Are Cortisone Injections Good Or Bad For Arthritic Knees
TUESDAY, Dec. 21, 2021 — Cortisone injections have gotten a bad rap in recent years as a treatment for arthritis pain, because steroids are known to damage cartilage and could potentially cause the joint to further deteriorate.
Occasional cortisone shots don’t appear to cause knees to deteriorate any faster than injections of hyaluronic acid, a substance injected to lubricate joints stiffened by arthritis, the researchers said.
“Knee replacement rates were, if anything, a little bit less in the group that got the cortisone injections,” said senior researcher Dr. David Felson, a professor of medicine and epidemiology at Boston University School of Medicine.
However, Felson added that the study only looked at people who’d gotten infrequent cortisone shots to their knee, and shouldn’t be interpreted as giving the green light to regular injections for years to come.
“What we know from the study that we can trust is that a few cortisone injections won’t really cause much trouble,” Felson said. “It’s conceivable that repeated injections every three months for years won’t cause any trouble, but you can’t say that.”
“If you use it enough, it will damage the cartilage,” said Leber, who had no role in the study.
Comparing two types of shots
Unlike cortisone, hyaluronic acid gel isn’t harmful to cartilage.
Wise use is crucial
What Is Hyaluronic Acid And What Does It Do
Hyaluronic acid, also known as hyaluronan, is a gel-like substance naturally present in the synovial fluid that lubricates your joints. Because arthritis patients lose hyaluronic acid as their joint wears away, the theory goes that replacing it with a process called viscosupplementation would make using the joint less painful. The injections are FDA-approved for knee osteoarthritis.
Its mechanism of action is not fully known, but is thought to at least temporarily increase the viscosity, or thickness, of the fluid that surrounds the joint it is injected into, says Donald Miller, PharmD, a professor at the School of Pharmacy at North Dakota State University. This may reduce pain and make joint movement easier.
You can think of it like WD-40 for your joints.
The Cortisone Debate Goes On
A December 2020 study published in the medical journal Rheumatology gives this overview assessment of the debate surrounding the use of cortisone for a bone on bone knee. Here are the summary learning points:
- Existing data indicate that intra-articular corticosteroids in knee osteoarthritis provide short-term pain relief and functional improvement which may last from one to several weeks.
- At present, synovitis is the most important predictor of treatment response, and also a target for anti-inflammatory treatment for intra-articular corticosteroids.
- Our explanatory note: If you have a lot of knee swelling cortisone maybe be of benefit. Please see our article treating chronic knee swelling.
Returning to the research study:
- subgroup of patients with the inflammatory phenotype with clinical features of pain, stiffness, joint swelling, and effusion are expected to be more responsive than other phenotypes who do not display clinical manifestations of inflammation.
- Our explanatory note: If you do not have chronic knee swelling, cortisone may not be an answer for you.
Returning to the research study: In some people swelling comes and goes, it is hard to suggest who cortisone would be successful for among these people.
Returning to the research study: The more suitable cortisone patient is:
The evidence then was a summary of the effects of cortisone on articular cartilage which included:
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Study Supports Hyaluronic Acid Shots For Knee Osteoarthritis In Certain Patients
For some people with knee osteoarthritis , hyaluronic acid injections can relieve pain and improve function sometimes dramatically. During the procedure, hyaluronic acid a substance similar to the naturally occurring gel-like lubricant that is found in the synovial fluid surrounding joints is injected into the knee. Because people with OA have a lower than normal concentration of hyaluronic acid in their joints, the theory is that adding the lubricant to the arthritic joint will reduce pain and help with movement.
The researchers found that HA shots were least likely to work for patients who were overweight or obese, had more severe arthritis , were older than 65, and/or had had HA or corticosteroid shots in the past. The factors most strongly associated with a lack of response were being overweight or obese and having more severe arthritis. And the more factors a patient had, the less likely it was that HA shots would help: 100 percent of patients who had none of the factors experienced improvements in pain and function compared to 69 percent of patients who had any two factors and 28.6 percent of patients with all four factors.
A Gentle Gel Cushion To Pad Your Knee
Depending on the course of treatment thats right for your unique health care needs, we deliver from one to five injections of gel-like fluid to your affected knee joint over the course of several weeks. We use a local numbing agent to keep you from experiencing too much discomfort during treatment. You may begin to notice improvement several weeks after treatment, and positive results can last for multiple months. If this treatment works for you, we advise a further course of treatment after about six months to maintain your pain-free joints. This procedure is covered by most major health insurance plans.
You may experience some mild initial side effects after an injection, including pain, elevated temperature, and some slight swelling. You may also see a flare-up of your arthritis symptoms immediately following treatment. For the first 48 hours after treatment, avoid too much weight-bearing stress on the treated knee. Try not to stand for too long, lift anything too heavy, or go jogging for a few days. If you notice symptoms of an allergic reaction or infection, contact our office right away.
To find out if viscosupplementation could be the right treatment to resolve your knee pain, schedule an initial consultation appointment with Dr. Badiyan today. He can advise you on the best intervention for your knee, joint, and arthritis-related pain. Book your appointment over the phone, or by using the online tool.
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Reverse Injection: Fluid Aspiration
Fluid aspiration from a joint, called arthrocentesis, is the process of inserting a needle into a joint to remove excess fluid. The knee is the most frequently aspirated joint.
Joint inflammation and swelling that occur due to osteoarthritis can produce excess synovial fluid within the knee, restricting movement and causing increased pain. Removing the fluid by aspirating the joint with a needle can help reduce pain and improve swelling.
- Your healthcare provider may use a local numbing agent, such as lidocaine, either topically around the knee or by injecting it within the knee joint.
- A needle is inserted into the knee joint at either side of the patella, and a syringe is used to pull fluid out of the knee.
- Fluid aspiration may be performed by itself or prior to receiving another type of injection, and generally takes 30 minutes or less to complete.
- The numbing agent will typically wear off after two to four hours. It is common to have some pain or soreness for one to two days after the procedure.
Pain relief from fluid aspiration can last for six months or more.
While arthrocentesis is often performed for diagnosis and prior to joint injection, it is not typically used on its own for therapeutic purposes, as it does not fix the underlying issue that caused the joint effusion .
How Does Prolotherapy Work In Your Knees
In this section, we will discuss Prolotherapy knee osteoarthritis injections. Prolotherapy is a remarkable treatment in its simplicity. The treatment can help many patients avoid joint replacement. But it is not a miracle cure. The research and evidence for how Prolotherapy may help you are presented here and intermingled with our own 27+ years of empirical observation of patient benefit.
In 2016, our Caring Medical research team published our study, A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain in the journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. In this review, we examined the research in the use of dextrose Prolotherapy for the treatment of tendinopathies, knee and finger joint osteoarthritis, and spinal/pelvic pain due to ligament dysfunction. In our section on knee pain, we referred to a study by Dr. Fariba Eslamian and Dr. Bahman Amouzandeh of Tabriz University of Medical Sciences. This is what they published in the journal Therapeutic Advances in Musculoskeletal Disease.
Prolotherapy has been reported as a useful method in the treatment of chronic musculoskeletal and joint diseases. It is proposed that Prolotherapy causes mild inflammation and cell stress in the weakened ligament or tendon area, releases cytokines and growth factors, and induces a new healing cascade in that area, which leads to activation of fibroblasts, generation of collagen precursors, and strengthening of the connective tissue.
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Is It Worth Getting Hyaluronic Acid Shots To Delay A Knee Replacement Should You Just Get The Surgery
Hyaluronic acid injections are often a last-ditch effort before knee replacement surgery. It bought me a year before replacements, Cathy Anderson Eberhardt told us on Facebook. But because the shots dont actually appear to affect the disease progression, some medical professionals think they just put off the inevitable, and only serve to tack on additional health care costs. For some people it can delay surgery or can avoid it altogether, but hyaluronans will generally not avoid eventual surgery in badly affected knees, Dr. Miller says. But, they will be helpful in patients not quite mentally ready for surgery.
Repeated Courses Of Treatment With Hyaluronic Acid Are Safe And Are Associated With The Delay Of Total Knee Replacement For Up To 3 Years
A July 2018 study in the American Journal of Orthopedics recognized that for some people: Total knee replacement is a significant procedure with potential risk for serious complications and high costs. Alternative lower risk therapies that can delay or total knee replacement are valuable to those who are poor candidates for surgery or wish to avoid total knee replacement as long as possible.
Are Hyaluronic Acid Injections the answer? Here is what the study concluded:Repeated courses of treatment with Hyaluronic Acid are safe and are associated with the delay of total knee replacement for up to 3 years. So again, we have a three-year delay after repeated courses of Hyaluronic Acid injections supported in the research. But what about the study that says Hyaluronic Acid Injections that delay inevitable knee replacement are a waste of time, money, and resources?
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Likely Factors For Success
The people who do seem to respond best to hyaluronate knee injections are of normal weight and have only the beginning stages of osteoarthritis. The injections are most effective in people with just mild to moderate arthritis. If youre highly overweight or obese and have advanced osteoarthritis, the injections are less effective.
Hyaluronate injections also seem more effective on people younger than 65. If youve never had treatment with hyaluronate or steroid shots, youre also a better candidate.
Comparison Of Ozone Therapy Cortisone Hyaluronic Acid Injections And Dextrose Prolotherapy Injections
There is a significant amount of research surrounding the use of ozone in treating various diseases. In this section, we will limit this research to comparative research.
An October 2018 study in the Journal of Pain Research compared ozone treatments with Hyaluronic Acid Injections or Dextrose Prolotherapy injection as the control group.
Please note that this is not a comparison of Prolozone® to the other treatments, this is a comparison of ozone alone.
The researchers wrote that the existing body of evidence had well demonstrated that ozone injection was evidently effective for short-term management of mild-to-moderate knee osteoarthritis patients . But the main challenge was on longer periods of time in which different studies had declared heterogeneous results.
The researchers gathered dates from a series of randomized control trials and made these observations:
- The short-term effectiveness of intra-articular ozone is better than placebo and corticosteroids
- The short-term effectiveness of intra-articular ozone is equal to that of dextrose Prolotherapy or hyaluronic acid injections.
- However, at 36 months after injections, the therapeutic efficacy of ozone decreased to a level, slightly lower than that of dextrose Prolotherapy or hyaluronic acid injections.
- After 6 months, ozone therapy was not associated with significant improvement of range of motion and functionality
A 2015 study in the journal Anesthesiology and Pain Medicine showed that:
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Then Why Is Your Doctor Still Recommending This Treatment
Lets let Dr. Leopold continue:
One reason might be that surgeons have relatively few effective nonsurgical alternatives that help patients with their joint pain, andbeing members of a helping professionwe find this frustrating. However, our lack of effective nonsurgical treatments cannot justify the use of an ineffective one, and it must not be used to justify surgery unless surgery is indicated. Some patients will have pain that persists despite well-tested nonsurgical treatments, but not enough to warrant major joint surgery others may not fit the biopsychosocial profile that supports a decision to perform elective arthroplasty. The answer to this is not to use a treatment like viscosupplementation that studies suggest is ineffective, nor to take a chance on surgery when it seems ill-considered to do so, but rather to explain to patients that there are some problems for which we have no effective treatments, and to help those patients adjust and adapt.
Combining Prp And Hyaluronic Acid
A team of Italian researchers examined the role of a combined hyaluronic acid and PRP treatment in a March 2021 published study.
In this study, clinical outcomes of patients suffering from mild or moderate knee osteoarthritis were treated with Leukocyte and platelet-rich plasma or PRP + hyaluronic acid intra-articular injections. Outcomes were observed 3 months and 1 year after the injective treatment.
A significant improvement of pain score was present in both groups, the Leukocyte PRP group, and the PRP + hyaluronic acid. Pain reduction was effective after 3 months and improved after 1 year. The group treated with PRP + hyaluronic acid showed a significant improvement in knee mobility and function scores. In both groups, however, the improvement in Knee injury and Osteoarthritis Outcome Score , a self-reported measure of functional ability and knee-related quality of life, did not reach significance.
What does this mean? The researchers concluded: In our point of view, we encourage the use of PRP injections as a simple, safe, and minimally invasive treatment approach. Our comparison of PRP + hyaluronic acid and Leukocyte-PRP suggests that PRP + hyaluronic acid could possibly determine better functional and mobility outcomes. However, our work could not be sufficient to definitively suggest a therapeutic choice: Further evidence is needed.
What is Leukocyte- and platelet-rich plasma treatment? What is its connection to hyaluronic acid?
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What Does The Procedure Involve
You can usually receive a knee injection in your doctors office. The procedure only takes a few minutes.
Youll be seated during the procedure, and your doctor will position your knee. They may use ultrasound to help guide the needle to the best location.
Your doctor will:
- clean the skin on your knee and treat it with a local anesthetic
- insert the needle into your joint, which might cause some discomfort
- inject the medication into your joint
Though you may feel some discomfort, the procedure is rarely painful if your doctor has experience administering this type of injection.
In some cases, your healthcare provider may remove a small amount of joint fluid to reduce pressure.
Theyll insert a needle attached to a syringe into the knee joint. Then, theyll draw out the fluid into the syringe and remove the needle.
After removing the fluid, the doctor can use the same puncture site to inject the medication into the joint.
Finally, theyll place a small dressing over the injection site.
In Clinical Observations At Caring Medical The Benefit Is Seen In Injecting Bone Marrow Directly After Extracting It
The theory is that the number of stem cells is not as important as how long they live in their natural environment. In other words, when the bone marrow is directly injected, the source of stem cells is fresh and has great potential for healing. We also believe that the body knows best it can use these immature cells to regenerate all injured tissues in the joint.
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Why Is Knee Injection Done
Knee injection is performed to treat the pain arising from various diseases of the knee joint. The type of medication injected and the frequency depends on the condition being treated. Based on the diagnosis and extent of the disease, the doctor would recommend a treatment plan.
Indications for the various agents used for knee injections are as mentioned below.
- Botox inhibits the sensory neurons causing pain. Hence, joint pain and stiffness significantly improve.
Platelet-rich plasma injections
- PRP is obtained from the patients own blood. It contains growth factors that stimulate collagen formation and lubricate the joint. PRP can improve joint function and reduce pain.
You Need To Lose Weight So The Cortisone Will Work Better
- You may also have been told to lose weight if weight is an issue. Many people believe that they cannot lose weight because of the physical limitations that their knee is causing them. They simply cannot exercise. We have a number of articles on weight loss and its beneficial effect on knee pain. You can explore them here:
- Your bad diet and weight is destroying your knees and will send you to a nursing home
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