Why The Knee Pain Relief Industry Is Becoming Increasingly Confusing
I spent a chunk of my career as a foreign correspondent, and another telling war stories. Touring the front lines in Ethiopia’s war with Eritrea. Running from tear gas during street protests in Seoul and Manila. To my chagrin, however, the story that my friends remember is how, back in 1990, while reporting on Nicaragua’s presidential elections, I tumbled into a sidewalk manhole and shattered the tibial plateau below my left knee.
An instant earlier, I’d been running after the newly elected president, Violeta Barrios de Chamorro, in hopes of a quote for my story on her triumph that day. If not for that manhole, I know I would have caught up to her. Chamorro had recently had knee surgery and was walking, very slowly, on crutches.
When I returned to California, an orthopaedist put me in a cast, advised me to stop running, and predicted I’d need a new knee by 50. I’m now 66, with the same knee that landed in the manhole, still doing all I can to prove the ortho wrong.
Sure, at times my knee hurts, but for many reasons, I’m still balking at knee surgery. Instead, like millions of Americans, I’ve explored the world of alternative treatments for pain relief, including the range of knee injections.
Spoiler alert: They’re a mixed bag, with questionable science to back them up (or not)—and experts have feelings about which treatment route bests the rest in any one person’s unique circumstances.
What Happened To Our Knees In The First Place?
It’s no secret that the average American is getting older—and heavier. The average life expectancy in the U.S. is now just short of 80, while in our increasingly sedentary culture, nearly 74 percent of adults are considered medically overweight, including 42 percent who fall into the obese category. None of this is good news for knees, which are the biggest joints in our bodies and bear roughly three to six times our body weight while walking.
One in four adults in the U.S. suffers from knee pain, research shows, and its prevalence has increased almost 65 percent in the past 20 years. More than 32.5 million adults suffer from osteoarthritis—the breakdown of cartilage from wear and tear and the most common kind of arthritis—and the risk increases with age. Knee pain is also the reason for more than 4 million primary care visits a year. Painful joints may lead to more falls, too, which cause their own complications.
Maybe Boomers like me have come to expect more from our knees—while also being more willing to do anything to ease resulting pain—than past generations, who didn’t live as long or try so hard to keep active and fit. (Just before Jane Fonda got a knee replacement at the age of 71, she reminisced about all the adventures she’d had with the “strong and faithful” joint, as she once described it, which took her mountain-climbing, running, and skiing.)
But before the fitness legend tweeted news of her surgery, all those injured and weakening joints were making knee replacements more popular. The knee-replacement industry generates nearly 800,000 surgeries a year. By 2030, the number of total knee replacements in the U.S. is projected to be 600 percent higher than in 2005.
Plus, arthritis affects more people than researchers previously thought and may commonly be a not-so-silver lining of the fitness revolution that began in the 1970s. While exercise is mostly a very good thing to do for your joints, some doctors feel that long-term high-impact activity, including running, may take a toll in people with arthritis. “Knee injuries are one of the most common injuries for sports,” says Michael Fredericson, MD, a professor of physical medicine and rehabilitation at Stanford University. “So with more people being active, there will be more injuries.”
A new knee may be a good (or an unavoidable) option for many people, and I know several happy post-op patients who have taken up pickleball, while sending love letters to their surgeons. Still, a knee replacement is no small ordeal. You will need general anesthesia or a spinal block and should count on six months or more of recovery time for a new joint that may have to be replaced again in about 20 years.
The main factor giving me pause, however, is that researchers have found that at least 100,000 post-op patients—about 1 in 10—are disappointed after surgery because of continued pain and other difficulties. (Compare that to nearly 95 percent satisfaction with hip replacements.) More than half a million cases- led to revision surgeries from 2012 to 2019 due to problems such as infections and joint instability, one recent study counted. Post-op infections were the most common reason for the redo.
Furthermore, many folks simply aren’t great candidates for the surgery. They may be overweight, meaning they’d still be putting unreasonable pressure on a new joint, another possible reason for a redo. Or they may have other illnesses, like poorly managed diabetes or hypertension, or they smoke, all of which increase the risks of the operation.
“I want to make sure we’ve exhausted nonsurgical treatments,” says Yale A. Fillingham, MD, an associate professor of orthopaedic surgery and vice chair of orthopaedic research at Thomas Jefferson University Hospital, Rothman Orthopaedic Institute. “As much as surgeons want to think we’re God, it’s best to keep people out of the operating room if possible.”
All this helps explain why there’s now a much bigger—and rapidly expanding—business of knee-replacement avoidance, including all manner of braces, creams, supplements, heating pads, massagers, infrared gizmos, and—the biggest and buzziest now—injections.
Entering: The Wild West Of Joint Injections
Over the past 15 years, as my wounded knee deteriorated, I’ve researched the five most popular types of (supposedly) pain-relieving shots. I’ve tried two of them. All have potential side effects (some serious, others less so) and critics among doctors and researchers. Three aren’t approved by the FDA and aren’t likely to be reimbursed by insurance. But even so, for every naysayer you can find another patient or expert who swears by one or more of these methods.
Cortisone is the best known of the formulas, and there’s solid evidence for its anti-inflammatory effect. But its main flaw is its potential to harm cartilage—repeated use can accelerate osteoarthritis. The American Academy of Orthopaedic Surgeons (AAOS) guidelines recently downgraded its recommendation for cortisone shots from “strong” to “moderate” for that reason. “The risk is not zero,” says Antonia F. Chen, MD, an associate professor of orthopaedic surgery at Harvard Medical School, of cortisone’s potential to worsen osteoarthritis long term. Nonetheless, Dr. Chen, together with other orthopaedists, considers the shots her go-to solution for patients who aren’t right for or don’t want surgery. Risks are relative, she notes.
Other experts are more enthusiastic about cortisone. “It’s like coming in for an oil change,” says Dr. Fillingham, who was cochair for the 2022 AAOS guidelines.
Some pros recommend a different injection: hyaluronic acid. People with osteoarthritis tend to have a deficit of the lubricating substance in the body, so the theory is that adding it might help reduce pain and stiffness. But the shots were barely more effective than a placebo, while carrying more risk for infections, a recent review in The BMJ found. Dr. Fredericson still offers them, saying the evidence has been mixed, with some supportive studies. “If it works for you, you’re a very happy camper,” he says. “I have one patient with severe knee arthritis who gets them twice a year and credits this for his still playing basketball at 73.”
Then there are even fringier injections, including platelet-rich plasma (PRP), stem cells, and ozone therapy. While more and more studies on PRP are coming out, so far the results are not hopeful. No significant change in symptoms or joint structure was found in a recent JAMA report on a randomized clinical trial.
32.5 million U.S. adults suffer from osteoarthritis
“Some patients do appear to get benefits, but the studies are inconsistent,” says Robert Brophy, MD, a professor of orthopaedic surgery and director of the Orthopaedic Clinical Research Center and chief of sports medicine service at Washington University School of Medicine. “This may be a case in which our clinical use is ahead of our scientific sophistication. We still have unanswered questions.”
As for stem cells? Guidelines published by the American College of Rheumatology (ACR) strongly advise against them, warning there is no standard procedure and that evidence that they work or are safe is lacking. “It’s modern-day snake oil,” Dr. Brophy says.
Still, increasing numbers of patients, including athletes like Rafael Nadal, may be paying as much as $12,000 per treatment. “The hope is that stem cell injections can regenerate cartilage, as opposed to just calming inflammation,” says Dr. Fredericson. (We’re not there yet, but perhaps in the next 10 years, he adds.)
Ozone therapy—which involves injecting anti-inflammatory ozone gas—invites more skepticism. Injections can cost as little as $200 per shot, according to some online ads. But there is no established protocol for treatment (i.e., no accepted standard dose) and no evidence of long-term results, a review in the British Medical Bulletin found.
Experts and practitioners, however, empathize with patients seeking relief, fast. At least some of the treatments above seem to help some patients sometimes (remember, too, any time you see a doctor for pain, there’s potentially a placebo effect as well). With this large a scientific gray area on the question of injections, it’s easy to see how their use, from foundational to the fringe, keeps growing.
Picking A Personalized Pain Plan
If you’re overweight or obese, health care providers will likely advise you to lose pounds to put less stress on your knees. But right behind weight loss as an intervention is physical therapy, particularly low-impact exercises like treadmill walking. When done correctly (big caveat!), strength exercises like squats can be very helpful at protecting against lower-body injuries, research has found.
Ultimately, every human knee is different, and treatment plans should follow suit. So, before agreeing to a solve, Google around and ask your doctor pertinent questions: “How many of these have you done? What is the success rate? Can you show me peer-reviewed studies?” And maybe even: “Can I talk to one of your patients?” Ask the same questions and more if you’re considering knee surgery, says David C. Ayers, MD, chair emeritus and distinguished professor of orthopaedics at the University of Massachusetts Chan Medical School.
The knee replacement industry generates nearly 800,000 surgeries a year.
Experts are hopeful that, in time, more minimally invasive techniques and other technological improvements such as robotic-assisted total knee replacement will increase patient satisfaction with knee replacements. Meanwhile, remember that knee shots are temporary measures at best, treating symptoms rather than correcting the physical problem. Also bear in mind that surgery and shots are not your only options to address knee pain, and PT and exercise interventions may be a solid start.
My last cortisone shot was in April 2023. The relief lasted through summer. Subsequently, I threw a lot of things at the wall, like daily anti-inflammatory turmeric, losing 20 pounds by intermittent fasting and lifting. Some (maybe all) seem to be working.
As I write, my knee isn’t bugging me. Pickleball, here I come.
Injections 101
Cortisone
This steroid is the most common injectable for osteoarthritis and considered the gold standard, short of surgery.
Pros It’s FDA-approved, and studies support its capacity to temporarily
reduce inflammation and relieve pain.
Cons Relief lasts several months at best, and most docs advise a limit—usually no more than three or four a year.
Hyaluronic Acid
The formula is a gel-like substance in the synovial fluid surrounding joints.
Pros It’s FDA-approved, and insurance often covers it.
Cons It likely won’t help for long. The AAOS guidelines give the treatment a “moderate” recommendation, meaning some consistent study findings have shown the benefits outweigh the harm.
Platelet-Rich Plasma (PRP)
The clinician draws your blood and separates out plasma for an injection meant to heal the problem site.
Pros Some studies suggest growth factors in plasma may stimulate healing.
Cons It’s costly and not up for FDA clearance, as it’s not a drug; the ACR strongly recs against it, citing lack of standardization in techniques.
Stem Cell Formulas
The injections, theoretically, enhance cartilage regrowth.
Pros Some proponents claim pain relief, though the evidence currently is only anecdotal.
Cons All major medical organizations and governing bodies warn against it due to concerns over safety and efficacy.
Ozone Therapy
Used in World War I as an antibacterial, the strategy of ozone injections for joints invites ire from experts.
Pros Some theorize it might also help reduce inflammation.
Cons The FDA’s thumbs-down rating for ozone as an intervention states that it is a toxic gas that has “no known useful medical application in specific or preventive therapy.”
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