This resource has been developed to help you understand the medicine that has been prescribed for you. It includes important information about:
- what benefits to expect from the treatment
- what are the possible side effects
- what tests you should have to monitor your condition and to detect unwanted effects
- other precautions you should take.
Please read it carefully and discuss it with your doctor.
Important things to remember:
- You should tell your doctor if pain and swelling in the joint increase following the injection.
- You should tell your doctor if your joint becomes red and hot following the injection.
Hyaluronic acid injections and osteoarthritis
You may be recommended to use Hyaluronic acid to treat osteoarthritis, a condition that affects the joints. It is most commonly used to treat osteoarthritis of the knee. Some common brand names include Euflexxa, Hyalgan, Supartz, Durolane, Monovisc, Orthovisc, Synvisc, Synvisc One, Gel-One.
In a normal joint, a layer of cartilage covers the ends of the bones. Cartilage helps the joint move smoothly and cushions the ends of the bones. In osteoarthritis, the joint capsule lining may thicken and produce more fluid than normal, causing joint swelling, pain and stiffness.
Hyaluronic acid is found naturally in joints and other parts of the body. In the joint, it is found in the cartilage and the synovial fluid that lubricate the joints to keep them working smoothly. There is a reduction in the concentration of hyaluronic acid in people who have osteoarthritis.
Hyaluronic acid injections are not first option for treatment in OA. Hyaluronic acid injections may be offered to people with osteoarthritis of the knee if other treatments have not worked. Hyaluronic injections can be expensive and do not work for all people.
What benefit can you expect from your treatment?
Research has not proven that injecting hyaluronic acid into the joint can help with pain or protect the cartilage1-3. The relief from hyaluronic acid injections is minimal, and there is not enough clear scientific evidence to prove that this treatment is effective. Response varies and the injections do not help everyone. If successful and cost-to-benefit is considered, the injections can be repeated after 6 months.
Are there any side effects?
Side effects from hyaluronic acid injections are not common. Most are limited to the site of injection and do not last long. Tell your doctor if you are concerned about possible side effects.
Local side effects may include:
- redness and tenderness at the site of the injection
- increased stiffness, swelling or warmth inflammation (flare) lasting 24 to 48 hours following the injection.
These local reactions may be treated by resting and applying ice to the injected area, or by simple pain relievers.
Less common or rare possible side effects include:
- Allergy including rashes, hives, itching, flushing and swelling of the face, tongue or throat, chest tightness and shortness of breath. If you experience any of these symptoms contact your doctor straight away.
- Less commonly, a joint may become severely inflamed after injection. This may be due to acute pseudogout arthritis from crystals in the joint. Very rarely, an infection in the joint may develop after the injection. If the pain and swelling in the joint that was injected increase a great deal or the joint becomes red and hot, contact your doctor quickly.
- Other side effects that have been observed include: headache, muscle pain, nausea, sore throat and flu-like symptoms.
What other precautions are necessary?
After the injection, it is recommended that strenuous activity (e.g. high impact sports such as jogging or tennis) or prolonged weight- bearing activities are avoided for about 48 hours after the injection.
Hyaluronic acid injections will not be given if you have an infection in your joint or a skin disease or infection around the area where the injection will be given.
Corticosteroid injections and osteoarthritis:
You may be recommended to use corticosteroid injections to treat osteoarthritis, particularly affecting joints like the knee. Corticosteroids are naturally produced hormones in the body. Man-made corticosteroids are potent anti-inflammatory medications used in various medical conditions, including inflammatory disorders. Corticosteroid injections have anti-inflammatory and immunosuppressive effects, and can reduce swelling and pain in the joint.
Corticosteroids come in various preparations, including methylprednisolone acetate, dexamethasone sodium phosphate, triamcinolone acetonide, triamcinolone acetonide extended release, betamethasone acetate, and betamethasone sodium phosphate. Studies have shown no superiority of one preparation over another in terms of clinical effectiveness4. Some common brand names are Celestone, Depo-Medrol, Kenacort.
What benefit can you expect from your treatment?
Current research studies suggest corticosteroid injections for OA have effects lasting up to 2-6 weeks. Due to its short duration of effect, regular use is not advised, and there is emerging evidence that repeated injections may speed up the progression of osteoarthritis.5,6
Corticosteroid injections may be indicated for use for people with knee osteoarthritis during acute flare-ups where they develop joint swelling and local inflammation, where other options are not available.
Are there any side effects?
Possible side effects include a very low risk of infection. Some people may experience a “steroid flare” after the injection where the corticosteroid irritates your joint, causing severe pain and swelling that occur typically around 6-12 hours after the injection, and symptoms may last for up to 3 days.
What other precautions are necessary?
Strenuous activities should be avoided for approximately 48 hours after the injection. Corticosteroid injections should not be given if there is an active joint infection or if there are circulatory problems in the legs.
Inform your doctor if you have any allergies to steroids or related substances.
Inform your doctor if you are pregnant, planning to become pregnant, or breastfeeding. It's crucial to discuss your specific medical condition and history with your healthcare provider to determine the most suitable treatment approach.
Watch the below Youtube video or listen to the podcast about the benefits and harms of steroid injections for osteoarthritis.
Youtube: https://www.youtube.com/watch?v=t0Ie6j1UO4Y
Platelet-Rich Plasma (PRP) injections and osteoarthritis
Platelet-rich plasma (PRP) is a product taken from an individual's blood. Blood consists mainly of liquid called plasma and solid components of red cells, white cells and platelets. PRP is a highly concentrated preparation of platelets obtained through separation of platelets from blood cells through a spinning process called centrifugation. The product platelet-rich plasma is then injected into the joint. The way PRP works is not clear despite multiple studies, but it is thought to help with the healing process in the joint.
What benefit can you expect from your treatment?
PRP is generally considered a safe treatment with possible improvement in pain lasting up to 12 months. However, most studies looking at PRP use in hip and knee OA, do not demonstrate a difference from placebo7.
Due to the lack of clear evidence supporting the benefits of PRP and concerns about the quality of studies available, the use of PRP for osteoarthritis is not recommended.7,8
Are there any side effects?
Possible side effects include a very low risk of infection, bleeding and tissue damage.
What other precautions are necessary?
Inform your doctor of any blood disorders or bleeding tendencies. Discuss with your healthcare provider any ongoing medications or conditions. PRP is not suitable for individuals with infections or circulatory problems in the legs. Mention any allergies, especially to blood products or components.
As research progresses, recommendations may evolve, and it is essential to have open communication with your doctor and healthcare team to determine the most appropriate treatment approach for your specific condition.
Learn more about PRP for knee OA with this podcast: https://www.jointaction.info/podcast/episode/5212a3cc/platelet-rich-plasma-injections-for-knee-osteoarthritis-with-prof-kim-bennell
Stem Cell Therapy and osteoarthritis
Stem cell therapy involves the use of stem cells which have the potential to develop into many different types of cells in the body. These stem cells have the potential to replace aged or damaged cells, including those involved in cartilage and bone. The specific type of stem cells used in this therapy are mesenchymal stem cells (MSCs).
The stem cells are collected from an individual's own body from the bone marrow or fat tissue, and there are commercially available preparations from unrelated donors. These can be injected directly into the osteoarthritic joint after laboratory preparation.
The exact process of how stem cell therapy works in osteoarthritis is not fully understood. It is thought that stem cells may improve joint structure, function, and pain by potentially restoring cartilage and boosting the natural repair mechanisms of the joint.
What benefit can you expect from your treatment?
Stem cell therapy is not recommended for osteoarthritis as research is still in its early stages and there is not enough high-quality scientific evidence supporting use. 9,10
The use of stem cell therapy for osteoarthritis remains an area of ongoing research, and caution should be exercised until more reliable evidence is available.
Are there any side effects?
Possible side effects include a very low risk of infection and bleeding.
What other precautions are necessary?
Discuss with your healthcare provider any underlying health conditions or medications.
Clarify the source of stem cells and the potential risks associated with the procedures of obtaining the stem cells from the body.
Be aware of the current limited scientific evidence and uncertainties regarding the benefits and risks associated with stem cell therapy.
It is crucial to maintain open communication with your doctor and healthcare team to make informed decisions regarding the most suitable treatment approach for your specific condition.
Prolotherapy and osteoarthritis
Prolotherapy, involves the injection of a form of sugar (D-glucose) mixed with local anaesthetics (pain relievers) into the joint. How this treatment works is not fully understood, but it is believed that the injection triggers a local inflammatory response. This, in turn, may stimulate a healing response.
What benefit can you expect from your treatment?
Based on the current available evidence, the use of prolotherapy is not recommended for knee osteoarthritis.11,12 While some studies suggest prolotherapy may improve pain and function for people with osteoarthritis it is important to know that the available studies are of low quality.11,12
Are there any side effects?
Possible side effects include a very low risk of infection. Other side effects include pain and stiffness of the joint, bleeding, and allergic reactions.
What other precautions are necessary?
Engage in open communication with your healthcare provider about your symptoms, preferences, and treatment options.
Be aware of the limited scientific evidence supporting prolotherapy for osteoarthritis. Understand that further high-quality studies are needed to establish the safety and efficacy of prolotherapy for osteoarthritis.
Remember, making informed decisions about your health involves collaboration with your doctor and healthcare team. They can provide guidance tailored to your specific condition and help you explore alternative treatments based on the latest research and evidence.
Resources
References
The below references have been used to develop this fact sheet with the most up-to-date evidence available.
- Jevsevar D, Donnelly P, Brown GA, Cummins DS. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence. J Bone Joint Surg Am. 2015;97(24):2047-2060.
- Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157(3):180-191.
- Hunter DJ. Viscosupplementation for osteoarthritis of the knee. N Engl J Med. 2015;372(11):1040-1047.
- Yu SP, Hunter DJ. Intra-articular therapies for osteoarthritis. Expert Opinion on Pharmacotherapy. 2016;17(15):2057-2071.
- Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2006(2).
- Gibbs AJ, Gray B, Wallis JA, et al. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis and cartilage. 2023;31(10):1280-1292.
- Costa LAV, Lenza M, Irrgang JJ, Fu FH, Ferretti M. How Does Platelet-Rich Plasma Compare Clinically to Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review and Meta-analysis. Am J Sports Med. 2023;51(4):1074-1086.
- Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris JD. Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy. 2016;32(3):495-505.
- Shen L, Yuan T, Chen S, Xie X, Zhang C. The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2017;12(1):16.
- Wong KL, Lee KB, Tai BC, Law P, Lee EH, Hui JH. Injectable cultured bone marrow-derived mesenchymal stem cells in varus knees with cartilage defects undergoing high tibial osteotomy: a prospective, randomized controlled clinical trial with 2 years' follow-up. Arthroscopy. 2013;29(12):2020-2028.
- Arias-Vázquez PI, Tovilla-Zárate CA, Legorreta-Ramírez BG, et al. Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials. Advances in Rheumatology. 2019;59(1):39.
- Arias-Vázquez PI, Tovilla-Zárate CA, Castillo-Avila RG, et al. Hypertonic Dextrose Prolotherapy, an Alternative to Intra-Articular Injections With Hyaluronic Acid in the Treatment of Knee Osteoarthritis: Systematic Review and Meta-analysis. American Journal of Physical Medicine & Rehabilitation. 2022;101(9):816-825.
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