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Jonathan Cluett, M.D.

Joint Lubricants Ineffective: More Harm Than Good

By June 20, 2012

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A recent study evaluated joint lubricants, called viscosupplements, commonly sold under names including Synvisc, Orthovisc, Euflexxa, or Supartz. These lubricating injections have been used for more than the past decade for the treatment of osteoarthritis of the knee. While no one thought they would cure arthritis, they have been thought to be an effective treatment to help control the symptoms of mild to moderate arthritis. These medications have been thought to be helpful in delaying the need for knee replacement surgery.

A recent analysis combined the results of many studies that have been performed to investigate the effect of these medications. This so-called "meta-analysis" takes into account many factors to evaluate how well performed these studies were, and the results they found. Overall, the studies show that the viscosupplementation injections offer no significant benefit. The cost of the injections is not justified by the lack of benefit. Furthermore, some studies showed that the injections may make patients worse, because of possible side-effects of the injection.

I use viscosupplementation injections in my own practice, and I have patients who feel as though they are an important part of the management of their arthritis. This study will force me to look carefully at the benefit of the injections, and while for the time being I may continue to offer the injections, it will change the conversation I have with my patients when I inform them of the possible risks and benefits of viscosupplementation.

Should these injections not be offered? Should Medicare and insurance companies stop paying for the use of these injections? Share your comments below!

Source: "Knee Injections for Arthritis? Save Your Money, Study Says"

June 26, 2012 at 8:46 am
(1) Tina says:

My orthopedist insisted about 4 years ago that I get them for my knees. I was very leery. The first injection wasnt bad, but I didnt notice any difference in my pain. When I went back for the second and told him he said that it might take until the second injection. Had the second and it hurt like heck! The third I jumped outta the chair the injection was so painful! Worse than my usual cortisone injections. He got upset with me when I told him it wasnt working and came back into his office with my leg locked about two weeks later. So much pain if I even thought about moving my leg! I will never again get those things and always tell people about my incident, because everyone thought the injections thought they were the next best thing to inventing electricity. 4 years later and much pain, I still have my knees. I’m only 52, but I will wait for replacements for a bit.

June 26, 2012 at 9:27 am
(2) Robin says:

I have had a series of the these injection yearly, for the last 5 years. I had a severe reaction to synvisc the second round and switched to Euflexa. I find the injections help reduce my pain and allow me to function at a more normal level. In my “bubble world” I am hoping that they delay the need for knee replacements until they have developed a viable stem cell approach to cartilage regeneration!

June 26, 2012 at 10:02 am
(3) Mark says:

I was diagnosed as bone on bone medial both knees 7 years ago and I have had a total of 48 injections–24 each knee–I began the first series of 5–which I had 3 times with hyalgan and then all the remaining series were 3–mostly synvisc-but my last 12 were Euflexxa-and I have found that they are very effective for me–I count the days until my next series–I have found Euflexxa to be more effective. I can still play 10 hours of basketball a week and walk 20 miles. Just last year I thought maybe I didn’t need the injections–or that they weren’t effective–so i lapsed to 9 months instead of going at 6 months–major mistake–I eneded up at 9 months walking with a cane!!!!! My next app’t is just 2 months away–can’t wait. When I first got my initla injections 6 years ago–I could barely move and thought then a knee replacement would be coming soon at age 55-but these injections greatly improved my condition.

June 26, 2012 at 1:12 pm
(4) Allan R. Dunn, M.D. says:

For the past 14 years I have been treating osteoarthritis of the knee with
intra-articular growth hormone (IAGH) injections. In a study of 66 knees soon to be published, 87% improved greatly and did not need total knee arthroplasty. Treatment of ankles results in 95% improvement of these patients who no longer need arthrodesis or total ankles. A study was recently completed adding HGH injections to microfracture of the knee in rabbits and the HGH injected knees grew real articular cartilage, not fibrocartilage that always results from microfracture. Read “Morphoangiogenesis-a unique action of growth hormone, Microvascular Res. 63:295-303, 2002. Allan R. Dunn, M.D. iaghdunn@aol.com. IAGH.COM

June 26, 2012 at 1:56 pm
(5) Mark says:

In my second post here –I will also mention that I never had anything near ” severe pain” from any injections of my knees with Euflexxa or Synvisc-however 46 mine were given by the ortho’s PA who was very experienced with giving them –he was skilled, concerned and courteous–of the 48 injections I got I experienced minor pain maybe 8 times–all were given on the top lateral outside –(put a clock face on your knees)about 4 o clock when looking down at my right knee and 8 o clock looking at my left knee–although I have spoken to some who got them under the knee–the noon position looking down–and I have had some say they were painful–neither have I experienced any infections or allergic reactions–the process certainly has been worth the minor few seconds of pain of the injections–and unfortunately I will have a new person doing mine in 2 months as my ortho’s PA has left the practice and is now longer available to me :>( stay tuned!!

June 27, 2012 at 10:15 am
(6) Kristine says:

I have had a total of 6 knee surgeries in my life, 5 in the past 2 years. 2 of those 5 were to remove retro-buttons that became dislodged from a hamstring graft to replace my left ACL. The rogue retro-buttons in my joint tore up my medial cartilage.

I was told I am too young for knee replacement at the age of 40. As a mother of 4, leading a healthy, active lifestyle is important to me. The pain I was experiencing prevented me from doing everyday tasks, and affected my ability to rehab effectively from my Right ACL surgery.

Having the Euflexxa shots felt like a miracle to me, and I didn’t experience any side-effects. I could exercise without pain. I was able to progress with the extended rehab in physical therapy, and focus on strength building in both legs. I plan to schedule my next series of injections in September, and am grateful that the injections are available to me.

October 23, 2012 at 9:56 pm
(7) saman says:

In sport my miniscue is torn and after some time i had mild brusing in tibial plateau. adoctor inject hgh+collajen in my knee cartilage and around knee it has massive pain

November 3, 2012 at 12:14 am
(8) Denny Ajere says:

I had the Synvisc injections 2 weeks ago. I am in more pain and discomfort than I was before the shots. Now I understand here that these shots are given once a week for three weeks. When I arrived at my Doctors Office, she explained how my insurance approved to cover for the expense but i have to have the injections on both knees in one visit. Which meant, three weeks of solution is in each injection for each knee. I agreed, and it had to be the most painful procedure I have experienced. My doctor did mention that I will not feel the difference for at least 4 to 5 weeks. I am entering my third week this Monday, November 5th. My question to everyone? Will I have a chance of feeling relief? Anyone else experience what I have? And any advice? Because I remain in pain.

April 1, 2013 at 8:23 am
(9) Diane says:

I had the euflexxa injection six weeks ago and had some relief from pain for about 2 weeks and now the pain is back.

The first injection went well, but the second and third were very painful because there was inflammation in the area.

April 1, 2013 at 8:53 pm
(10) andrew smith says:

I had the Euflexxa shots (3 of them, a standard treatment) and it is awesome! Had very very litte or NO PAIN for 12 months! I would recommend it. By the way, I can run a 12:56 2-mile at age 43.

April 14, 2013 at 12:38 pm
(11) Marlene says:

I had the 1 Treatment of syn-visc 6 mts ago, since we are trying to hold off on total knee replacement. minimal discomfort in both Kness when shots
were given. Some discomfort after, butNo pain for 6 mts. I just had another 1 shot in each knee on Thursday. The pain was excrucing, it is still,it’s Sunday and I amusing a walker. I have been taking anti- inflammatory every 5 hrs. For pain and movement. Never again……u

April 29, 2013 at 11:31 am
(12) Linda says:

I had the 3 shot series of Euflexxa injected into my right knee in March / April of 2011, and it was extremely therapeutic, with NO side effects. At that time I was experiencing such pain in my knees, I was one step away from being wheelchair bound. The shots to my right knee alleviated all pain. I am extremely grateful to my rheumatologist for suggesting this treatment.

May 15, 2013 at 9:11 pm
(13) linda says:

I had the synvic shots and the first shot very painful the second shot was just as painful. but after a couple of weeks the pain stoped they last about six months. they work well,with no sideaffects. but so dam painful afterwards.

June 19, 2013 at 8:18 pm
(14) Gary says:

I had the synvic one shots all at once. No problem with the injection but it only provided relief for several weeks. Pain and difficulty walking are back.

September 9, 2013 at 10:43 am
(15) arpitha says:

I took injections for both of my knees ,pain has not subsided-feeling pain even after 1 month . I assumed that it delay knee replacement surgery but disappointed. I cannot stand for long time and walk as it is affecting my profession. advice others as not to take ,only waste of money.

September 17, 2013 at 7:09 pm
(16) Maggie says:

5 years ago was told that I needed total knee replacements on both knees. In an effort to delay the surgery I had the synvic shots in both knees in one shot for each knee. The shots only caused mild discomfort for a few seconds but I didn’t see any noticeable difference. Based on that, my dr. recommended that I not have anymore. The pain continues to worsen and does affect my life greatly but I’m still holding out hoping for stem cell treatment. After reading these comments, I will look in to the Euflexxa shots.

September 19, 2013 at 9:05 am
(17) JOhn Mc says:

I have been receiving Euflexxa in both knees (in 3 shot series) every six months for the past 2 1/2 years. The shots are relatively painless, and after several weeks I am back to full activity pain free. Considering that when I started I was ready to start using a cane, and needed help getting out of a chair, I have no complaints. The only concern I had was once, because I was going out of the country, the doctor game me a double dose in each knee (series of 2 instead of the normal 3 shots) and it felt like my knee was very swollen – can only fit so much medicine in an enclosed space comfortably.

October 2, 2013 at 8:19 pm
(18) TomP says:

I have had both Synvisc and Euflexxa and the Euflexxa was by far the best result. I could not hardly get up and around and was looking at knee replacement surgery but no more. I am back to normal activity with very little pain and discomfort.

October 19, 2013 at 10:48 am
(19) Beth, PhD, RN says:

It may be a matter of making a better selection of patients who are good candidates for this treatment. I have significant osteoarthritis in both knees along with torn meniscus, loose bodies, etc. Euflexxa injections in one knee gave me my life back. I have had one series and at nine months it is still going strong. If they can put off replacements even a year or two, and give me good quality of life in that interval, I’m very happy. It has really made a huge difference for me. Given the number of people who do respond positively it’s hard to accept a statement that the injections do not work. Making good treatment decisions is a complex process. I would be in much worse shape now if I have not been offered Euflexxa. I had a very experienced and skilled provider and had minimal pain with the injections.

October 30, 2013 at 4:08 pm
(20) Mandy77 says:

I am 48 and now have OA in both knees from years of running and other forms of cardio. Working out is my stress relief and I am now suffering from depression – can’t even imagine life without activity. The OA in both knees has progressed to the point that even elliptical and recumbent bike is uncomfortable. My Dr. says to try Synvisc and said he has had more success with this brand than Euflexxa. After reading many of these posts, I am hearing more success with Euflexxa. Regardless of the pain I’ve heard about the injections, I am going to try one of the two because I feel I have no other option at this point. However if these injections make my knees worse than they are, I will be so disappointed in the mistake. Any feedback or confirmation of my thoughts would be so appreciated.

November 13, 2013 at 3:59 pm
(21) David says:

Agree with Beth (comment #19) and am a bit shocked at the author’s definitive, authoritative tone on this topic, particularly in the headline. Bottom line is: no one can accurately and honestly state what he’s saying in the headline. The diverse data/literature doesn’t support such a cut and dried claim.

I’m 6 months out from my Euflexxa series and the benefit for me has been tremendous. (I was initially interested in Synvisc but my insurance covers Euflexxa). I have significant post-traumatic Patellofemoral arthritis and the “visco” shots significantly reduced the pain and “noise” in that knee, allowing me to greatly increase my strengthening exercise regimen, which has created a virtuous cycle with regard to strength and better kneecap tracking.

My own research indicated that about 50% of patients see a benefit with these products, and my surgeon told me the same thing when we discussed it as an option (he brought it up in response to my complaints of ongoing pain and functional restrictions). I feel fortunate to be in the 50% that see a difference (I felt the difference very quickly, i.e. within 2 weeks of the 1st of 3 shots).

January 8, 2014 at 12:26 am
(22) b. reedy says:

received shots of euflexxa today. It was so painful, I almost passed out. Why can’t they give you novacaine?

February 1, 2014 at 4:51 pm
(23) L. B. says:

I received 3 shots of Euflexxa just over a month ago. The first one was fine. I felt mild pain at the back of the knee after the second, and major pain behind the knee after the third. It has been over a month and my knee is worse that it was before Euflexxa. I wanted to find out if anyone got relief after a few weeks. Since the shots made my knee worse, I am looking for relief from the shots themselves. Not the original knee pain (although that would be the best outcome).

February 14, 2014 at 10:43 am
(24) anne says:

I am 47 and former competetive runner. At age 18 I was in an accident and severed my acl and trashed my meniscus. I had total reconstruction and continued to train for my college team and for a private racing team after college (with moderate pain). After my second total reconstruction in 2000 I have had constant pain and usually stop jogging after 10-15 minutes. I have switched to biking and swimming (boo) and 2-3x week running/walking 20 mins (with pain). Each year it gets worse. I finally went to my ortho to talk about knee replacement. Outdoor exercise is key to my mental health. He felt I am too young and suggested trying Supartz. I am 3 weeks out from my third injection and I am amazed. (By the way, each successive injection was more painful than the first but it only lasted a minute or so). I ran 3 times last week for over 30 mins pain free for the first time in almost 15 years. I do think these injections work for some people and not others but I was willing to take the risk. I am so grateful they work for me. I’m trying to pace my return to running but it’s so fun! My ortho tells me I can safely get these every 6 months if necessary and my insurance covers it. Anything to extend my active life and keep the rest of me healthy! After so many years I think I can be content with running 30-45 mins 3x a week to extend this benefit.

February 21, 2014 at 4:18 am
(25) Etienne says:

My mother is 84, in gairly good health but in severe pain because of knee osteoarthritis. Apparantle the cartilidge has been completely worn out. Obviously, according to her surgeon, a knee replacement is the only answer. My question is this: At her age, how will her quality of life really improve? The convalescence period will probably be 2 years, the pain will initially be worse and mobilty even more impaired. Above that is the severe risk of the operation itself at her age. IS IT REALLY THE ONLY ANSWER???

February 21, 2014 at 7:52 am
(26) carl says:

I have had two series of euflexxa in my left knee and one series in my right knee. Before the injections I could hardly walk down a flight of stairs and I was in constant pain. The first series in both knees at the same time made it possible for me to not only have no pain but I was able to return to jogging. This lasted for one year. I had another series in my left knee and that lasted 17 months, could return to running again. The pain is very minimal compared to the pain i had just trying to walk with the arthritis pain, the third injection is usually the only one that is uncomfortable. To me this is like a miracle to be able to go from not being able to walk without pain to running again.

March 27, 2014 at 2:19 pm
(27) Beth says:

Euflexxa worked beautifully for me. One knee had 15 months of near pain free mobility after one series. The other knee did not improve but it turned out that one had a badly torn meniscus and improved with surgical intervention. Perhaps the key is targeting the treatment to the right people, because if you are one of the many who has wonderful results, you certainly can’t support the statement that “it doesn’t work.” I am a researcher in a health care field and find such blanket statements to be very troubling. There needs to be a better job of getting it to the right people, keeping it as an option for the many people who have received a great deal of help from Euflexxa and similar products.

April 4, 2014 at 11:16 am
(28) Russ Pendleton says:

I have had three injections in one knee and one in the other. I get about one week slight benefit. After that it is pretty much as it was before.

I am interested in two things though – firstly, don’t the surgeons suck out all the joint fluid during many arthroscopy procedures – then what cushioning is in the joint space? None surely, until more fluid is produced by the body which takes a while – the injections are surely good for that use. Secondly, after arthroscopy, the local anaesthetic works very well as a pain killer. Can we not just have long acting local anaesthetic injections in the joint? It would at least kill the pain which is the main thing for me – stops me sleeping…

April 4, 2014 at 10:59 pm
(29) Nancy says:

I got the series of three shots ending about a month ago. I should be in optimum pain relief by now. I do not have bone on bone, but do show some wear and roughness. My right leg, which only gave me trouble walking down stairs, is now giving me lots of trouble. I have acute pain that moves from one side of the knee to the other when walking,and that knee sometimes locks up, which is also painful. Add this to the awful pain I experienced during the injections, and I could not recommend these shots to anyone

April 19, 2014 at 7:47 am
(30) Wendy says:

I had the euflexxa series last summer and start my next series on Monday. It was 8 months of total relief for me. The first injection was painful because my knee was so inflamed. The next 2 weren’t bad at all. Just a little stiff walking out to the car. Unfortunately, I have be cursed with all kinds of autoimmune issues from rheumatoid arthritis to OA to Psoriatic arthritis and more. I wish they could inject this med all over me and not just in my knees. But even having relief in my knee, makes it easier and it’s one less place that hurts. One more thing, as a nurse, if the injections cause more pain or severe pain, call your MD immediately. They need to know, especially if it’s a reaction to the product injected.

April 25, 2014 at 1:56 pm
(31) John says:

I’m only 35 and I recently had surgery for a torn meniscus. After the surgery the doctors found that I had sever grade 3/4 chondromalacia. Doc advised me that the next option is a total knee replacement. He recently said this drug might help by giving me a few more years on my knee. I’m a police officer and I would rather have a lot more years with my original knee… How has this drug helped the forum and is a total knee replacement all that bad??

April 26, 2014 at 3:51 pm
(32) Kimilee says:

I don’t care what the study showed, Euflexxa injections have changed my world. I agree that each successive injection hurts worse. I immediately put a Thermacare heat wrap on my knee, not the recommended ice. It prevents me from having to take extra narcotic meds on the day of injection. They work even better, and I have much less pain with my new doctor doing them. She does the injections guided by ultrasound.

Prior to my injections, 5 minutes on a Physiostep, going very slow at no resistance, put me in excruciating pain for days. Now that my injections are complete, I am up to 10 minutes flat out. There is no residual pain except in my sore muscles that aren’t used to being used. If history serves, I will be able to use my knee for 6-8 months without pain.

Next week I am trying Synvisc in my better knee. It would be nice not to have to go through 3 injections and waiting 3 weeks for results.

May 7, 2014 at 5:11 pm
(33) Calvin W says:

I had arthroscopic meniscus surgery on both knees. After 2 surgeries on rt knee for a torn meniscus, a knee brace, and over a year of therapy, my doc suggested synvisc one. The results were amazing. The reduction in pain allowed me to advance more in therapy, and after 4 years the knee remains much better, and I have never had a second shot.

The other knee, however, is really problematic. I have constant pain, and take generic arthrotec 75 and ice on an as needed basis to manage pain and stiffness. Iím 49, in normal weight range, and canít run but a few steps, and have a great amount of pain if I walk too much, or sit still too long. Doc suggested Euxflexaa for knee. Results are nowhere as satisfactory. I really donít think 2nd round of 3 shots did much good. I have asked doc to try synvisc for next (3rd round of shots). I have had goodresults since I started working with a trainer to strengthen leg muscles, but of course, that is additional $ as itís not covered by insurance. However, I have had my best results from exercise and personalized leg exercises/ weight training.

May 10, 2014 at 4:55 am
(34) Oldchicago says:

Had Euflexxa 3-shot series in both knees for bone-on-bone osteo about 10 months ago. They were extremely effective for at least 6 months and am due for another series this month. My personal investigations lead me to believe the injections MUST be actively guided using ultrasound visualization of the joint. The docs and PA’s I’ve talked to say without ultrasound performed by an experienced practitioner there is a near certainty the individual patient may experience both pain and possibly more extensive localized inflamation.

May 20, 2014 at 10:19 pm
(35) quilter says:

I’m actually seeing my dr tomorrow to set up my 4th series of 3 Euflexxa injections in both knees. I’ve found a great amount of relief from them.
While lying down and with a straight knee I had the first two series injected by a PA and the injections were quite painful.
The last series was done at a new medical group while I was in a sitting position and not one of the six (3 in each knee) was painful. I asked the doctor if the pain amount was dictated by the position of the knee and he said no.
that does make me wonder.

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