What to try before choosing a joint procedure

What to change when movement hurts more

Easy strength work and shorter periods of activity often come first. The joint shouldn't feel much worse when you wake the next morning.

Change only the walking distance, speed or hills at first. One change makes it easier to tell what caused more soreness.

What to ask about each joint procedure

Joint gel is thick fluid placed into a knee with a shot. Cortisone is a drug given by a shot to calm swelling for a time.

PRP is blood spun to keep more platelets, the small blood parts that help clotting. Staff then place that concentrated blood into the sore joint with a needle.

For a marrow procedure, staff draw soft tissue from inside the pelvic bone. A fat procedure removes fat through a small tube, leaving another sore area.

What to compare before making a choice

Studies of PRP disagree about how much relief it adds. One large careful study found no clear gain over a saltwater shot.

Studies haven't shown marrow or fat choices work better than PRP. Most research also concerns milder knee wear, not a badly worn hip.

Surgery may deserve an opinion when rest soreness or lost movement is severe. It isn't a failure after simpler care, though recovery takes longer.

What to settle before booking the visit

Ask when you may drive, use stairs and sleep on that side. Find out what help you'll need during the first days home.

Keep using home care that the clinician says is safe. Don't book until the steps, limits, cost and follow-up are clear.

Sources

1. A network meta-analysis restricted to LARGE randomized trials (at least 100 patients per group; 57 RCTs, 22,795 participants, 18 intra-articular interventions) found treatment effects were consistently larger in the 35 high-risk-of-bias trials than in the 22 low/unclear-risk trials. In the main analysis excluding high-risk trials, triamcinolone had the highest probability of exceeding the minimal important difference at weeks 2 and 6; hyaluronic acid had no effect on pain (SMD -0.04, 95% CrI -0.19 to 0.11, 11 trials) but higher odds of dropouts due to adverse events (OR 2.01) and of serious adverse events (OR 1.86). The effects of 16 of the 18 interventions were smaller than the MID and most were consistent with placebo effects.

   Pereira TV, et al. — Effectiveness and safety of intra-articular interventions for knee and hip osteoarthritis based on large randomized trials: A systematic review and network meta-analysis.. Osteoarthritis and Cartilage, 2025. DOI: 10.1016/j.joca.2024.08.014.

2. A Bayesian network meta-analysis of 48 Level I-II randomized trials (9,338 knees) with a minimum 6-month follow-up ranked the four commonest intra-articular injections. HA and PRP both significantly improved pain versus placebo; HA, PRP and BMAC all significantly improved function versus placebo. SUCRA rankings were PRP 91.54, BMAC 76.46, HA 53.12, corticosteroid 15.18 and placebo 13.70 - corticosteroid ranked barely above placebo at six months and beyond.

   Jawanda H, et al. — Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.. Arthroscopy, 2024. DOI: 10.1016/j.arthro.2024.01.037.

3. The largest head-to-head trial of cell-based orthobiologics to date randomised 480 patients with KL II-IV knee OA across four arms: autologous bone marrow aspirate concentrate, autologous adipose stromal vascular fraction, allogeneic umbilical cord tissue-derived MSCs, and a corticosteroid injection control. At 12 months NONE of the three orthobiologic injections was superior to another or to the corticosteroid control on either co-primary endpoint (VAS pain, KOOS pain), and none of the four groups showed a significant change in MRI osteoarthritis score from baseline. No procedure-related serious adverse events were reported.

   Mautner K, et al. — Cell-based versus corticosteroid injections for knee pain in osteoarthritis: a randomized phase 3 trial.. Nature Medicine, 2023. DOI: 10.1038/s41591-023-02632-w.

4. The BMJ meta-analysis of viscosupplementation pooled 169 trials (21,163 participants) and found clear evidence of small-study effects and publication bias. In the prespecified main analysis of 24 LARGE placebo-controlled trials (8,997 participants) hyaluronic acid reduced pain by SMD -0.08 (95% CI -0.15 to -0.02), equivalent to 2.0 mm on a 100 mm scale - far below the -0.37 minimal important difference - and trial sequential analysis showed there has been CONCLUSIVE evidence of clinical equivalence to placebo since 2009. Fifteen large trials showed a significantly higher risk of serious adverse events (RR 1.49).

   Pereira TV, et al. — Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis.. BMJ, 2022. DOI: 10.1136/bmj-2022-069722.

5. A meta-analysis of 6 RCTs (860 patients, 334 receiving BMAC) found overall complication rates of 41.91% for BMAC versus 41.25% for comparator injectables (P=0.85), with knee effusion the commonest BMAC complication at 18.26%. Early and late complication rates did not differ significantly from HA, steroids, PRP, SVF, MSC or saline. The number needed to harm for BMAC relative to other injections was 152.

   Fucaloro S, et al. — Complication rates of bone marrow aspirate concentrate injections versus other injectable therapies for knee osteoarthritis: A systematic review and meta-analysis.. Journal of Orthopaedics, 2025. DOI: 10.1016/j.jor.2024.10.005.

6. A double-blind randomized trial allocated 192 patients with KL 1-3 knee OA to three weekly injections of leukocyte-RICH or leukocyte-POOR PRP (mean leukocyte concentration 7,991 x10^6/L vs 0.1 x10^6/L). No difference was found in any clinical score at 2, 6 or 12 months (IKDC improved 45.6 to 60.7 vs 46.8 to 62.9; P=.626). Mild adverse events were numerically more frequent with leukocyte-rich PRP (12.2% vs 4.7%) but not significantly so.

   Di Martino A, et al. — Leukocyte-Rich versus Leukocyte-Poor Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Double-Blind Randomized Trial.. American Journal of Sports Medicine, 2022. DOI: 10.1177/03635465211064303.

7. A multicenter single-blind RCT randomised 200 patients 1:1:1 to a single injection of saline, hyaluronic acid or amniotic suspension allograft. ASA produced significant KOOS and VAS improvements maintained through 12 months with a 63.2% OMERACT-OARSI responder rate, no radiographic differences, and no concerning immunoglobulin or anti-HLA responses. Adverse events with ASA were comparable to HA, while NO treatment-emergent adverse events were reported in the saline group.

   Gomoll AH, et al. — Safety and Efficacy of an Amniotic Suspension Allograft Injection Over 12 Months in a Single-Blinded, Randomized Controlled Trial for Symptomatic Osteoarthritis of the Knee.. Arthroscopy, 2021. DOI: 10.1016/j.arthro.2021.02.044.

8. RESTORE, the largest and most rigorously blinded placebo-controlled PRP trial in knee OA (n=288, participant-, injector- and assessor-blinded), gave three weekly injections of a commercial leukocyte-poor PRP or saline. At 12 months the change in knee pain was -2.1 vs -1.8 points (difference -0.4; 95% CI -0.9 to 0.2; P=.17) and the change in medial tibial cartilage volume was -1.4% vs -1.2% (difference -0.2%; P=.81). Twenty-nine of 31 prespecified secondary outcomes showed no between-group difference. The authors concluded the findings do not support the use of PRP for knee OA.

   Bennell KL, et al. — Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial.. JAMA, 2021. DOI: 10.1001/jama.2021.19415.

9. FDA states verbatim of stem cell products, stromal vascular fraction (adipose-derived cells), umbilical cord blood, Wharton's jelly, amniotic fluid and exosome products: 'None of these products have been approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain.' The only FDA-approved stem cell products in the United States are blood-forming (hematopoietic progenitor) cells derived from umbilical cord blood, approved only for disorders of blood production, and there are currently NO FDA-approved exosome products.

   U.S. Food and Drug Administration — Consumer Alert on Regenerative Medicine Products Including Stem Cells and Exosomes. FDA (Center for Biologics Evaluation and Research), 2020.