Injections into the knee joint for handling osteoarthritis: Corticosteroids along with other treatments
In the realm of treating knee osteoarthritis (OA), a common condition that affects millions worldwide, the focus has shifted towards non-invasive and non-pharmacological approaches, with injectable therapies like hyaluronic acid, platelet-rich plasma (PRP), Botox, stem cell, and prolotherapy taking a secondary role.
Hyaluronic acid (HA) injections, intended to improve joint lubrication and reduce pain, have been widely used. However, large-scale reviews and guidelines often prioritise physical and exercise therapies as first-line treatments. Despite some evidence suggesting HA provides variable efficacy, it is typically considered after more established conservative measures such as bracing, exercise, and physical therapy.
Platelet-rich plasma (PRP) injections, which deliver concentrated autologous growth factors to enhance healing and reduce inflammation, are another option. While there are promising small studies, robust clinical evidence from large randomised controlled trials is still limited. As a result, PRP remains an adjunct or experimental therapy in specialist settings rather than a guideline-recommended standard care.
Botox (botulinum toxin) injections are mostly investigated for pain modulation via inhibition of nociceptive pathways, but their use in knee OA is not widespread or strongly supported in mainstream clinical practice guidelines. Evidence remains preliminary and limited.
Stem cell therapies, which aim to regenerate cartilage and modulate inflammation, currently lack sufficient high-quality evidence to be recommended in routine clinical practice. These interventions are largely experimental.
Prolotherapy, which involves injecting irritants to promote tissue repair, is an intriguing option, but its use in knee OA remains controversial due to inconsistent evidence. Systematic reviews report mixed results, with some patients experiencing pain relief but overall insufficient robust evidence to make it a standard treatment.
Current consensus and guidelines emphasise non-invasive physical therapies such as knee bracing, structured exercise, hydrotherapy, and education as the backbone of knee OA management. These interventions have the strongest evidence base for improving pain and function. Physical therapy interventions are strongly recommended as first-line to reduce pain and disability and may reduce the need for pharmacological and invasive treatments.
Many clinicians also follow evidence-based clinical practice guidelines, which currently prioritise non-pharmacological modalities before considering injectable therapies. Awareness of and adherence to guidelines is still suboptimal in practice.
Injectable treatments like HA, PRP, and others are generally considered adjuncts or second-line options for selected patients who do not respond adequately to conservative management.
It's important to note that long-term use of injections may result in side effects. If pain returns after a corticosteroid injection, a person may not be able to have another shot right away.
In 2018, Zilretta, an extended-release injection of triamcinolone acetonide, was approved by the FDA for the management of OA-related pain. This injection can help relieve moderate to severe pain.
In conclusion, while hyaluronic acid, PRP, Botox, stem cell, and prolotherapy injections are being explored and used in some cases for knee OA, current guidelines primarily support non-pharmacological, conservative therapies as the foundation of treatment. These injections are viewed as adjunctive or experimental pending stronger, more consistent evidence from ongoing studies. Clinicians are advised to individualise treatment and consider injections only after established modalities have been attempted.
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