Why There’s No Clear Winner in Treatments for Knee Pain


Pain-relieving treatments for arthritis in the knee all work better than doing nothing, but it’s hard to point to a clear winner, a new research review has concluded.

Using data from almost 140 studies, the researchers found that all the most widely used arthritis treatments, ranging from over-the-counter painkillers to pain-relieving injections, brought more relief to aching knees over three months than did placebo pills.

Overall, the biggest benefit came from treatment using hyaluronic acid (HA), a treatment that some professional medical groups often don’t consider effective. Hyaluronic acid is a lubricating substance found naturally in the joints. Over the years, studies have shown mixed results when testing to see whether adding man made synthetic HA helps arthritic joints, and the treatment remains under debate.

Lead study author Dr. Raveendhara Bannuru cautioned that despite his team’s findings, it’s not clear whether HA itself deserves the credit. That’s because his team found a large placebo effect across the HA studies. Patients who received injections of an inactive substance often reported pain relief, too. As a whole, the people who were given placebo injections did better than people in other trials who were given placebo pills. 

According to Bannuru’s team, that suggests there is something about the “delivery method” – injections into the knee joint, whatever the substance – that helps ease some people’s pain. But there’s no clear explanation for why that would be. According to the U.S. Centers for Disease Control and Prevention, at least 27 million Americans have osteoarthritis – the “wear and tear” form of arthritis where the cartilage cushioning a joint breaks down. The knees are among the most commonly affected joints.

In the earlier stages of knee arthritis, doctors often recommend oral painkillers like acetaminophen  or nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen.Injections are another option, either with hyaluronic acid or the anti-inflammatory drug cortisone. Bannaru says the problem is that very few studies have actually tested different treatments head-to-head. His team used a statistical method that allowed it to compare results from earlier clinical trials of either oral medications or injections. In general, the review found, all therapies were better than placebo pills at easing pain at the three-month mark. But some stood out. Hyaluronic acid were most effective, followed closely by cortisone. NSAIDs came in next, with acetaminophen coming in at the bottom.

If you suffer from arthritis in your knees, you have options beyond pills and injections. “Even though we didn’t test [them] in our study,” Bannuru said, “it’s important for people with knee arthritis to know there are several non-drug treatments, such as exercise and physical therapy and even regular chiropractic care.”


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