Injections for Arthritis and Hip & Knee Pain: A Complete Guide

It’s rare to find a patient who’s had joint replacement surgery and not tried injections beforehand. Although the reverse is true—some people have injections but not joint surgery—generally, patients who get injections in their hip or knees are on the road to a replacement. In this sense, injections can be seen as sort of “delaying the inevitable” or buying yourself extra time before seeking a permanent, long-term solution for chronic joint pain, arthritis, and mobility issues.

For joint problems, injections are considered a “middle of the road” treatment. This means that before injections, less invasive alternatives like oral medications or physical therapy have likely been tried but the last-resort of surgery has not.

When it comes to injections the stakes are a little higher than just plain ol' physical therapy. There is also a lot of information to take in to be properly informed. For example, what is the best knee injection?
What is the best hip injection? What does success look like? To help you make sense of the different injections your orthopaedic surgeon may (or may not) suggest, we’ve put together this Complete Guide to Injections for Joint Pain and Arthritis.

Read on to learn the differences between the injection types for arthritis and joint pain, the pros and cons, their effectiveness, cost, and more!

What You Need to Know About Injection Therapy

  • You may not benefit greatly from injections. The results you get from joint injections are very much dependant on the individual. Some people experience relief lasting up to 1 year while others do not have any relief at all. Also, some patients report that first rounds of injections work but subsequent injections do not.
  • Injections can buy you extra time before surgery. Despite the length of time an injection is effective being dependant on the individual, most patients are able to delay surgery with injections. Buying extra time can be critical for patient preparation, better timing etc.
  • Not all injections are covered by insurance. Depending on your insurance coverage, the injection type, and the frequency in which your orthopedist does the procedure, you may have to pay out of pocket.
  • You’ll have to wait between injections and other treatments.Time must lapse between one injection to the next. You'll also have to wait 3-6 months after your injection before having surgery on your joint to lower your risk of infection.
  • It’s a temporary fix. Although some of the new, “experimental” injections types claim long-term healing potential, historically, injections only offer temporary relief from pain and inflammation. Standard injections do not cure arthritis or grow cartilage.
  • There are 4 different types of injections. 2 injection types are common-practice while the 2 others we'll break-down in this guide are new and experimental.

4 Types of Injections

The two main injection types your orthopedic surgeon or medical team are likely to recommend are: Cortisone injections and Viscosupplementation Injections. Both injection types come with a lot of alternate names (which we will detail below). If you’ve received an injection from your ortho in your hip or knee, it’s likely that the injection will fall into one of the two categories.

1. Cortisone injections

(also known as CorticoSteroids or Steroid Injections)

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Cortisone injections are sometimes called “corticosteroids” or just “steroid injections”. The injections are made up of the medication “cortisone”. Cortisone is injected right into the troubled joint area and is used to treat inflammation. It does not directly treat pain, but as a side effect of cutting down joint inflammation, pain is relieved.

For the anti-inflammatory effects of the cortisone injections to be effective, one must have inflammation and swelling to begin with. For those with arthritis, this isn’t a problem as arthritis is an inflammatory disease.

The Procedure: Cortisone injections are painful when applied, so the area is numbed with local anesthetic. The local anesthetic will temporarily take away all feeling from your joint area. The numbing process lets your physician know that they’ve found the troubled spot (if joint pain is relieved) and that an injection may address the inflammation and pain you’re experiencing. Once the area is numbed, the cortisone is administered. For those getting an injection in their hip, an ultrasound or x-ray is used to guide the physician to the exact spot.

Timeline: The numbing medicine can last up to 24 hours. It can take several days for the steroid injection to take noticeable effect. The average success for cortisone injections range from patients feeling little relief to experiencing 6+ months of relief. Effective up to 1 year. Can be repeated 3-4 times a year.

Cost: Covered in full or partially by most insurance companies.

Pros
  • More powerful than oral anti-inflammatory medications.
  • Can offer relief of 6 or more months in some patients.
  • Can postpone the need of joint replacement surgery.
  • Suppresses immune system (beneficial for controlling rheumatoid arthritis where the immune system mistakenly attacks its own tissues).
Cons
  • Repeated use can cause bone loss/thinning, weakening of tendons, nerve damage, and cartilage loss (this is why it’s not recommended more than 3-4 times a year).
  • Risk of Infection (low).
  • Risk of allergic reaction (low).
  • Can cause blood sugar levels to rise (problem for diabetics).
  • Exposure to high levels of cortisol over an extended period can increase the risk of hypercortisolism (Cushing's syndrome). Cushing's syndrome comes with a host of long-lasting or permanent side effects.

2. Viscosupplementation Injections

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(also known as Hyaluronic/ Hyaluronan injections, Gel Injections, Rooster Comb injections, Intra-Articular Injection and Joint-Fluid Therapy)

Viscosupplementation injections are commonly called “hyaluronic injections” or “gel injections” or “rooster comb injections”. With this injection type, a gel-like fluid (called hyaluronic acid) is injected right into the joint. Hyaluronic acid is a naturally occurring substance found in the fluid that surrounds the joint. People with osteoarthritis have less than normal hyaluronic acid in their joints. Adding hyaluronic acid (which is usually in its water-soluble form, sodium hyaluronate) to a troubled joint helps with movement and pain, absorbing the impact placed on your joint.

Lubricating your joint is like greasing up a rusty bike chain!

Majority of hyaluronic injections actually contain processed chicken or rooster combs (hence the name “rooster injections”). People with allergies to poultry, eggs and feathers may need to avoid this type of injection!

The Procedure: Depending on the brand and product your physician uses, in a single injection episode anywhere between 1 and 5 shots will be administered. Before injecting into the knee, the excess fluid will first be drained. Some critics of hyaluronic injections and some medical studies argue that it is the removing of this excess fluid that actually provides the most benefit--not the hyaluronic acid itself. Once excess fluid is drained the knee or hip is injected. For a hip joint, the injection is administered with the aid of an x-ray or ultrasound for accuracy.

Timeline: The injection can take several weeks to take full effect. Effective up to 6 months. Can be repeated 2-3 times a year.

Cost: Covered in full or partially by most insurance companies.

Brands

There are a variety of names of injections for knee pain and hip pain. Your physician likely works with a handful of brands, all of which are very comparable with only slight differences in how they are administered.

  • Euflexxa- Sodium hyaluronate. A single injection episode is actually 3 injections given over a 3 week period. This is a safe choice for those with poultry or egg allergies as it is not derived from poultry. Also, available for patients with hip or knee pain related to osteoarthritis.
  • Orthovisc- Sodium hyaluronate. Given as 3 injections given over a 3 week period. Only for patients with knee pain related to osteoarthritis.
  • Nuflexxa- Sodium hyaluronate. Given as 3 injections over a 3 week period. Available for patients with hip or knee pain related to osteoarthritis.
  • Hyalgan- Sodium hyaluronate. An episode is 5 injections given over a 5 week period. Only for patients with knee pain related to osteoarthritis.
  • Supartz- Sodium hyaluronate. Nearly identical to Hyalgan. 5 injections delivered over 5 weeks. Only for patients with knee pain related to osteoarthritis.
  • SynviscOne- Hylan. The newer version of Synvisc, where only a single injection is required. Available for patients with hip or knee pain related to osteoarthritis. Trials on pain relief have only been conducted on knee patients.
  • Monovisc- Made by Orthovisc, this is their brand’s answer to a single injection viscosupplementation. Only for patients with knee pain related to osteoarthritis.
Pros
  • Hyaluronic acid can offer relief for 6 or more months in some patients.
  • Draining of fluids from joints (done in the procedure) can also offer pain relief and reduce swelling.
  • Can postpone the need of joint replacement surgery.
Cons
  • Risk of Infection (low).
  • Can cause a local reaction which includes temporary pain, warmth, slight swelling, redness, fluid retention in joint, muscle pain etc.
  • Feelings of nausea and headache.
  • Mixed reviews and research about whether or not it really helps. This study suggests it does.

The following two injection types your orthopedic surgeon or medical team may recommend (although less commonly) are: Platelet Rich Plasma (PRP) Injections and Stem Cell Injections. Unlike standard injections, these experimental forms not only aim to reduce pain and increase mobility, but actually claim to heal the damaged joint.

3. Platelet Rich Plasma (PRP) Injections

Platelet Rich Plasma (PRP) is relatively new to orthopedics but has been used during surgery for cell regeneration for the last 20+ years. PRP is derived from your immune system’s platelets which are found in blood. The platelets are then concentrated and can be injected into the troubled joint area.

PRP injection therapy is said to stimulate healing by producing more collagen. The formation of collagen occurs naturally in skin, bones and tissue. Building collagen in a troubled joint means adding support and even correcting underlying issues caused by arthritis, dysplasia and diseased bone and cartilage. This can reduce pain and improve function.

Timeline: Lasts 3-4 months and can be repeated 1-2 times a year. Cost: Not covered by insurance. $500+.

Pros
  • PRP injections are safe with few risks or side effects since the injection substance is naturally occurring in your body.
  • Some studies show that PRP is most effective in combating joint pain--even more so than cortisone or viscosupplementation. AAOS published a study in April 2017 where a controlled patient group that had PRP therapy “showed a 90 percent decrease in pain from baseline. Patients in the steroid group showed an 8 percent increase in pain from baseline.”
Cons
  • Risk of infection (low).
  • Risk of local reactions like tissue damage and nerve damage (low).
  • It’s hard for experts to judge the effectiveness of PRP in joint replacement candidates.
  • Effectiveness is based on overall health of patient.
  • Long-term effects are unknown since it has not been tested or researched over a long-period for treating osteoarthritis.
  • Standard guidelines of treatment for osteoarthritis have not been established.
  • Expensive and not covered by insurance.

PRP injections are offered by private clinics across the USA. Since they are not regulated, prices vary. Single treatments range from $500 to $1250+ depending on location and clinic.

4. Stem Cell Injections

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Stem cells are like a “magic cell” that can turn into other cells and help heal a damaged area. Stem cells are anti-inflammatory and regenerative, therefore the idea is that when injected into a joint with arthritis (which is inflamed and degenerative), it can heal the area.

Stem cells are found throughout your body and are extracted from a part of your body that has a high-volume of cells--generally bone marrow, fat tissue, or circulating blood. For the procedure, your own stem cells are extracted and reinjected into the damaged area. Unlike cortisone hip or knee injections or hyaluronic injections, stem cell injections have not been approved by the FDA to treat arthritis.

Timeline: A single stem cell injection episode is 2 sessions (1 to extract and reinject stem cells and a second for a platelet injection (similar to PCP). Lasts 3-4 months and can be repeated 1-2 times a year. Cost: Not covered by insurance. $1000+.

Pro
  • Studies point to stem cell therapy helping the body grow new tissue.
  • Helps reverse effects of arthritis by rebuilding damaged tissue and counteracting bone degradation.
Cons
  • Extracting bone marrow can be very painful.
  • Risk of infection (low).
  • Risk of local reactions like tissue damage and nerve damage (low).
  • It’s hard for experts to judge the effectiveness of stem cell injections.
  • Long-term effects are unknown since it has not been tested or researched over a long-period.
  • The most expensive injection type.

Comparison Chart: 4 Types of Injections

Cortisone Visco PRP Stem Cell
AKA CorticoSteroids, Steroid Injections Hyaluronic/ Hyaluronan injections, Gel Injections, Rooster Comb injections, Intra-Articular Injection and Joint-Fluid Therapy Platelet Rich Plasma -
What? Made of cortisone. Injected into the numbed joint area to treat inflammation and indirectly, pain. Adding hyaluronic acid is like adding lubrbrication to the joint. Helps with movement, pain, and absorbing impact. PRP is from platelets in blood. Natural injection is said to stimulate healing by producing more collagen. Stem cells are extracted and reinjected into the damaged area.
Procedure Area is numbed with local anesthetic and injection is administered. Fluid is drained from joint and injection is administered. Done in a single shot or up to 5 shots over 5 weeks. PRP is derived from your immune system’s platelets and concentrated into an injectible. Injected into joint area. Stem cells are extracted from bone marrow, tissue or blood and reinjected into joint. Often a follow-up platelet injection is administered.
Time to take effect Can take weeks to be effective. Can take weeks to be effective. Can take weeks to be effective. Can take weeks to be effective.
How many times per year? Can be Repeated up to 3-4 times a year. Can be Repeated up to 2-3 times a year. Can be Repeated up to 1-2 times a year. Can be Repeated up to 1-2 times a year.
Cost Covered full or partially by insurance. Covered full or partially by insurance. Not covered. $500+ Not covered. $1000+
How long does it last? Days to 1 Year. Days to 6 months. Days to 3-4 months. Days to 3-4 months.
Pros More powerful than oral anti-inflammatory meds.

Postpones the need of joint replacement surgery.

Suppresses immune system (good for rheumatoid arthritis).
Draining fluids from joints offers pain relief and reduces swelling.

Postpones the need of joint replacement surgery.
Safe with few risks or side effects.

Some studies show that PRP is more effective in combating joint pain than cortisone or visco.
Studies show that stem cell therapy can help the body grow new tissue.

Helps reverse effects of arthritis by rebuilding damaged tissue.
Cons Repeated use can cause bone loss/thinning, weakening of tendons, nerve damage, and cartilage loss.

Risk of infection.

Risk of allergic reaction.

Can cause blood sugar levels to rise

Increased risk of hypercortisolism (Cushing's syndrome).
Repeated use can cause bone loss/thinning, weakening of tendons, nerve damage, and cartilage loss.

Risk of infection.

Risk of allergic reaction.

Can cause blood sugar levels to rise

Increased risk of hypercortisolism (Cushing's syndrome).
Risk of infection.

Risk of local reactions like tissue damage and nerve damage.

Unknown how effective it is.

Long-term effects are unknown.

Costly.
Extracting bone marrow can be painful.

Risk of infection.

Risk of local reactions.

Unknown how effective it is..

Long-term effects are unknown.

The most expensive injection type.

Are you having or researching hip or knee replacement surgery? Let us help match you with a best surgeon in your area who offers PeerWell's best-in-class PreHab program for free. Sign-up to learn more.

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Hi, I'm Grace. I write all things surgery for the PeerWell blog. You may remember me from such titles as: "Diabetes & Joint Replacement 101" & "Sex After a Joint Replacement".

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