Cortisone injections, hyaluronic acid injections, or platelet rich plasma injections? Which treatment should you choose to help relieve pain and disability related to symptomatic knee arthritis? This new systematic review and meta-analysis compared common injections we use to help provide symptom relief for arthritis. And the results are NOT what you think they’re going to be.
Osteoarthritis is one of the most common causes of pain and disability worldwide. And once arthritis has developed in a joint, we can’t reverse it and we can’t get rid of it. The problem is if we don’t do anything about it, arthritis tends to get worse and worse and eventually you need a joint replacement surgery. But that’s a big deal and most people don’t want a joint replacement surgery.
So the next question we want to ask is, are there any medications that we can put into the joint to not only reduce symptoms related to arthritis, but also to slow down the progression of arthritis? And over the last few years, there have been many studies comparing common injection therapies for arthritis. These include cortisone injections, hyaluronic acid injections, and cellular injections such as platelet rich plasma and stem cell therapy.
But the big question is, how effective are these injections and how do they compare to corticosteroid injections? Cortisone has essentially served as the gold standard treatment for doctors and patients when it comes to pain relief for arthritis. But should it be? This study tried to answer that question. More specifically, the authors wanted to know should we continue to offer cortisone injections to reduce symptoms related to arthritis, OR should we move on to newer and potentially better treatment options?
The authors took data from ten randomized controlled trials, eight of which studied knee osteoarthritis and two of which studied thumb osteoarthritis. These studies compared cortisone injections to hyaluronic acid injections, platelet rich plasma injections, and saline injections. They combined the data for the HA, PRP, and saline injections and called them the “other” group. They then compared this “other” group directly to the cortisone group. Again, their goal is to determine should we continue to offer cortisone injections or move on to other types of injections?
So let’s look at what they found. In terms of pain, the authors found greater improvements for the Other group when compared to the cortisone group at 6 months and at 9 months but not at 12 months or 24 months. In terms of functional improvement, the Other group again had better improvements at 3 months, 6 months, 9 months, and 12 months, but not at 24 months.
The authors go on to conclude that “alternative injectables, particularly hyaluronic acid and platelet rich plasma, provided greater symptomatic benefits over the long term” for knee arthritis. Moreover, they say that “recurrent corticosteroid injections failed to demonstrate superiority over placebo saline injections.”
The authors also rightly point out that corticosteroid injections are not as safe as previously thought. There is a growing body of evidence that corticosteroid injections lead to complications such as accelerated osteoarthritis progression, subchondral insufficiency fractures, osteonecrosis, and rapidly destructive joint disease.
Ok so this study just adds to the growing body of evidence that we really need to move away from cortisone injections to treat symptoms related to arthritis. Multiple studies have shown even just one intra-articular corticosteroid injection significantly increases the risk of developing rapidly destructive joint disease. This is characterized by the progressive loss of the normal architecture of a joint which will eventually necessitate a joint replacement surgery. So this is a big deal.
In addition, our current study arrived at the same conclusion that a previous study did, which is that cortisone injections are NOT superior to placebo saline injections. In that other study, people that got saline injections had no difference in pain and symptoms compared to people that got cortisone injections. However, the people that got cortisone injections had greater cartilage volume loss and that, by definition, means worse arthritis. So again, cortisone did not result in better pain control but it resulted in more side effects, namely worsening progression of arthritis. This is definitely NOT something that you want to have injected multiple times into your joints.