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Two 2013 systematic reviews of interventions concluded that the modest benefit of propionyl-L-carnitine on walking performance was equivalent or superior to that obtained with drugs approved for claudication in the US (e.g., pentoxyphylline, cilostazol) yet inferior to improvements seen with supervised exercise interventions (69, 70)

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For instance, elevated 4-HNE in synovial fluid has been reported in multiple studies, but significant variations in detection methods and patient stratification such as disease stage and inflammation degree between studies mean the strength of evidence for 4-HNE as a driver of OA inflammation amplification still requires cautious interpretation