Cortisone refers to a family of 4-5 different steroids (Depomedrol, Celestone, Methylprednisolone, Triamcinolone, or Kenalog). Steroids are tiny lipophilic molecules that can go through cell membranes, enter the nucleus of the cell, and shut off the production of inflammatory proteins and cytokines like IL-1, TNF-alpha, etc.

Because cortisone can move through cell membranes, a small portion of the cortisone can enter the capillaries around the joint and be transported throughout your body. Most of the steroid medicine works on the knee, but some of the steroid can affect the rest of the body.

Cortisone shot usually start working in a day and will typically last a few weeks to a few months.

Patients can get a cortisone shot every 3 months as long as the shots are affective. Each additional shot usually works about 90% as well as the previous shot which means most patients will benefit from 5-7 shots in their lifetime.

When patients no longer get any benefit from cortisone shots, it may be time to consider a knee replacement.

Diabetics may see a slight bump in the glucose levels and some patients report an increase in their appetite. Patients with dark skin will occasionally see a slight lightening of their skin color around the injection site.

Insurance does not require a prior authorization to get a cortisone shot because these shots are inexpensive.

Toradol is an injectable NSAID that can relieve knee pain. It works within a few hours but only lasts a few days. I often combine Toradol with Depo-Medrol when I do an injection.

Lubrication shots are known by many names: gel shots, viscosupplementation, hyaluronic acid (HA), chicken shots, and roster cone injections. There are many brand names, but the active ingredient is always hyaluronic acid (HA).

• Monovisc, Orthovisc, Synvisc, Hyalgen, Supratz, Eufleuza

About a third of patients report positive outcomes with lubrication injections. About a third of patients get no response. Some patients get an inflammatory response that makes them worse.

The AAOS removed lubrication shots from their list of appropriate treatment options around 2018 because most research papers show little to no benefit beyond the placebo effect.

Lubrication injections usually require prior authorization and failure of previous treatment (i.e., a cortisone shot) for the insurance company to approve the shot. These shots usually cost around ~$1000.

If you want lubrication shots, please let Dr. Kurtz and/or Kristie know before you come to the clinic so we can attempt to obtain the required prior authorization prior to your visit.

Zilretta is a long acting steroid shot. The steroid molecule is encapsulated in a dissolvable microsphere that slowly dissolves over 3-4 months. The microspheres have a variable size which allows for some of the steroid to be released early and some to be released months later.

In my experience, patients respond similarly to Zilretta injections and standard cortisone injections. Zilretta cost ~10X more than cortisone, so I usually recommend cortisone injections.

Platelet Rich Plasma (PRP) shots involve drawing blood out of your arm, separating the platelets from the red blood cells, and injecting the platelets into your knee joint.

These platelets can be best thought of as little sacks of chemicals (growth factors and other proteins) that burst open from mechanical trauma after they are injected into a knee joint.

PRP shots will not regrow cartilage.

They may relieve pain for 1-2 months but don’t work for everyone.

Insurance does not cover the cost of PRP shots. TOA charges patients ~$700 for a PRP shot, which covers our cost of the kit used to spin down the platelets.

BPC-157, also known as the wolverine peptide, is a short sequence of amino acids that may anecdotally help with tissue recovery. BPC-157 is a naturally occurring peptide (short protein) in the lining of the stomach. There are no human clinical studies to justify its claims of tissue recovery, but there are some mouse studies that show improved blood flow and tissue recovery. There are 2 human studies that were basically phone interviews with 14 patients who reported no adverse outcomes or side effects.

For reference, insulin, Oxempic, Montjaro, and Wegovy are FDA-approved peptides, so peptides as a class of medications seem promising.

BPC-157 cannot legally be manufactured in compounding pharmacies, so patients obtain it on the “black market” from China. This means there is no oversight on the production of the medication. It is popular with gym aficionados.

My personal opinion is that I hope BPC-157 will improve soft tissue healing but cannot recommend it at this time. I need to see at least some human research that shows some clinical improvement. I have seen other medications in the past with claims and anecdotal stories similar to those of BPC-157 that did not hold up with independent analysis. I think it is unlikely that BPC-157 would be harmful.

Stem cell injections have not been shown to regrow cartilage or substantially improve knee arthritis symptoms. Stem cells that are injected into the knee joint have no capability of adhering to the cartilage cells on the articular surface of the knee. These injected stem cells just float around in the synovial fluid until they are crushed from mechanical trauma.

When considering the potential utility of stem cell injections, it is helpful to understand how knee cartilage is made. Chondrocytes (cartilage cells) begin as immature chondrocytes about 3-4 mm below the articular surface. These immature chondrocytes are formed in a scaffolding with the other immature chondrocytes next to them. As these cells mature, they slowly advance to the articular surface, firmly attached to the chondrocyte next to them. Each chondrocyte remains connected to the next chondrocyte for the entire life of those chondrocytes.

As an analogy, if you pick up a piece of tree bark on the ground and put it back on the damaged tree, the bark will not grow back to the tree. The wind and rain will just knock the bark off the tree. Both chondrocytes and tree bark must start and finish their journey connected to their neighbor at all times.

As an optimist, you might argue that when stem cells rupture from the mechanical trauma, they might release helpful proteins into the knee just like a PRP injection. While these proteins inside stem cells could be beneficial, the high cost of these stem cell injections does not justify the theoretical benefit in my opinion.

Stem cell injections are not FDA regulated. They are not scientifically shown to improve arthritis symptoms. Please be careful in pursuing this option, as there are many charlatans in this space. The FTC is suing predatory stem cell clinics for making false claims.

Closed chain exercises are preferable to open chain exercises for patients with knee arthritis. Closed chain exercises mean that the patient’s foot stays on the surface during the exercise. Examples of closed chain exercises include road bike, stationary bike, recumbent bike, rowing machine, elliptical machine, and Nordic track. Examples of open chain exercises include running, jogging, walking and jumping.

Physical therapy can help some patients strengthen muscles and improve mobility. PT is also helpful to get patients prepared for a knee replacement.

Yoga helps maintain flexibility and balance. The gentle nature of yoga means is it safe for most patient to try. As always, please seek expert advice when trying something exercises and positions.