Saturday, July 18, 2015

Forbes on Hyaluronic Acid Injections: Don’t Waste Your Money

I found this article by a Forbes writer (who suffers from knee pain) to be a good read.

Readers of this blog may recognize that meta-study he references that’s critical of hyaluronic acid injections. I wrote about it back in July 2012.

I then followed a year later with this post, which in many ways was more interesting, as it deconstructed a counterpoint meta-study that found the injections provided “significant improvement in pain.”

So was it simply a matter of warring meta-studies, with nothing resolved in the end? Well  . . . the second meta-study, it so turned out, was “supported” to some unclear degree by makers of viscosupplements and put out by an “open access” publisher. Lots of funny odors coming off that one.

So is hyaluronic acid -- a kind of synthetic synovial fluid, which is the “oil” that your knee joints need to stay lubricated and easy moving -- a waste of money?

Judging from anecdotal evidence, I don’t know. I’ve read comments from some patients who claim to experience a lessening of symptoms after the procedure. However, the effect of the shots can wear off in as little as three or four weeks. And then, you have other patients who claim that they felt worse after getting the shots.

So it’s kind of a crapshoot. Anyone considering viscosupplementation should look long and hard at the treatment. This is a moneymaker for a number of drug companies, and for doctors who give the injections. Make sure that when they recommend what to do with your knees, they’re looking out for you, and not their own wallets.


  1. Thank you for your post. The injections I have tried are PRP and I am wondering if other knee pain sufferers have had success? I've had 2 PRP injections and my knees are awful, I feel no different :( For those who had success, how many injections did you require before you started to notice a change? Thanks!

  2. I had 3 PRP injections about 5-6 weeks apart. I noticed a definite improvement within days of the first (reduced pain), not so much after the second, and similar response to the first after the third. But I don't believe it is a miracle cure which can substitute for other things - like doing activity within your envelope of function and time. I think PRP is just part of a multi-faceted approach to healing knee cartilage and/or CNS issues.

    1. TriAgain,

      Have you had lasting results from the PRP? How are your knees? Has PRP + knee friendly motion restored some function in your knees?

      My doc recommends I get PRP every 8 weeks, and he describes it as a one (or maybe two) shot miracle in which I'll be fully healed and able to hike a mountain....After 2 shots I still can't maneuver a staircase, nor straighten my leg out without a stabbing sensation behind the patella. However, the nurse in the clinic had a lifetime of knee pain and told me she had 6 treatments over the course of a year and is now pain free but didn't notice any improvement until after the third injection.

    2. This is really hard to answer, but I'd say I had some lasting repair from PRP, but still no-where near the function and more or less pain free situation I was in before my chronic knee troubles started.

      I used to race long-course triathlon and train 8-12 hrs week, doing things like 4-5hr rides followed by 1hr runs in training. Now I can't run at all, and even a few minutes of easy spinning on a bike causes discomfort later on.

      I'd say my pain is 70% improved now, and PRP probably played a role, but massively modifying what I do on my knees (i.e. no running, cycling, squatting down, crouching) and mostly doing exercise that I'd once have regarded as pathetic for the last 3yrs (e.g. regular 20-30min walks) plus time have probably played a bigger role in pain reducrion. I'd say my knee function is only improved maybe 30% however - I can't do anywhere near what I used to yet, and don't expect I ever will. My long term goal is to be able to ride an MTB again moderately for 30-60mins a few times a week, and continue to fly-fish which involves a lot of walking on uneven ground.

      Coming to the realisation that triathlon and running were over from me probably helped too, as well as doing some meditation/neuroplasticity exercises to deal with the pain and depression of losing the sport that gave me purpose and energy in life.

      Interesting story about the nurse - I was told similar by the nurse at my PRP clinic about a patient who played hockey and was all good after 3 shots. They also told me 3 shots was when I'd start feeling improvement, but I felt it after one.

      Do you know what is wrong with your knees? Is is a defined injury, or the dreaded PFPS-type thing like mine where both knees suddenly lose the plot?

    3. I feel your pain! Knee pain is hell, it is hard to wrap the brain around going from being extremely active - to feeling like a crippled up senior. I'm glad to hear that you are finding some relief and success; it is a long road. I haven't raised my heart rate for at least a year and that is the goal I am desperately trying to get to, as it has so many health benefits. And, walk up/down stairs like a normal person again.

      My official diagnosis is osteoarthritis. I did have a bad fall on my left knee, which eventually lead to a melt down of my right knee (overcompensation). I believe overtraining (crossfit, weight training) is the true cause of my knee pain and the fall was just the last straw.

      I've considered looking into scheduling an appointment at Doug Kelsey's clinic, but that means flying in from Canada and I'd have to see what the cost of a consultation even is. My knees are priceless and I don't want a lifetime of pain and plan is to continue my daily walks and PRP and see if I can notice a significant improvement.

      My friends are all avid hikers and mountain bikers so I miss that so much and would love to return to those activities. I've been battling this for 2 years and started my low load/high rep rehab plan in Feb. So I'm only a few months into it as I did physio for months. My PT told me spin class is great for knees, so I was spinning away with high resistance.... absolutely destroyed my knees. So frustrating that with our medical knowledge, the health community is still SO wrong about how to treat knees.

      Interesting! I find that typically the nurse is the best person to ask! I would be so grateful if I'm healed after 3 shots like that hockey player. Hey, I think Tiger Woods had 4 PRP shots in his knees to restore function? Maybe it's possible!

      Do you get the stabbing sensation in your knees if you move a certain way? Such as stairs, sitting down, getting in/out of a car? I certainly do, and my knees always have that burning, tingly, achy feeling. I've even started clenching in my sleep from the stress of it all.

      Are you going to continue with PRP?

    4. PRP helps, but you need exercise to build up on that. If I would have had PRP only and no exercise, my situation would be the same. Don't waste all your money on PRP if you don't see improvement after 3 shots. And if it's to much to travel to Austin, get in touch with one of his coach - they do an amazing work even by Skype.
      Hope this helps

    5. Athenea,
      Did you do a consultation via Skype? Or did you Skype + had an in-person consultation? I have emailed their clinic to inquire about online coaching but have not heard back yet.

    6. Hi! I am currently doing Skype consultations. I live in Ireland so for me going to US is kinda far away. I don't know if Sports Center can recommend you a coach. I found mine in Kelsey's blog (About section).
      Yes, ideally I would have loved to go there in person and get checked but well... my knees have been checked by pretty good doctors here in Ireland and in Spain (where I'm from) so it is clear what my problem is.

      I was very skeptical about working with someone via Skype, specially for "physical activities" but my coach is doing an amazing job. And the good thing is that, because she is so experienced, just by listening to what your symptoms are (frequency, intensity and a bunch of more things you get asked), she is able to develop a tailored exercise programme for you.
      My experience is good. 7 months ago I could barely walk for 5 min. Now I'm in much better shape, going for 1 hour walks with no pain, stronger body etc.
      I'm not trying to sell you anything but if you are struggling give it a go. I think she can do a first consultation for free to check if she can help.
      All the best,

    7. Wonderful! May I please ask what your coaches name is? Thanks! :)

    8. This comment has been removed by the author.

    9. Have you ever heard of the website ? It is a very good reading and is in the same line of thinking as Richard. I also believe Richard links to them in some articles (not really sure though). Not exactly the same line of thinking, as I don't remember they mentioning cartilage regeneration, but they believe in the envelope of function and continuous improvement, while also dismissing minor alignment flaws as the major cause of PFPS. Well... where I want to get is that the PT's that write this website work in Vancouver, so it could be a nice option for you.

  3. Sounds like we are in a similar place. It is definitely the toughest thing I've had to deal with in my 51 years. What is harder is that it happened so quickly. Feb 2012 I did the best race of my life. April 2012 I tore my medial meniscus during an easy run and had a loose piece removed with arthroscopic surgery in May. By June 2012, I was crippled in both knees.

    Re the stabbing sensation. I used to get that from time to time (more like a stab/catch) before all my chronic troubles started and MRIs suggested it was due to patella chondromalacia - I had some patches on cartilage damage on the back of my patella, esp the right one (which is not the knee I had meniscus surgery on, but is now the worst knee). but it never put me out of action for more than week. Some rest and using a knee brace (ThermoSkin brand) to keep it warm always saw it settle quickly. I had those symptoms for years but it never put me out of action or bothered me for long. I used to get it most when going downhill, or pushing in the clutch in my 4WD, or getting out of a low car.

    In 2011, and early 2012 I do remember getting some medial joint line pain, and a strange sensation in both knees while running. This started 12mths before my meniscus tore and the real trouble started. Perhaps some early warning signs here, and the meltdown would have happened anyway even without the meniscus surgery on the left knee.

    After the surgery, the joint line pain in both knees got worse, and I developed that permanent burny/tingly/achy feeling you describe - you have nailed it, that is exactly what it is, plus the knees feel stiff and fragile. The focus of the pain is directly under the kneecap, but it moves about a bit, even going up and down into other areas above/below the knee joint.

    As for continuing with PRP, I'm not sure. It's been almost 12mths since my last injection and with activity modification, I'd have to say my knees are still improving, but at a glacial pace! If things start going backwards or plateauing, I'd go for another round of PRP.

    I'm in Australia where PRP seems to be cheaper than other countries, though I have to travel 5hrs and stay overnight for treatment.

    If I can get back to being 90% pain-free and able to ride an MTB a little, I'd probably settle for that and forget more PRP. I hear you about getting the heart rate up - initially I could only do that via swimming (with pull buoy & ankles tied together as kicking aggravated) but it is pretty boring compared to running & cycling. Now I have a little 30min gym circuit with some boxing which is also somewhat aerobic, but it's a bit risky/experimental still.

    The only exercise I've found to be entirely knee-safe is moderate walking. I got the Kelsey book and tried his routine but it was too much. It might have worked with his personal guidance however the US is a long way from Oz!

    I suspect the best plan is actually the one Paul Ingraham describes in his book which is 3 mths of doing almost nothing (massive lifestyle modification) followed by 6 or so mths of gradually re-introducing activities which used to aggravate. But is it nearly impossible to do without quitting your job and getting near full-time help.....which is more or less what Richard did in his book.

    Almost all PT's/physios/medicos etc positively dangerous when it comes to this type of chronic PFPS. Like you discovered, their exercises make it worse. I've given up on them, and get more ideas on what to do from fellow knee-pain sufferers, especially those who have made good gains. My GP is an exception as he was a runner who got bad patella chondro too, so he knows the 'saw-tooth' shaped trajectory of the recovery, and understands the mental anguish. But even he was pretty devoid of ideas, so I have to figure it out for myself.

    I've reached the stage where the loss of sport became secondary to the desire to lose the constant pain.....though a few endorphins from an MTB ride would be nice.

  4. Just thought I'd share an update on my rehab/recovery process so far. I took nerve pain medication (Gabapentin) for 3 weeks, then spent 2 weeks tapering off of them completely (at my doctor's recommendation) before beginning a walk-run program. By then, I was cycling regularly (and up to 70+ k/day on a bike touring trip, albeit slowly) and could walk down small steps without pain, which seemed fairly miraculous. It was like hitting a reset switch in my brain.

    Running though, even a few steps, still produced stabbing pain. After 4 weeks of the gradual walk-run program, I'm now able to run continuously for 30 min on flat road, although not without some pain. I'm currently trying to decide if I should continue a very gradual ramp-up in running time, stay at 30 min 3x/week, or cut back a bit.

    Doctor says "no pain" is not necessarily the goal, given that nerve pain is one of my primary problems and gets worse the more I fuss and stress over little pains. Also, throughout the walk-run program, I've never really been completely pain free while running, but I've been able to increase my mileage/time without getting worse, and the pain never lingers after the run and often gets better while I'm running. Definitely makes me think my nerves are the main culprit and I need to find a way to re-wire them specifically for running. In any case,

    I'm definitely not out of the woods yet and will continue my slow and patient recovery process and hopefully update with some more positive news in the future. Wishing everyone here the best with their recovery in the meantime.

  5. runnerD, when you say 'nerve pain', does the Dr think it is the actual nerves in your knees, or central nervous system changes?

    If it is CNS change, start looking at the stuff on neuroplasticity - this website is a good place to start: This is what I'm looking at, as part of my cure.

    Regardless, your recovery sounds very rapid compared to me and others. Just shows how different knee problems can be.

    1. TriAgain, my doctor didn't specify. Just called it neuropathic pain, which could be peripheral or central, as far as I understand. Not sure if there is a way to isolate which it is?

      Yes, knee pain and the recovery process seems to be very individualized. What worked for Richard - documenting and tracking every ache and pain and its consequences - did not work for me because I would worry and stress more by paying such close attention to my knees. Once the drugs took away my pain for awhile, I was able to finally stop thinking about my knees 24/7 and get back to easy movement which seemed to dramatically increase my level of function. Still a long way to go though, as a return to long distance trail running is still my ultimate goal.

    2. It is intriguing that your doctor appears to have nailed the neuropathic pain so quickly, and not go down the 'strengthen your VMO with single leg squats' that seems to be the common recipe most trot out.

      Did you have MRI etc. scans which revealed no real physical damage - hence the doctors quick and very fortunate move to consider nerve pain?

    3. I spent quite a few months going to physio before seeing the doctor and did the whole single leg squat routine, etc, which of course only made my knees worse. The doctor I see is a specialist in sports medicine - he's the best doctor I've encountered and also comes highly recommended by others (including other doctors I know).

      I had an MRI done on my left knee, which revealed focal full thickness loss of cartilage behind the kneecap (Grade IV chondromalacia), mainly toward the outer part of my knee. But my doctor believes I should still be able to run without pain and identified the constant aching and burning pain I started getting shortly after as an abnormal pain pattern that wasn't explained by the physical damage seen in the MRI. Hence his conclusion regarding neuropathic pain.

    4. Absolutely intriguing runnerD. Before my chronic problem started I had MRIs which showed similar damage to yours behind the kneecap, and my OS expressed his surprise I could still do triathlon with few problems.

      Then I tore my left meniscus, had surgery for that, and ended up with the same dual knee pain issues you have. I'm pretty sure that surgery triggered a CNS change where my CNS decided triathlon was dangerous for my knees.

      I can recall talking to so many people my age over the years who said they could not do things like triathlon because their knees were buggered, and thinking how lucky I was to reach my late 40's and still be OK. This probably planted the CNS implosion seed, which was triggered into growth when I did actually have one fairly minor knee surgery.

      My wife and a friend had identical surgeries with the same O/S and were back running within a month. And my pain is not just at the meniscus site, but more widespread, which again makes me think CNS gone haywire.

      I was on Lyrica (pre-gabalin) for a while for nerve pain, but it made me so feel so drunk I couldn't work properly.

      However, it was me who had to suggest to my medicos the possibility of neuropathic pain - hence an eventual session with a pain specialist, PRP and Lyrica plus other natural meds. Like you, they were all initially working on the structural theory. And even then, most were still hedging their bets, giving nerve pain meds but also the dreaded single leg squats.

      Sounds like you struck a very good medico! Also sounds like I'm on the right track with my own research, though I do ponder if I need to get back on nerve pain meds.

    5. It definitely sounds like you're on the right track, TriAgain. My plan is to continue with building my running volume as much as possible, then revisit the meds again if I need it to get over a second pain hump that might be specific to running. I was lucky enough to not have any side-effects from the drugs, so perhaps you can find one that doesn't interfere with daily function.

  6. RunnerD, that is so positive!
    Incidentally, I am taking Neurontin too (generic Gabapentin) for a different reason: I had a bad episode of jaw pain following dental work. After multiple visits to the dentist, the endondentist, I was finally sent to the pain specialist I had seen before for the same reason. Atypical neuralgia, hence the Gabapentin.
    I'm not sure if it made a difference, because I was definitively getting better even before I got the neuralgia. For the last 6-8 weeks, I have been doing more and getting less set backs, and even these don't last long. About 2 months ago, I did my first hiking trip, albeit a very easy and short one. Success! I did another one last month, and it felt so good.
    Then the dental pain started and I was taking Nurofen and paracetamol for it, and of course it stopped the pain in my knee too. I was a bit nervous as I didn't want to overdo it, but I could definitively do more than usual. I definitively had some pain when I stopped taking painkillers, but it wasn't as terrible as I had feared. And within days, I was fine again. I believe the Neurontin helped somehow, but to what extent?
    Even though I stopped the water physio classes in May, I am still going twice a week to the pool and do some water exercises. One session with some swimming (with and without the buoy) followed by 10/15 min of deep water running. One session for all the physio exercises: running, jumping, cycling, etc. Some days are great, some a bit less. But my pain and knee function definitively improved. I even got back on my bike, only once a week and for a very short time, interspersed with some walking. So far, so good.

    1. deloupy, that sounds fantastic! So glad to hear that you are able to hike again. I think just being able to get out and enjoy the outdoors again was a huge psychological boost for me, and I've come to realize that feeling positive about my knees is an important part of the recovery process, strange as it may sound.

    2. Deloupy congratulations! that's great news! I am happy for you!