A Tale of Five Knee Joint Injections: You Get What You Pay For

Published on Jan 23, 2022

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It’s always hard to explain to patients how training and expertise in medicine vary widely. The good news is that in the more established areas of medicine represented by board certification, while the skill levels between doctors are different, there is a minimum standard of competency. However, once one gets into Regenerative Medicine where no legit board certification exists, the skill levels are so different that it’s startling. Today I’ll explain that through a simple knee joint injection, Let’s dig in.

Board Certification

In most areas of medicine, you have a board certification process that is overseen by a group called ABMS (American Board of Medical Specialities). That process begins with residency training lasting years and then usually consists of fellowship training lasting 1-2 years. Then there’s a written exam and then an oral exam and finally, the doctor is board certified. What this does is to make sure that a minimum knowledge standard is rigorously applied.

In Regenerative Medicine, there is no ABMS accepted board. There are what I would call “fake board certifications” that I have blogged on that are not the same as an ABMS board. There are a few fellowships in the area of musculoskeletal Regen Med or Orthopedics and these at least try to instill a minimum competency level. We have one such fellowship program which likely exposes young doctors to more hands-on Regenerative Medicine than any other on earth because our fellows do 100% Regen Med. That’s not the case at most other Orthobiologics fellowships out there.

However, 99% of doctors, mid-levels, and alternative health providers are poorly trained to do something like injecting your knee with Platelet-Rich Plasma or something they call “stem cells”. The best way to demonstrate how bad that training is at this point is to help you understand what happens with knee injections.

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What’s Being Injected?

The broad category of what’s injected here is called Orthobiologics. To learn more about that topic, watch my video:

Injecting the Knee

Let’s say you have knee pain due to arthritis and you’re considering Orthobiologics. You would think this is a simple thing, right? You find someone advertising this, you find a good price, and go in and get your injection. After all, how different could this treatment be between doctors and clinics? The truth is that what you get varies so widely that the treatments offered are not even similar. Let’s dive in.

To help you understand this vast disparity, I’m going to create various levels of knee injection expertise based on which structures are injected and how:

Level 1- The Blind Leading the Blind
Level 2- Simple US Guided Intra-articular-The good bad, and the ugly.
Level 3- IA+Tendons+Ligs-Lions, Tigers, and Bears…
Level 4- Fluoro and Ultrasound-Guided IA-Now We’re Cooking with Gas…
Level 5- IA+IO-Reaching the Summit

Level 1-The Blind Leading the Blind

This is a knee injection where the goal is to inject inside the joint. At level 1, the provider has never been taught how to do this with guidance, so they do it without. Meaning, this is a blind injection where the provider has no way to make sure that the Orthobiologic gets into the joint. Why is this a problem? Because about 1-2 in 5 times the doctor misses the joint. This is BELOW the standard of care, but this still happens in about half of all knee injections. This is more likely to happen at an orthopedic surgery practice or at an alternative medicine clinic where a mid-level like a PA is hired to inject.

Level 2-Simple US Guided Intra-articular-The Good, the Bad, and the Ugly.

If the first expertise level was injecting the knee joint blind, then level 2 is with guidance. Here the doctor or provider uses ultrasound imaging to make sure they’re in the joint. That’s great as it reduces the miss rate. The problem here is that this is normally learned not during an extensive year plus long training program where the provider is proctored dozens of times to make sure they’re doing this right, but instead during a weekend course.

Why is that an issue? Because if you have a knee that swells, this can be an easy injection as you aim for the pocket of fluid. If you don’t have much fluid in the joint, this can become a difficult injection with a higher miss rate. To see how difficult that can be, watch the video that I created for the Interventional Orthobiologics Foundation (IOF) to teach doctors:

Meaning, even with this easy injection, experience matters. I know this personally as I agreed to have my knee injected at a weekend course only to find that the provider, who should have known better, injected my quad tendon instead of my knee joint. Meaning, because my knee wasn’t swollen that day, he parked the needle in the wrong spot despite ultrasound.

Also, realize that the doctor has to drain any fluid that’s found before injecting the Orthobiologic agent. About half the time, that doesn’t happen, causing a problematic dilution in what’s injected (i.e. your joint fluid volume + what’s injected).

Level 3-IA+Tendons+Ligs – Lions, Tigers, and Bears…

The problem with just injecting only the joint with Orthobiologics is that you’re often missing things that need to be treated to maximize the patient’s outcome. That’s usually tendons and ligaments. The tendons around the knee can become beat up and swollen, so just injecting inside the joint capsule misses that issue. Hence, while the inside of the knee may be happy, the tendons are still pissed off, meaning the patient still has knee pain because the doctor didn’t inject all of the right areas.

The same holds true for ligaments. Loose ligaments due to wear and tear or injury can cause the joint to get beat up and create arthritis. Hence treating arthritis inside the joint will help for a while, but if the ligament is still loose, the pain will quickly return as every step causes too much motion and beats up the joint. In these cases, the ligaments have to be injected to tighten them and protect the joint.

Hence, with a provider who has level 3 expertise, they inject the joint using guidance and then also inject the painful tendons and lax ligaments. How often is this more advanced approach used? I would estimate that about 1 in 5 providers who can perform a competent ultrasound-guided knee joint injection have the knowledge to diagnose and inject the pissed-off tendons and lax ligaments around the knee. Meaning that only about 1 in 10 of the providers you could go to has this skill level.

Level 4 – Fluoro and Ultrasound-Guided IA – Now We’re Cooking with Gas…

Using ultrasound in the knee means that the machine bounces sound waves into the joint and back out and uses a computer to create an image. However, what happens if what you want to inject is covered or hidden by bone? Now those sound waves won’t be able to reach your target and that part of the knee will be invisible to the ultrasound machine. In those cases, level 4 providers use fluoroscopy. That’s a very expensive machine that costs about as much as a very high-end Tesla that requires a specialized room and technician. It uses x-rays and radiographic contrast to make sure the doctor is injecting in the right spot. The best example in the knee of when fluoroscopy is far superior to ultrasound is injecting the ACL.

The Anterior Cruciate Ligament (ACL) is a major stabilizer of the knee joint that lives deep inside the knee. The ultrasound imaging of that ligament is poor, so if you want to inject it properly, you need fluoroscopy:

This is what a proper knee ACL injection looks like:

Since the knee ACL can be lax and is a major protector of the joint, these level 4 providers can include it in what’s injected.

Level 5 – IA+IO – Reaching the Summit

Finally, we reach the summit or what the most experienced and trained providers can offer in the knee. Over the past 5 years, there has been more and more research that the pain of knee arthritis is caused by not only what’s happening in the joint, but also in the bone. Meaning swelling in the bone called a BML or BME (Bone Marrow Lesion or Edema) can cause pain and thus, in some patients the bone should be injected as well as the joint, ligaments, and tendons. Level 5 providers have you covered for all of these structures.

A level 5 provider can use fluoroscopy to place a small specialized needle (an 18 gauge trocar) into the area of the swollen bone and inject the Orthobiologic at that spot as well. Again, all of this just means a higher likelihood of positive results.

Reviewing Levels and Costs

As you can see, the clinic that advertises Orthobiologic knee injections may be able to perform anything from a below the standard of care knee joint injection that takes 3 minutes and may miss the joint to a 60-minute procedure that uses ultrasound and fluoroscopy to inject the joint accurately and all of the lax ligaments, and all of the beat-up tendons, plus the swollen and degenerated bone. The bizarre thing is that more often than not, these two procedures are priced similarly. Why? Because 99% of consumers don’t know the difference.

Now that you know, please share this blog with anyone considering these procedures, as not knowing anything about what to expect only increases the likelihood of being scammed. How can you make sure that your provider knows this stuff? One way is to pick a provider on the Regenexx network. Another is to reach out to the IOF to find trained providers in your area.

The Same Concepts Apply to All Joints and the Spine

While it would take a small book to explain the joint by joint and area by area differences in levels 1-5, hopefully, you can see that the same wide disparity in what you get exists everywhere you can be injected. For example, we have providers injecting the low back who stick a blind needle somewhere in the muscle in a 3-minute procedure and those that take an hour injecting 15 different structures using ultrasound and fluoroscopy. The same holds true for shoulders, hips, ankles, elbows, necks, feet, and hands.

The upshot? The goal this morning is to help you understand the vast differences in the quality of injections between clinics. Only an educated consumer can avoid being scammed in the Stem Cell Wild West. Hopefully, you can share this blog widely so that more patients know enough to ask the right questions.