In patients with knee osteoarthritis and low vitamin D levels, monthly treatment with oral vitamin D3 (50,000 IU; n = 209) or placebo (n = 204) for 2 years did not lead to significant between-group differences in MRI-measured cartilage volume loss or knee pain score. The results do not support the use of vitamin D3 supplementation to prevent pain or cartilage loss in knee OA.