Traditional Medicine’s Approach to Treating Knee Arthritis is Blowing Up
Three new studies have recently been added to many others that our current traditional treatment of knee arthritis is probably hurting more people than it’s helping. So let’s explore this morning what’s up. Let’s also explore how you can protect yourself from the medical care system potentially making your arthritis worse.
What are the Most Frequent Treatments for Knee OA?
NSAID drugs like Motrin, Advil, Aleve, Celebrex, and others are one of the main ways that the traditional medical care system treats arthritis pain. Another mainstay treatment for knee arthritis in particular is a corticosteroid injection. However, what if we had research with evidence that both of these treatments make arthritis worse?
The RSNA Conference Studies
The RSNA is the Radiological Society of North America which held its annual conference in Chicago this year. Data from several new studies were presented at the conference that use the NIH-funded OAI dataset (Osteoarthritis Initiative) (3). OAI describes itself as:
“The Osteoarthritis Initiative (OAI) is a multicenter, longitudinal, prospective observational study of knee osteoarthritis (OA), currently in its 14th year of follow up. This Initiative is a public-private partnership between the NIH and private industry that seeks to develop a public-domain research resource to facilitate the scientific evaluation of biomarkers for osteoarthritis as potential surrogate endpoints for disease onset and progression.”
Let’s quickly review each study.
NSAIDs Worsen Knee Arthritis Pain
Physicians in San Francisco used data from OAI to observe 273 patients with moderate to severe knee arthritis who took NSAIDs for four years versus 793 control patients who didn’t take NSAIDs (1). Joint inflammation and cartilage quality worsened at the four-year follow-up for patients taking NSAIDs versus those who did not take these drugs.
Steroid Shots Worsen Knee Arthritis
In the first study involving knee steroid injections, researchers from San Francisco again used 210 patients in the OAI dataset (2). 70 patients had received intraarticular knee injections and these were compared to a control group of 140 who did not get injections. Both groups were followed for two years. Of the 70 patients who received knee injections, 44 had been injected with corticosteroids, and 26 with hyaluronic acid. All of the groups were matched by arthritis severity, age, sex, body mass index, pain, and physical activity scores. MRIs were performed on all patients and were scored using WORMS, which is a grading system for knee arthritis severity. The data showed more arthritis progression in patients who had steroid shots. The MRIs in the hyaluronic acid group demonstrated slowed arthritis progression compared to the control group.
In the second study, researchers in Chicago selected 150 patients from the Osteoarthritis Initiative database, including 50 patients who had received steroid injections, 50 who received hyaluronic acid injections, and 50 who were not injected over a 3-year period (2). All groups were matched by sex, body mass index, and X-ray findings. These groups were tracked with x-rays over time. Compared to the patients who had an injection of hyaluronic acid or no treatment, the patients injected with steroids had significantly more osteoarthritis progression.
Is Any of this New Information?
While the data showing that NSAID drugs may make knee arthritis worse is newer, the idea that steroid injections are really bad for knee cartilage is not new at all. For example, we’ve had experimental data from the lab and animal studies for decades that show that corticosteroids harm cartilage cells (4,5). We even have a randomized controlled trial from the New England Journal of Medicine showing the same in actual knee arthritis patients (6).
What Can You Do as a Patient?
Based on the existing data, I recommend that my patients refuse steroid knee injections. If you’re stuck being only able to afford what insurance will cover, then, based on these studies, you would be better off with hyaluronic acid shots, which are usually covered as well. You should know that there are studies that show that HA shots may have weak effects in general (7-9). In my personal clinical experience, this is likely because these injections are often performed blindly without imaging guidance and sometimes never make it into the joint. Meaning in my patients who get ultrasound-guided HA injections, the injections usually work to help arthritis pain. Of note, for most of my patients, HA works for the first few years and then for reasons unknown, wears off and produces less positive effects over time.
Based on the existing randomized controlled trials that have compared HA to Platelet Rich Plasma (PRP) for the treatment of knee arthritis, PRP produces superior effects (10-17). However, PRP is often not yet covered by insurance (except in situations where Regenexx has a direct contract with the employer to offer these procedures). Hence, if you’re trying to get the knee injection that will help your arthritis the most and the cost is not as critical, then PRP would be the way to go based on the existing high-level research.Join us for a free Regenexx webinar.
Heads Up: This Topic Makes Some Physicians Testy
I posted the press release from RSNA about the two new knee steroid injection studies on Linkedin. I had several physicians who were clearly upset about this information. Why that happened is worth exploring.
Many physicians have been using NSAIDs and knee steroid injections for their whole careers. Because both seem to help their patients function and they are covered by insurance, they have become the standard of care. However, as the research on harm has increased, in particular with steroid knee injections, some physicians have begun to question their use and have begun offering alternatives like HA and PRP. However, on the other end of that spectrum, there is a group of physicians who don’t like being told that what they have been doing is likely causing harm and that they should do something else. Call it institutional momentum.
However, when it comes to injecting steroids into joints, the data has been evolving toward harm for quite some time. Any physician who was following the literature could easily see that there were problems brewing. In fact, it’s this data that caused me to ban high-dose steroid injections from my practice years ago. If you read this blog regularly, you know that I’ve been highlighting research studies that show steroid injections are bad news for at least 15 years.
The upshot? In modern medicine, an educated patient who is involved in their own care simply gets better healthcare than one that doesn’t take the time to arm themselves with information. These new studies on knee arthritis progression are great examples of how patients need to be actively involved in shaping the care they receive.
(1) PR Newswire. NSAIDs May Worsen Arthritis Inflammation. https://www.prnewswire.com/news-releases/nsaids-may-worsen-arthritis-inflammation-301681834.html. Accessed 11/29/22.
(2) PR Newswire. Steroid Injections Worsen Knee Arthritis. https://www.prnewswire.com/news-releases/steroid-injections-worsen-knee-arthritis-301685584.html Accessed 11/30/22.
(3) NIH. Osteoarthritis Initiative. https://www.niams.nih.gov/grants-funding/funded-research/osteoarthritis-initiative. Accessed 11/30/22.
(4) Wyles CC, Houdek MT, Wyles SP, Wagner ER, Behfar A, Sierra RJ. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015 Mar;473(3):1155-64. doi: 10.1007/s11999-014-3925-y. Epub 2014 Sep 4. PMID: 25187334; PMCID: PMC4317436.
(5) Dragoo JL, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012 Sep;20(9):1809-14. doi: 10.1007/s00167-011-1820-6. Epub 2011 Dec 21. PMID: 22186921.
(6) McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA.2017;317(19):1967–1975. doi: 10.1001/jama.2017.5283
(7) Xing D, Wang B, Liu Q, Ke Y, Xu Y, Li Z, Lin J. Intra-articular Hyaluronic Acid in Treating Knee Osteoarthritis: a PRISMA-Compliant Systematic Review of Overlapping Meta-analysis. Sci Rep. 2016 Sep 12;6:32790. doi: 10.1038/srep32790. PMID: 27616273; PMCID: PMC5018721.
(8) Richette P, Chevalier X, Ea HK On behalf of the French OsteoArthritis study group, et alHyaluronan for knee osteoarthritis: an updated meta-analysis of trials with low risk of biasRMD Open 2015;1:e000071. doi: 10.1136/rmdopen-2015-000071
(9) Pereira T V, JÃ¼ni P, Saadat P, Xing D, Yao L, Bobos P et al. Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis BMJ 2022; 378 :e069722 doi:10.1136/bmj-2022-069722
(10) Raeissadat SA, Rayegani SM, Hassanabadi H, et al. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial). Clin Med Insights Arthritis Musculoskelet Disord. 2015;8:1–8. Published 2015 Jan 7. doi: 10.4137/CMAMD.S17894
(11) Montañez-Heredia E, Irízar S, Huertas PJ, et al. Intra-Articular Injections of Platelet-Rich Plasma versus Hyaluronic Acid in the Treatment of Osteoarthritic Knee Pain: A Randomized Clinical Trial in the Context of the Spanish National Health Care System. Int J Mol Sci. 2016;17(7):1064. Published 2016 Jul 2. doi: 10.3390/ijms17071064
(12) Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017 Mar;25(3):958-965. doi: 10.1007/s00167-015-3705-6.
(13) Lana JF, Weglein A, Sampson SE, et al. Randomized controlled trial comparing hyaluronic acid, platelet-rich plasma and the combination of both in the treatment of mild and moderate osteoarthritis of the knee. J Stem Cells Regen Med. 2016;12(2):69–78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5227106/
(14) Tavassoli M, Janmohammadi N, Hosseini A, Khafri S, Esmaeilnejad-Ganji SM. Single- and double-dose of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: A randomized controlled trial. World J Orthop. 2019;10(9):310–326. Published 2019 Sep 18. doi: 10.5312/wjo.v10.i9.310
(15) Lin KY, Yang CC, Hsu CJ, Yeh ML, Renn JH. Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial. Arthroscopy. 2019 Jan;35(1):106-117. doi: 10.1016/j.arthro.2018.06.035.
(16) Huang Y, Liu X, Xu X, Liu J. Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis : A prospective randomized controlled study. Orthopade. 2019 Mar;48(3):239-247. doi: 10.1007/s00132-018-03659-5.
(17) Di Martino A, Di Matteo B, Papio T, Tentoni F, Selleri F, Cenacchi A, Kon E, Filardo G. Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial. Am J Sports Med. 2019 Feb;47(2):347-354. doi: 10.1177/0363546518814532.