The Benefits of Hyaluronate Sodium For Knee Osteoarthritis Injections

knee injectionsIn general, the development of hyaluronate sodium for knee osteoarthritis dates back to the early to mid 1990’s. The full mechanism on how these compounds work has not been fully understood, but it is believed that they stimulate the cells in the joints to produce joint fluid and thus provide lubrication and cushioning within the joint. In the United States, these compounds have only been FDA approved for the use in the knee joint, but around the world they have been used successfully in a number of joints including shoulders, hands, hips and feet.

Knee Joint Injections

The first compound used was Synvisc. This has been produced from the rooster combs (the flesh on the top of their head) and was highly refined. Initially, it was administered in a series of five injections and has gradually been changed to a single injection. Orthopedic knee surgeons were the first to perform such injections and still probably perform the most of these injections. Since it was the first product on the market, many physicians are likely to use it.

From experience, however, it has significant drawbacks. The number one is that since it is refined from an animal product, there is a definite significant percentage of people who will have an acute inflammatory reaction to this injection. The reaction in the joint is not distinguishable from a joint infection and does often require further intervention, from checking the patient for infection, aspirating the joint, possible hospitalization, and further injection of the joint with steroid.

Since the early 2000’s, artificial hyaluronate sodium compounds have been genetically engineered and are absolutely pure compounds without any material that could cause an allergic response. All these compounds are somewhat similar and have similar effectiveness. Again, initially they came in a series of five injections, but they then refined it to a series of three injections, and now some are a single dose injection. The effectiveness in a variety of studies ranges for reducing knee pain from about 10 percent of people to 30 percent and a maximum of up to 50 percent. Injections often have to be repeated every six months to be most effective.

Who Would Benefit From Knee Injections?

The indications for these injections are osteoarthritis of the knee. Patient selection includes those who cannot take NSAID medications like ibuprofen, those who have not had long relief with steroid joint injections or are limited with steroid use, and those who have mild to moderated degenerative changes to the joint.

Once a patient is found to be a candidate for hyaluronate sodium joint injections, product selection is the next issue. In reality, this is the grey zone for recommendations, and experience with these products is helpful. Manufacturers of the products are pushing the single dose compounds, which these are convenient, however from providers it seems these may be somewhat less effective at producing results than those that are a series of three injections. Again, patient selection may be the most important factor but this is hard to tell definitively. The products that are a series of five injections do not seem to work better than those that are three injections. Further, none of the products are really better than the others when they are genetically engineered pure chemicals.

Choosing the hyaluronate sodium products for injection is based now on several practical issues. The first is to choose an artificial product that is pure. From personal experience, it is a nightmare to deal with an inflammatory reaction to one of these products and the only one that has this issue has been Synvisc, and you’d be best to avoid this injection unless you have a very experienced orthopedic surgeon who can assess your risk of a bad reaction. The best results are from genetically engineered pure products that are a series of three injections, since these tend to induce the cells in the knee to produce joint fluid on their own.

Single shot products may not be as good at inducing the knee cells to produce lubrication from a technical standpoint. The choices then are from three products that include Hyalgan, Euflexxa, and Supartz. These should all produce relatively equal results for the patients, but again on average if the knee osteoarthritis is not extreme, relief in about 30 to 50 percent of the patients is expected. All these products are FDA approved for the knee and the services to provide injections are usually covered by all insurances and are not considered experimental.

The last selection criterion is based on product cost and if an insurance carrier has a specific drug preference. The recommendation for a hyaluronate sodium supplementation product therefore would be one of the three products that include Hyalgan, Euflexxa, or Supartz unless the insurance carrier requires a single shot product, either Orthovisc or Monovisc.

Beyond the above discussion, all these injections should be done with some type of visualization procedure, either fluoroscopy or ultrasound to prove needle location and delivery to the joint space. Secondly, for those patients who want the state of the art treatment and who can pay cash, studies indicate that PRP injections have about a 50 percent success rate for pain relief for at least six months at a time. Furthermore, for the cash paying clientele, they can also use hyaluronate products as well as PRP in many of the joints in the body with about a 50% percent success rate.

4 Common Causes of Knee Pain

knee pain treatmentThere are many causes of knee pain and treatment is dependent on determining the exact cause.  The knee has many components including multiple ligaments, tendons, cartilage, bursa, and bones. Because there are so many components, determining the problem is often difficult. Age and activity level can often be a clue to the existing problems.   Younger and more athletic people have injury type problems, while older people develop issues related to degeneration.  Below are four of the most common causes of knee pain:

  1. Osteoarthritis is the most common type of degeneration that occurs in the knee.  It is the progressive wear of the joint cartilage that occurs with age and use of the joint.  Read more about Osteoarthritis causes and treatment.
  2. Obesity worsens and stresses the joints even more as people age.  The knee becomes chronically swollen, and painful with activity. Treatment is symptomatic – keep the knee moving and strong, and use over the counter medications for the pain as necessary.  If you are obese, try to reduce your weight to relieve additional stress.  When the deterioration is severe, there are orthopedic surgeries that can help including knee replacement.
  3. Traumatic injuries to the knee include torn ligaments, meniscus tears, and tendonitis.  Bony injuries also occur to the patellar and the other bones of the joint area.  The anterior cruciate ligament is the most common ligament damaged in sports, caused when there is a sudden change in direction of the body. The side ligaments can also be injured in sports. These are usually treated conservatively.  The meniscus is part of the cartilage in the knee and is a shock absorber.  Injury to the meniscus occurs with twisting while weight bearing, and is fairly common in older active adults. Surgical repair is simple if conservative management is unsuccessful.
  4. Bursitis & Tendonitis. Brusitis is inflammation of small sacs of fluid that cushion ligaments and muscles around the knee. This condition often resolves with rest. Tendonitis commonly occurs to the patella tendons in runners, skiers, and cyclists. This condition is also best treated with rest.

Pain in the knees is relatively common.  Traumatic injuries often respond to conservative care.  If not resolving, evaluation by a physician is recommended to determine the cause and best treatment options.  Age related changes, such as osteoarthritis, are usually treated conservatively as long as possible.  If conditions worsen, physicians can prescribe stronger medications, special joint injections, and help determine when surgery may be beneficial.

6 Common Running Injuries & Pain Management Tips

running injuryRunning can be stressful to the body, causing injury and pain.  Areas of the body that are often affected by running include the low back, pelvis, hips, knees, ankle and foot joints, as well as the muscles, ligaments and tendons of the lower extremities.  Injuries happen for a number of reasons including overuse, body mechanics, training, and not allowing injuries that have occurred to heal adequately.  Running can be an excellent way to maintain fitness, but listen to your body, and try to use a degree of moderation.

Running Injuries

Listed below are 6 common running injuries and techniques to manage pain associated with each:

  1. Shin splints:  This is a pain along the front of the tibia.  This is thought to be a strain of the muscles attaching to the tibia.  It commonly occurs when increasing distance or frequency of running too fast.  Treatment is icing, rest, gentle stretching and anti-inflammatory medications.
  2. Runner’s knee:  This is pain under the kneecap due to irritation of the patellar cartilage.  It is a mechanical problem related to alignment and forces through the knee.  Up to 15% of runners may have this issue, and up to 40% of runners develop knee injuries.  Ice and anti-inflammatory medications for pain are reasonable, and muscle strengthening and the use of a soft knee brace with patella cut out can help. Knees are also prone to ligament sprains, which present as pain on the inside or outside of the knee, and also for tears of the meniscus, which presents as catching of the knee and internal knee pain.
  3. Stress fractures:  These are small cracks at the surface of the bone.  Common areas are the tibia and feet.  They are caused by the stress placed on the regions with the impact of running and occur most commonly with over training.  These absolutely need to be allowed to heal.  Stop running and stressing the area, when the pain is gone, then one can slowly resume activity.
  4. Ankle sprains:  The ankle is stabilized by ligaments, which allow normal motion.  Sprains are over stretching or tearing of these ligaments often by twisting or rolling the ankle.  Acutely icing the ankle, wrapping, and elevation will allow the injury to heal.  If pain continues or the ankle remains unstable and with activity, one frequently twists the ankle, then surgical repair may be necessary.
  5. Hamstring and Illio-tibial band syndromes:  These are the muscles on the side and back of the upper leg.  Pain in these areas is due to muscle strains.  Initially ice and rest are beneficial. Then, proper warm-up, stretching and training as well as post activity cool down can help treat and prevent this condition.
  6. Plantar fasciitis:  The plantar fascia is a tissue that extends from the heel to the toes along the bottom of the foot.  Pain is usually felt in the arch of the foot.  This tissue can easily be stressed by multiple impacts of the foot with running.  Running shoes with the proper support and alignment for the foot is important as well as whether one runs on pavement or softer surfaces such as dirt.  Icing, stretching the foot and anti-inflammatory medications are used in treatment. When more severe, splints at night and foot orthotics may be prescribed.

Maintaining aerobic fitness is a common goal of many people.  Running has become a favorite of many and for some almost an addiction.  Due to the intensity of this activity, injury is fairly common.  Most injuries can be treated simply, listen to your body, allow it to rest and heal.  When injuries are not healing, seek out good medical attention.

Other good sources of info on running injuries:

Osteoarthritis of the Knee – Treatment Options

osteoarthritis of the kneeEarlier this week, we discussed the signs and symptoms of osteoarthritis in the knee. Today we will further investigate this condition by discussing the treatment options for osteoarthritis.

Treatment of osteoarthritis of the knee includes a wide range of options, starting with lifestyle modifications, medications, and progressing to surgical management. 

Always start simple. Change starts with the individual and is not magical.  The most common first step is to lose excess weight so you are not stressing the joints.  Change the type of activity you are doing from high impact to low impact exercise. Go from jogging to cycling and swimming, or try an elliptical. Walking is always a good alternative as well.  Exercise maintains range of motion, flexibility, and health. Add in strengthening and function may also improve. 

Medication Management

Medication management is the next level of care. Having a physician involved in this level is beneficial to prevent negative side affects.  Natural substances you can take include:

  • A combination of glucosamine and chondroitin. These are natural substances found in joints. If taken orally they are supposed to promote normal joint health.  Scientific studies are mixed on whether they are truly helpful, but they rarely if ever would be harmful, if early in the disease, it may be worthwhile.
  • Fish oil. This can help with joint lubrication.

Prescription level medication starts with acetaminophen, to aspirin and anti-inflammatories, to steroids and injectable compounds.  Acetaminophen is only an analgesic and it treats pain.  Aspirin and ibufrophen or naproxen, are a class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs), and can treat pain and swelling.  These medications are stronger, may be taken orally and may be available as crèmes, but have many side affects and should be used with caution.  Skin preparations however are very safe and may be extremely helpful.

Corticosteroids are very powerful anti-inflammatory hormones, and sometimes on a limited basis orally or as injections can be helpful in controlling pain and swelling for long periods of time.  Lastly, viscosupplementation with injectable hyaluronic acid compounds is used to improve joint fluid production for periods of 3-6 months.

Surgical Options

End stage knee osteoarthritis can be treated surgically.  Orthopedic surgeons can do several things from cleaning up and removing damaged tissue in the joint arthroscopically when appropriate, to replacing the knee joint.  Surgical intervention is a consideration when the damage is severe, not responding to more conservative options, and otherwise when the patient is healthy enough to undergo surgery.

Osteoarthritis will occur eventually in all of us as we age.  The key to control degeneration is to maintain good health habits.  Keep your weight under control, excess weight will stress out your joints.  Exercise, this will keep everything moving, and maintain your strength.  Work with your doctor if more advanced treatments are needed.

Osteoarthritis of the Knee – Signs & Symptoms

knee osteoarthritis st. cloudAs we age, many of us develop knee pain.  One of the most common knee conditions is Osteoarthritis – slow degeneration of the cartilage of the knee. 

Symptoms of Osteoarthritis

The symptoms of osteoarthritis are:

  • Gradual onset of stiffness in the joint, especially after sitting for a period of time or lying down
  • Difficulty bending and straightening the knee
  • Swelling and pain when first moving the knees, sitting, or kneeling
  • In more severe cases, the size of the knee may become larger

As we get older, joints in the body age and deteriorate. This starts as early as our twenties, and is more common when we are past forty.  Historically, the body was designed to get us to between age forty and fifty. Prior to the onset of modern medicine roughly 150 years ago, disease, trauma, and natural conditions like heart problems killed us by age fifty.  So as we age, there is increasing wear from normal use and trauma on our joints including our knees.  Weight also often increases as we age and further stresses weight bearing joints.

Factors & Signs

Factors that contribute to osteoarthritis development are:

  • Age
  • Trauma
  • Weight
  • Genetic tendency (some families may be more prone to its occurrence)

In the doctor’s office, when we examine a knee with osteoarthritis, we usually see a large knee, maybe slightly swollen but not warm, and stiff to move.  Plain X-rays will reveal a large joint, often with narrowing of the joint space especially on the inside aspect, and the joint surfaces may appear to be irregular from deterioration.

Read our follow up blog on the treatment options for Osteoarthritis.