In this episode of PodMD, Orthopaedic Surgeon Dr Geffrey Keighley will be discussing the topic of injectables in arthritis. We discuss how injectables are used in managing arthritis, the three main types of injectable treatments that might be offered to patients, the advantages of using injectables compared to other treatment options, and more.
- Transcript
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Today I’d like to welcome to the PodMD studio Dr Geffrey Keighley.
Geff is an Australian-trained Orthopaedic Surgeon based in Tugun. He completed his training and a Fellowship in Hip and Knee Surgery, with a focus on robotic surgery, in addition to obtaining his Master’s of Traumatology at the University of Newcastle.
Today, we’ll be discussing the topic of injectables in arthritis.
*Please listen to our disclaimer at the end of this podcast
Geff, thanks for talking with us on PodMD today.
Geff: No, thank you for having me.
The topic of today’s discussion is injectables in arthritis. To start us off, Geff, could you tell us a little bit about how injectables are used in managing arthritis?
Geff: Yeah, of course. So injectables are just one sort of facet of the non-operative management of arthritis. And, you know, typically we’re talking about hips, knees, shoulders, ankles. And it sort of just forms one sort of backbone of management.
So, in managing arthritis, we want to make sure patients have good physio, good strength, manage their weight, manage their activities of daily living and take suitable analgesics. So typically this is in the form of, you know, paracetamol and short-term anti-inflammatories for acute flares, but sometimes in the setting of refractory management and before we start talking about joint replacement, we can think about the use of injectables in the knee.
Could you walk us through the three main types of injectable treatments that patients might be offered?
Geff: Yes. There’s sort of three broad areas in current practice. So corticosteroids is the one that most people will be aware of and have been used for decades. And this is just a synthetic steroid or, you know, naturally occurring substance that’s an anti-inflammatory. And this is injected straight into the affected joint and acts as a local anti-inflammatory agent.
Probably the second one that a lot of people know about is platelet-rich plasma. And so platelet-rich plasma, or PRP, is a process whereby you extract the patient’s blood, you spin down the, it’s centrifuged, and then just the plasma layer is injected into the affected joint. comes in sort of two forms. There’s the leukocyte-rich, which includes the buffy layer of the plasma and leukocyte poor, which excludes the buffy layer. And theoretically in the setting of arthritis, the leukocyte-rich is what people tend to think is more effective. But it’s also got fairly mixed pictures in terms of, and not any concrete evidence in terms of which one is the most appropriate.
And then the third sort of category is viscose supplementation, which is, which most people would sort of know as hyaluronic acid. And so basically it’s hyaluronic acid is a normal lubricating molecule in the joint that in the setting of arthritis tends to get a bit diluted with sort of an effusion and increased activity. So the idea behind the Visco supplementation is that you’re injecting the lubricant itself, but then this is theoretically supposed to increase the natural production of hyaluronic acid.
How do you usually decide between using the different types of injections, for example, steroids versus other therapies?
Geff: So this tends to be sort of a largely practitioner-referenced decision. I have to admit, I tend to prefer corticosteroids, mainly because it’s common, relatively inexpensive, and relatively reliable adjunct that has known pharmacokinetic properties and is also, a very measurable, like a very measurable quantity that’s injected.
My main issue with PRP is that not only is it more expensive, but it tends to be a bit practitioner dependent and because it’s done on site by a single practitioner. And it’s hard to exactly quantify what is going into the knee and how much. And it can entirely depend on the patient’s own, the quantities of anything in their own blood. And so the science is still a little bit unclear.
And then I don’t, I have to admit my personal feeling in the use of viscose supplementation is that while the theory is that it promotes the lubrication in the setting of arthritis and having seen plenty of arthritic joints, the primary issue is a lack of a smooth end bearing surface that distributes load. But, you know, when the weight’s placed on a surface, the fluid gets displaced from between the areas that you want and that just sort of floats into the areas that aren’t being used.
So I find it hard to reconcile the physics with the actual function of the stuff. And I think this sort of, this plays out a little bit in some of the evidence, although I will say at the start here, there’s the evidence is mixed on most of this, most of these formula.
Yep, absolutely. And what are the biggest advantages of using injectables compared to other treatment options?
Geff: Well, I guess the, you know, the good thing is that you have treatment delivered directly to the site of pain and pathology. And so, particularly in the setting of patients who can’t take oral anti-inflammatory medications because of their side effects or because of other medications they might be taking or because of reactions. This is a way to deliver a therapeutic dose of either anti-inflammatories or other substances directly at the site of pathology.
What’s the typical advice that GPs should give to their patients about activity levels post-injection?
Geff: Yeah, so I typically tell people to avoid any sort of, you know, major activity other than basic daily living for 24 to 48 hours. And it I also warn them, particularly in the setting of steroids, that they can get a steroid flare, which can happen hours to day after an injection. But this generally subsides in about one to three days. And the anti-inflammatory effects are variable.
And I do tell patients this, that, you know, some people get relief for, you know, days, some get months, some get years. But typically, I’m happy for people to return to gentle activity in one to two days, but give it at least a week before they do anything too heavy or strenuous.
Okay, excellent. So not too long of downtime, which is great.
Geff: No.
In what scenarios should GPs consider referring patients for injectable therapies in arthritis?
Geff: Yeah, so it’s, again, it’s all sort of part of a broader non-operative management plan. And, you know, I tend to think that in someone who’s having an acute arthritic flare, so they’ve either, you know, they’ve misstepped or they’ve done something to stir up an arthritic joint and they can’t get that swelling and inflammation under control over a couple of days with rest and ice and adequate analgesia, and they’re having ongoing grumbling functional problems, well, then I would consider the use of something.
But in general, I try to avoid more than about two injections a year, and I typically try and space them at least three months apart, or certainly for steroids. The other injectables like the PRP and the hyaluronic acid and things, they have their own sort of, the people who deliver it have their own formulas and their own sort of systems for managing it. And so that, again, it’s very sort of practitioner dependent.
Are there any newer or experimental injectables currently being researched that maybe GPs should be aware of?
Geff: Yeah, so, I mean, there is talk about using stem cell therapy and there’s a few other sort of fringe injectable options that are coming and going. But the evidence for all of this, particularly stem cells at this stage, is very much lacking. And, the more science that goes into these injectables, typically the more expensive they are, but not necessarily with reliable outcomes.
So, these are the sort of three main ones. But yeah, and the evidence for the other stuff is still a bit slow in coming. But yeah, that’s not to say that it won’t come. And it’s just that, in 2026 right now, we’re sort of, we’re still sort of limited to these three main options really.
Could you please identify the three key take home messages from today’s podcast?
Geff: Yeah, so I guess the injectables are an adjuvant therapy. So they’re not the only thing that patients should be doing. So that should be as part of a broader arthritis management program, including physiotherapy, adequate analgesic activity, modification, and weight loss. And at present, the evidence is sort of mixed on the effectiveness and the outcomes, but typically the PRP and hyaluronic acid tends to be a lot more expensive. You know, there’s some evidence to say that PRP lasts a bit longer than the hyaluronic acid or sometimes in steroids.
But to be honest, there’s, you know, patients will have a variable response to all of these modalities. And I’ve had patients swear by one and not the other in all three cases. So, I think use them judiciously. My typical use is for the use of steroids, because I know how it works. And I use it as a way to reduce the pain and inflammation in an arthritic flare that allows participants to get back into an arthritis-specific programme, because I think where the evidence is, is in arthritis-specific physiotherapy and maintaining strong joints and strong muscles to reduce the sort of micro-emotion that can lead to these flares. So I use the injectables and well, I use steroids typically as a way to cut the pain cycle of sort of weakness, pain, weakness, pain, so they can get back into the physio and strengthen up the joints.
Excellent. This has been great, Geff. Thanks again for your time and insights you’ve provided.
Geff: No, thank you very much for having me.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
