
tal roles in mediating macrophage infiltration and OA pain sensitivity. A study found
that mice lacking CCL2 or CCR2 were protected against OA with reduced monocyte or
macrophage numbers in joint tissue [66]. Blocking CCL2/CCR2 signaling also markedly
attenuated OA-like phenotypes, such as macrophage accumulation, synovitis, and cartilage
lesions in mouse OA. These data demonstrated that monocytes recruited via CCL2/CCR2
promoted inflammation and cartilage damage in OA. Another experimental OA study
found that local CCL2/CCR2 signaling in the joint caused knee hyperalgesia through
the direct stimulation of intra-articular CCR2 positive sensory nerves [67]. In the study,
the intra-articular injection of recombinant CCL2 directly excited sensory afferents and
caused knee hyperalgesia in wild-type mice, while the administration of a CCL2 receptor
Int. J. Mol. Sci. 2022, 23, 4642 7 of 22

antagonist alleviated established hyperalgesia. Moreover, sensory neurons in the L4-DRG

were excited by in vivo calcium imaging observed in DRG; the coexpression of CCR2 and
sensory nerve markers such as PGP9.5 and CGRP was also found. These results suggest
that CCL2/CCR2 signaling contributes to OA pain not only through recruiting monocytes
or macrophages to the local joint and DRG, but also through the direct activation of sensory
afferents. Targeting CCL2/CCR2 signaling may be a promising therapeutic approach for
OA treatment.

4.4. TNF-α and IL-1β

Inflammation is involved in the initiation and development of OA [36,68]. Chronic
and low-grade inflammation is distinct from that in prototypical inflammatory arthritis–
rheumatoid arthritis. It affects the whole joint, resulting in joint pain, synovial hypertrophy,
synovitis, the inflammation of the infrapatellar fat pad, accelerated cartilage loss, and
osteophyte formation [13,69]. Varieties of proinflammatory cytokines, such as TNF-α,
IL-1β and IL-6, are produced and primarily mediated by innate immune cells and, to a
lesser degree, adaptive immune cells [70,71].
TNF-α and IL-1β are the most extensively studied proinflammatory cytokines in-
volved in the pathophysiology of OA. Despite encouraging results from animal studies,
anticytokine therapies in clinical trials have not achieved satisfactory pain relief in OA pa-
tients, revealing unclear mechanisms by which TNF-α and IL-1β mediate OA pain [72,73].
A study reported that concentrations of IL-1β in synovial fluid were inversely associated
with knee pain; TNF-α was correlated with total WOMAC pain, and especially with pain
during movement and at rest [68]. Li et al. found that the scores of the numeric rating scale
were negatively correlated with levels of TNF-α, and the scores of visual analog scales were
negatively correlated with the expression levels of IL-1β, IL-6, and TNF-α in the synovial
fluid. They highlighted the importance of anti-inflammation therapy in the early stage of
OA, when the expression of IL-1β, IL-6, and TNF-α is high [74]. TNF-α might be mainly
responsible for both inflammatory pain and bone pathology. In addition to driving the
chronic inflammation of the joint via NF-κB, TNF-α plays important roles in activating
macrophages, and stimulating osteoclast proliferation and differentiation, which are closely
related to OA pain. A previous study also showed that, in a monosodium iodoacetate
(MIA)-induced mouse model of OA pain, both TNF-α and IL-6 expression increased in
synovial tissue and joint capsules between Days 1 and 28, with the peak at Day 4 [75]. A
single injection of TNF in the knee induced the persistent dose-dependent sensitization
of peripheral sensory neurons, which was detected by mechanical allodynia; this effect
was reversed by the simultaneous administration of etanercept or a COX inhibitor [76,77].
TNF-α is thus a promising therapeutic target with unknown underlying mechanisms for
OA pain.
IL-1β is the other important proinflammatory cytokine involved in the chronic and low-
grade inflammation in OA pathophysiology [35]. Many studies demonstrated that IL-1β
is a critical cytokine upregulating catabolic and inflammatory pathways during cartilage
and bone homeostasis by increasing the production of matrix-degradative enzymes in
chondrocytes and promoting osteoclast differentiation [78]. Moreover, IL-1β increased
expression of NGF which mediated pain genesis [79,80]. Inhibiting IL-1β and its interaction
with cell surface receptors (IL-1LR) was proposed and investigated for the treatment of OA.

4.5. NLRP3 Inflammasome

The NLRP3 inflammasome is a member of innate immune system receptors and an
important molecule involved in the regulation of active IL-1β. Its activation requires two
phases [81]. In the priming phase, the expression of inactive NLRP3 and pro-IL-1β mRNA
is increased via nuclear factor kappa B (NF-κB)-mediated transcriptional regulation. In the
second phase, the assembly of the inflammasome is triggered resulting in the activation of
caspase 1 and release of IL-1β and IL-18 [82]. Our previous study showed that the activation
of inflammasomes results in the cleavage of caspase-1, which subsequently processes pro-
Int. J. Mol. Sci. 2022, 23, 4642 8 of 22

IL-1β, and promotes the maturation and release of IL-1β, ultimately producing many
proinflammatory cytokines such as IL-1β and TNF-α, and degradative enzymes, including
MMP13 and Adamts5, which drive synovial inflammation and cartilage degradation [83].
Growing evidence demonstrates that the NLRP3 inflammasome is dysregulated during OA
development and contributes to the generation of chronic pain. In a rat model of painful
neuropathy, NLRP3 expression increased in the DRG, and the intrathecal injection of NLRP3
siRNA markedly prevented mechanical allodynia. In naive rats, the intrathecal injection
of AAV-expressing NLRP3 could markedly decrease the paw withdrawal threshold [84].
Another study found the spinal microglia, and NLRP3 formation and activation contribute
to opioid-prolonged neuropathic pain [85]. Cheng et al. found that dexmedetomidine
improved pain symptoms and the cartilage lesions of papain-induced OA in rats through
the inhibition of the NF-κB pathway and NLRP3 inflammasome [86]. Therefore, targeting
inflammasome activity may be a novel and effective therapeutic strategy for OA pain.

4.6. Wnt/β-Catenin
Wnt/β-catenin signaling pathway is required for embryonic joint formation and adult
bone homeostasis balance. Studies showed increased β-catenin expression in OA cartilage,
and the overexpression of β-catenin in chondrocytes induces upregulated expression of
matrix-degrading enzymes [87]. In addition, the hyperactivation of the Wnt/β-catenin sig-
naling pathway induces a rapid increase in the production of matrix metalloproteinases and
Adamts, leading to proteoglycan degradation [88]. We previously established
β-catenin(Ex3)Col2CreER mice in which β-catenin degradation was selectively inhibited,
resulting in β-catenin accumulation in articular chondrocytes, and these conditional-
activation mice eventually led to OA-like phenotypes, such as the progressive destruction
of articular cartilage and osteophyte formation [89]. These studies demonstrated that
Wnt/β-catenin plays a vital role in the pathogenesis of OA, and inhibiting β-catenin may
be a novel approach to modify OA pathology.
Wnt proteins are mainly expressed in mature neurons, and Wnt signaling plays a vital
role in the pathophysiology of the nervous system, such as neurogenesis, neuroinflamma-
tion, and neurodegeneration [90–93]. The dysregulation of Wnt signaling is implicated
in central nervous system injury, neurodegenerative diseases, and chronic pain. Accu-
mulating evidence showed Wnt signaling disorder in DRG, the dorsal horn of the spinal
cord, and sciatic nerves in rodent models mimicking chronic pain, which were reviewed by
Zhou et al. [94]. Wnt3a and Wnt5a, two Wnt ligands that activate the canonical and atypical
pathways, respectively, were markedly upregulated in the DRG and the dorsal horn of the
spinal cord in different models of chronic pain, including inflammatory and neuropathic
pain [95,96]. The administration of small-molecule drugs of Wnt agonists and ligands such
as Wnt1 and Wnt5a induced mechanical allodynia in wild-type mice, which is abolished by
Wnt inhibitors [96,97]. Studies demonstrated that blocking Wnt signaling pathways using
NSC668036 (disheveled inhibitor), iCRT14, and XAV-939 (β-catenin inhibitor) reverses
pain and pain-associated behaviors in different models of chronic pain [98,99]. More-
over, multiple studies suggest that the aberrant activation of Wnt signaling causes chronic
pain through the increased expression of proinflammatory cytokines and chemokines,
and enhances the activation of macrophages in the DRG, microglia, and astrocyte within
the spinal-cord or brain regions, ultimately resulting in neuroinflammation and sensitiza-
tion [95,100–106]. A study by Zhang et al. demonstrated that XAV-939 increased mechanical
withdrawal thresholds through the downregulation of serum TNF-α and IL-18 in a rat
DRG compression model [101]. Other studies found that XAV-939 decreased IL-1β in DRG
in a rat neuropathic pain model [98]. Wnt inhibitors reduced CCL2 expression in the DRG
of a rat neuropathic pain model, which plays a crucial role in macrophage migration and
infiltration [98]. These findings indicate a neuroimmune regulatory role of Wnt signaling in
the generation of chronic pain. Taken together, this evidence demonstrates that the aberrant
upregulation of Wnt signaling contributes to chronic pain, and Wnt signaling could be a
novel and promising target for chronic pain, including OA pain.
Int. J. Mol. Sci. 2022, 23, 4642 9 of 22

The Wnt/β-catenin pathway plays a critical role in the pathogenesis of both joint
structure and chronic pain. Thus, targeting this pathway may represent a safe therapeu-
tic intervention in relieving OA pain, reducing bone, cartilage, and synovial pathology.
Regarding the limited understanding of Wnt signaling in the molecular mechanisms of
OA pain, further studies may focus on how Wnt/β-catenin signaling regulates inflamma-
tory cytokines and chemokines, and the crosstalk of Wnt/β-catenin signaling with the
immune system.

5. Common Animal Models for OA Pain Research

Preclinical experimental OA models are important tools for exploring the pathogenesis
of OA pain, and to evaluate the effects of targeted therapeutic interventions. Although
several models, such as surgically, chemically, and genetically induced, spontaneous, and
mechanical loading-induced OA models were developed for OA studies, only a few can
definitely generate pain behaviors, and be utilized for studying the mechanism of OA
pain [33,52,107]. Among them, the chemical MIA-induced OA and surgical models are
the most popular. Miller et al. reviewed published papers about OA pain animal models
and found that the MIA and surgical models accounted for 54% and 33% since 2008,
respectively [108]. The MIA model was first recorded to induced an OA-like phenotype
in 1987, and OA-related pain behaviors were known until 2003. This model induces a
rapid, reproducible, robust painlike phenotype, and extensive joint pathology, which raises
questions over its relevance to human OA [109]. The intra-articular injection of MIA leads to
chondrocyte death through the inhibition of glyceraldehyde-3-phosphatase and disrupting
cellular glycolysis, resulting in cartilage degeneration and bone destruction, which mimics
certain aspects of OA pathology [110,111]. Comparison of the most commonly used animal
models for OA pain were seen in Table 1.

Table 1. Comparison of the most commonly used animal models for OA pain.

Mechanism of
Model Species Procedure Disease Onset Advantages Disadvantages References
Model
Disrupt chondrocyte Rapid, reproducible,
glycolysis via robust pain-like Extensive and rapidly
Intra-articular inhibiting behaviour and developing pathology
MIA Rat, mouse 1 week [109–112]
injection of MIA glyceraldehyde-3- peripheral/central does not mimic
phosphatase sensitization partially human OA.
dehydrogenase characterized.
Severe OA and
Surgical subchondral bone
Transection Technically difficult
ACLT Dog, Rat destabilization of 2–3 weeks destruction, though [113–115]
of ACL and time consuming.
the knee less rapidly than
MIA model.
Modest OA, less
Transection of rapidly than ACLT
Surgical
medial and MIA model. Less difficult [107,112,116,
DMM Mouse destabilization of 4–8 weeks
menisco-tibial DMM model than ACLT 117]
the knee
ligament amenable to
genetic manipulation.
Abbreviation: Monosodium iodoacetate, MIA; Transection of the anterior cruciate ligament, ACLT; Destabilization
of medial meniscus, DMM.
Int. J. Mol. Sci. 2022, 23, 4642 10 of 22

The surgical destabilization of animal knees is performed to mimic mechanical-

instability-induced human OA. This slowly progressive model is generally considered
to be more ideal than the MIA model for exploring OA pathogenesis in early stages and
during pharmacological intervention. The most commonly used surgical techniques are the
transection of the anterior cruciate ligament (ACLT) and medial meniscal destabilization
(DMM) [112]. The anterior cruciate ligament originates from the posterolateral wall of
the femoral condyle, and enters the center of tibial plateau, which restricts the tibia from
moving forward [113]. The ACLT-induced OA is a little more aggressive and severe than
DMM. A previous study from Glasson et al. reported that ACLT is not recommended as a
mouse model of OA, and that this procedure could develop severe OA and subchondral
bone destruction [112,114]. DMM surgery is performed to induce OA by transecting the
medial meniscotibial knee ligament causing joint destabilization in mice. This procedure is
relatively easier to operate than ACLT and leads to OA-like phenotypes, such as the slowly
progressive loss of articular cartilage, osteophyte formation, and synovitis, which is similar
to those seen in sport injuries and aging-related OA [107,116,118]. Therefore, the DMM
model is an important tool to investigate OA-associated mechanisms, pain, and therapies.
There is evidence showing that joint destabilization results in an acute, transient pain phase
associated with postoperative trauma and a later chronic OA pain phase [119]. In our lab,
we characterized the pain pattern in a DMM-induced OA model, and found increased pain
sensitivity and decreased spontaneous activity in mice after DMM surgery [117]. Recently,
a study compared sensory innervation in the three models of rats above and found that the
DMM and MIA models showed typical changes in mechanical hyperalgesia and cold hy-
peralgesia at Day 14 [115]. They also found that increased Netrin1, NGF, CGRP, and TRPV1
expression was observed in the DMM synovium at Day 14, and in the ACLT synovium at
Day 28 compared with in MIA. CGRP and NGF expression in DRG was the highest in the
DMM model. This study indicated that surgical modeling may be more useful for KOA
pain research.

6. Emerging Preclinical Drugs Targeting OA Pain

Emerging pharmacological therapies in clinical trials with primary outcome measures
of OA pain are summarized in Table 2.
Int. J. Mol. Sci. 2022, 23, 4642 11 of 22

Table 2. Summary of new pharmacological therapies for OA pain in clinical trials.

Route of ClinicalTrials.gov Affected

Type of Drug Drug Name Clinical Phase and Status Primary Measures or Results References
Administration Identifier OA Joint
CGRP antibody Galcanezumab S.C. NCT02192190 Phase 2, completed knee No improvement in WOMAC pain [60]
IL-1 receptor antagonist Anakinra I.A. NCT00110916 Phase 2, completed Knee No improvements on OA symptoms [72]
TNFα antibody Adalimumab S.C. NCT00686439 Phase 2, completed knee Improvement in WOMAC pain. [73]
Reduction in joint pain and
NGF inhibitor Tanezumab I.V. NCT00394563 Phase 2, completed Knee [120]
improvement in function
NCT02709486, Improvement in pain within the first
NGF inhibitor Fasinumab S.C. NCT02528188, Phase 3, completed Knee, hip week, and pain and function were [121–123]
NCT02697773 improved throughout 24 weeks
Improvements in OA pain
S.C. NCT02447276 Phase 3, completed Knee, hip [124]
and function
NCT02683239,
S.C. NCT03161093, Phase 3, completed Knee, hip WOMAC pain subscale score
NCT03304379
NCT00863304, Improvement of pain, physical
Tanezumab I.V. NCT00830063, Phase 3, completed Knee, hip function, and patient global [125,126]
NCT00744471 assessment of OA
TrkA inhibitor ASP7962 P.O. NCT02611466 Phase 2, completed Knee No improvement in WOMAC pain [127]
GZ389988A I.A. NCT02845271 Phase 2, completed Knee Improvement in WOMAC pain [128]
No improvements on symptoms or
TNFα antibody Adalimumab S.C. ACTRN12612000791831 Phase 2, completed Hand [129]
bone marrow lesions
S.C. NCT00597623 Phase 3, completed Hand No improvement in WOMAC pain [130]
CCR2 antagonist CNTX-6970 P.O. NCT05025787 Phase 2, recruiting Knee WOMAC pain
NGF/TNF-α
MEDI7352 P.O. NCT04675034 Phase 2b, recruiting Knee NRS
bispecific antibody
IL-1α/β antibody Lutikizumab S.C. NCT02384538 Phase 2, completed Hand No improvement in pain score [131]
IL-1R1 antibody AMG 108 I.V. NCT00110942 Phase 2, completed Knee Minimal clinical benefit [132]
IL-1α/β antibody Lutikizumab S.C. NCT02087904 Phase 2, completed Knee No improvement in WOMAC pain [133]
NLRP3 inhibitor DVF890 P.O. NCT04886258 Phase 2a, recruiting Knee KOOS pain sub-scale
Int. J. Mol. Sci. 2022, 23, 4642 12 of 22

Table 2. Cont.

Route of ClinicalTrials.gov Affected

Type of Drug Drug Name Clinical Phase and Status Primary Measures or Results References
Administration Identifier OA Joint
Lorecivivint NCT04385303 Phase 3, active, not
Wnt inhibitor I.A. Knee Improvement in NRS Pain [134]
(SM04690) (NCT03928184 *) recruiting
NCT03660943,
TRPV1 inhibitor CNTX-4975 I.A. Phase 3, completed Knee WOMAC
NCT03661996
NE06860 P.O. NCT02712957 Phase 2, completed Knee NRS
TRPA1 antagonist LY3526318 P.O. NCT05080660 Phase 2, recruiting Knee NRS and WOMAC pain
SCN9A # antisense drug OLP1002 S.C. NCT05216341 Phase 2, recruiting Knee, hip WOMAC and VAS
Central analgesic Cannabinoid P.O. NCT04992962 Phase 2, recruiting Knee NRS and KOOS
Tubulin inhibitor Colchicine P.O. NCT03913442 Phase 4, recruiting Knee VAS pain scores
Aryl hydrocarbon
Resvertrol P.O. NCT02905799 Phase 3, recruiting Knee NRS
receptor antagonist
Peroxynitrite decomposer ACP044 P.O. NCT05008835 Phase 2, recruiting Knee NRS

* Terminated due to business reasons by Sponsor; # SCN9A gene encoding Nav1.7sodium ion channel; Abbreviation: Subcutaneous injection, S.C.; Intravenous injection, I.V.; Oral
administration, P.O.; Intra-articular injection, I.A.; Numeric rating scale, NRS; Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC; Visual analogue scale, VAS;
Knee injury and osteoarthritis outcome score, KOOS.
Int. J. Mol. Sci. 2022, 23, 4642 13 of 22

6.1. Nerve Growth Factor Inhibitor

NGF/TrkA signaling once received great attention as a promising target for treating
OA chronic pain since good results of pain reduction were reported in subjects with
moderate-to-severe knee OA [120]. However, due to adverse events including rapidly
progressive joint damage in patients receiving a treatment of anti-NGF antibodies, clinical
trials of anti-NGF antibodies were suspended by the Food and Drug Administration (FDA)
in US [135]. Phase 3 clinical trials of anti-NGF antibodies were resumed from 2015. Results
of randomized and placebo-controlled Phase 3 trials of tanezumab and fasinumab were
published in 2019, and further confirmed the efficacy of these two anti-NGF antibodies in
relieving pain and improving joint function over 16 weeks in treating severe hip or knee
OA (NCT02709486, NCT02528188, NCT02697773, NCT02447276) [121–124]. In Phase 3
trials of intravenous tanezumab versus oral NSAIDs for the treatment of knee or hip OA,
tanezumab reduced pain, and improved function and global scores, especially in patients
of poor analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) (NCT00863304,
NCT00830063, NCT00744471) [125,126]. However, both drugs increased the risk of rapidly
progressive joint damage leading to total joint replacement compared to the placebo group.
NGF inhibitors could effectively relieve pain symptoms in OA patients, but their safety
should be carefully evaluated. How exactly blocking NGF leads to rapid OA progression
needs to be carefully investigated. Despite rapidly progressive joint damage occurring in
knee OA trials, treatment with an NGF inhibitor showed positive results in lower back
pain. The results of a Phase 3 trial demonstrated that fasinumab significantly improved
lower back pain with progressive OA, observed in only few accompanied peripheral OA
cases (NCT02620020) [127]. Blocking TrkA is the other strategy to inhibit NGF/TrkA
signaling, probably with fewer adverse effects. The oral administration of ASP7962, a
TrkA inhibitor did not reduce OA pain compared with naproxen in a Phase 2a clinical trial
(NCT02611466) [128], However, the intra-articular injection of TrkA inhibitor GZ389988A
greatly improved WOMAC pain and overall knee pain (NCT02845271) [136].

6.2. TNF Antibody

Erosive hand OA is the most aggressive subtype of OA, predominantly affecting
women, and characterized by the articular inflammation and radiologically central erosion
of the joint [137]. In patients with erosive hand OA, 40 mg subcutaneous injections of adali-
mumab showed no effect on pain, synovitis, or bone-marrow lesions with MRI-detected
synovitis in comparison with a placebo after 12 weeks (ACTRN12612000791831) [129]. The
result of a multicenter, randomized controlled trial (RCT) demonstrated that adalimumab
administration was not superior to NSAIDs in decreasing pain scores in patients with
hand OA (NCT00597623) [130]. Despite negative results in this nonweight-bearing small
joint, positive effects of adalimumab were found in knee OA. In 2012, Maksymowych et al.
reported that adalimumab significantly improved mean WOMAC pain and target joint
swelling at 12 weeks in patients with knee OA (NCT00686439) [73]. An open-label RCT
study evaluated adalimumab versus hyaluronic acid (HA) in patients with moderate-to-
severe knee OA. Enrolled patients received an intra-articular injection of 10 mg adalimumab
or 25 mg HA, followed by oral 200 mg/day celecoxib for 4 weeks. Pain decrease in VAS and
WOMAC scores from Week 1 to 4 was markedly greater in the adalimumab than that in the
HA group [138]. A Phase 2 double-blind RCT of subcutaneous injections of adalimumab
compared to placebo in knee OA with clinical features of inflammation and persistent pain
has just been completed (NCT02471118). The results should come out soon.
MEDI7352 is a monoclonal antibody specifically binding to NGF and TNF-α, thus
blocking their effects. A Phase 1 clinical trial of MEDI7352 in patients with painful knee
OA after subcutaneous or intravenous injection of single or multiple ascending doses was
completed last year (NCT02508155). A Phase 2b RCT to evaluate the efficacy and safety of
MEDI7362 in subjects with painful knee OA is ongoing (NCT04675034).
Int. J. Mol. Sci. 2022, 23, 4642 14 of 22

6.3. IL-1β Antibody

Two teams reported that IL1 receptor antagonist anakinra decreased VAS pain and
global handicap in patients with severe erosive hand OA who had failed conventional
treatment [139,140]. However, in a Phase 2a RCT, treatment with lutikizumab, a dual
variable domain immunoglobulin neutralizing both IL-1α and IL-1β, failed to improve
joint pain and function, and structural destruction in patients with erosive hand OA
(NCT02384538) [131]. Chevalier et al. found that a single intra-articular injection of 50 mg
or 150 mg anakinra in OA knee (NCT00110916) could not improve OA symptoms [72].
Results of a clinical trial using systemically administered AMG 108, an anti-IL-1R1 human
IgG2 monoclonal antibody, demonstrated statistically insignificant improvement in the
WOMAC pain scores of knee OA patients (NCT00110942) [132]. New strategies through
gene therapy for IL-1Ra were developed for OA treatment. This approach leads to the
sustained release of cytokines in local joints. The safety of a single intra-articular injection
of recombinant adenoassociated virus carrying IL-1Ra was evaluated in patients with
moderate knee OA in a Phase I clinical trial (NCT02790723). In addition to positive results
in hand OA, treatment with lukitizumab (ABT-981) seemed to achieve good results in knee
OA. Two Phase 1 studies demonstrated that treatment with lukitizumab was well-tolerated
and reduced inflammation biomarkers in patients with mild-to-moderate knee OA (NCT
01668511) [141,142]. In a Phase 2 trial, lukitizumab markedly reduced WOMAC pain
at Week 16 in patients with knee OA (NCT02087904) [133]. Recently, the Canakinumab
Anti-inflammatory Thrombosis Outcomes Study (CANTOS) found that IL-1β inhibition
with canakinumab had lower incidence rates of total joint replacement compared with the
placebo group (NCT01327846) [143].

6.4. Wnt Inhibitor

A Phase 1 clinical trial reported that the intra-articular injection of novel Wnt signaling
pathway inhibitor lorecivivint (SM04690) significantly alleviated the pain and improved
the knee function of patients with OA (NCT04385303) [134]. Although the Phase 2a trial
failed to meet the given primary endpoint, the administration of SM04690 was tested to be
safe and well-tolerated, and the optimal effective dose of SM04690 was then identified by
its Phase 2b trial [144,145]. Except for suppressing Wnt signaling, lorecivivint exhibited
anti-inflammatory and chondroprotective activities in OA preclinical studies that seemed
to be independent of β-catenin. Instead, they may have been mediated by the blockage of
two important kinases, CLK2 and DYRK1A.

6.5. NLRP3 Inhibitor

IFM-2427 (DFV890) completed Phase 1 clinical trials in COVID-19 patients with pneu-
monia. Phase 2 clinical trials in COVID-19 patients with pneumonia are complete, but no
results have been released yet. A Phase 2a proof-of-concept clinical trial is proceeding to
determine the efficacy of oral administration of DFV890 vs. placebo in OA patients for
relieving knee pain (NCT04886258). Dapansutrile™ (OLT1177™) is a new generation of
oral NLRP3 inhibitor exhibiting great safety and good efficacy in acute gout treatment [146].
It has no effect on the priming phase of the NLRP3 inflammasome formation and on TNF-α
expression. Despite no results having been achieved from topically applied OLT1177 gel
in treating moderate-to-severe OA pain, OLT1177™ deserves further investigation on OA
pain (NCT02104050).

6.6. Ion Channels Modulator

TRPV1 is a ligand-gated, voltage-gated, and nonselective cation channel that is abun-
dantly expressed by sensory neurons. On the basis of their excellent pain control effects
in vitro, TRPV1 modulators are attractive drugs that are undergoing clinical investigation
for the treatment of OA pain. In 2018, CNTX-4975, a novel TRPV1 agonist, was granted
fast-track designation for OA pain treatment by the US FDA. In a Phase 2 multicenter
double-blind study, CNTX-4975 treatment achieved dose-dependent improvement in knee
Int. J. Mol. Sci. 2022, 23, 4642 15 of 22

OA pain until 24 weeks after patients had received a single intra-articular injection of 0.5 mg
CNTX-4975 or 1.0 mg CNTX-4975 or placebo [147]. To further evaluate the efficacy and
safety of TRPV1 agonists and antagonists for OA pain treatment, larger trials are required,
and the longer-term effects of these drugs need to be evaluated.
TRPA1 is a membrane-associated cationic channel that is widely expressed in neurons,
and it mediates neurogenic and inflammatory pain to act as a sensor for toxic stimuli
induced by exogenous compounds [148]. The abnormal activation of TRPA1 is closely
associated with neuropathic pain, and TRPA1 inhibitors or gene deletions reduce painful
behavior in OA mice [149]. A Phase 2 study to evaluate the safety or efficacy of LY3526318,
a TRPA1 antagonist, in patients with knee OA pain is currently ongoing (NCT05080660).

7. Conclusions
OA pain involves complex peripheral and central mechanisms. Nerve sensitizations
are major characteristics for pain transmission in OA patients that may contribute to the
discordance between pain and joint pathology. NGF inhibitors reduce OA pain, but their
safety should be carefully evaluated, and mechanisms underlying rapid OA progression
should be further explored. Bidirectional interactions between the immune and nervous
systems are recognized to be a major pathological mechanism of chronic pain. Neural
CCL2/CCR2 signaling contributes to OA pain through recruiting both monocytes and
macrophages to local joints, DRG, and the spinal cord, which represent new molecular neu-
roimmune regulatory mechanisms for the generation and maintenance of OA chronic pain.
Despite the disappointing results from human trials, CGRP should be further investigated
with subgroups of females and a higher expression of CGRP in serum or joint fluid. TNF-α
is greatly involved in inflammatory and immune pathways, and bone pathology. TNF
receptors include TNF receptor 1 (TNFR1) and TNFR2. These two receptors have distinct
tissue localization and functions. TNFR1 is expressed ubiquitously in most cell types and
functions primarily in mediating proinflammatory responses; TNFR2 is mainly expressed
in immune, neuronal, and endothelial cells, and functions as an anti-inflammation and im-
munoregulatory factor. New drugs specifically targeting TNF receptors may be developed
with safer and more effective properties. These urge us to better understand the exact role
of TNF receptors in the pathogenesis of OA and pain. The NLRP3 inflammasome pathway
plays an important role in the generation of OA pain. The activation of the NLRP3 inflam-
masome in chronic pain may occur more frequently in DRG and the spinal cord. Current
knowledge about the role of Wnt signaling in OA is limited, and further studies may focus
on how Wnt/β-catenin signaling regulates inflammatory cytokines and chemokines in the
DRG and dorsal horn of the spinal cord, and the brain, and the crosstalk of Wnt/β-catenin
signaling with immune system. Unravelling how these multifactorial components and
their interactions function in the generation and maintenance of OA pain could provide
novel insights into developing more specific and effective drugs for OA pain management.

Author Contributions: Conceptualization, D.C.; manuscript preparation, H.Y.; manuscript revi-

sion, D.C., L.T., W.W.L., and T.H. All authors have read and agreed to the published version of
the manuscript.
Funding: This project was supported by the National Natural Science Foundation of China (NSFC;
grants 82030067, 82161160342, and 82172397) to D.C and L.T., and a grant from the Youth Innovation
Promotion Association of Chinese Academy of Sciences (2020353) to L.T. This work was also sup-
ported by the National Key Research and Development Program of China (2021YFB3800800) to L.T.
and D.C., and by a grant from the Research Grants Council (RGC), HK (RGC 17101821) to W.W.L.
and D.C.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Mol. Sci. 2022, 23, 4642 16 of 22

Abbreviations
Osteoarthritis, OA; nerve growth factor, NGF; tropomyosin receptor kinase A, TrkA;
calcitonin gene-related peptide, CGRP; C–C motif chemokine ligands 2, CCL2; chemokine
receptor 2, CCR2; tumor necrosis factor alpha, TNF-α; interleukin-1beta, IL-1β; the NOD-
like receptor family, pyrin domain–containing protein 3, NLRP3; transient receptor po-
tential vanilloid subfamily member 1,TRPV1; transient receptor potential melastatin 3,
TRPM3; transient receptor potential ankyrin 1, TRPA1; dorsal root ganglion, DRG; sub-
stance P, SP; destabilization of medial meniscus, DMM; monosodium iodoacetate, MIA;
transection of the anterior cruciate ligament, ACLT; the Food and Drug Administration
(FDA); nonsteroidal anti-inflammatory drugs, NSAIDs; randomized controlled trial, RCT;
Numeric rating scale, NRS; Western Ontario and McMaster Universities Osteoarthritis
Index, WOMAC.

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