Will stem cell, platelet-rich plasma (PRP) or Durolane (hyaluronic acid) injections help?

Stem Cell, PRP, and Durolane Injections for Joint Pain

Based on the highest quality guideline evidence, stem cell and PRP injections are strongly recommended against for knee and hip osteoarthritis, while hyaluronic acid injections (Durolane) may be considered only as a last resort after all other treatments have failed, though they are also conditionally recommended against for knee OA and strongly recommended against for hip OA. 1

Stem Cell Injections: Strong Recommendation Against

The American College of Rheumatology/Arthritis Foundation (ACR/AF) strongly recommends against stem cell injections for knee and hip osteoarthritis. 1 The primary concerns include:

• Lack of standardization: There is significant heterogeneity in stem cell preparation methods, making it impossible to determine what is actually being injected 1
• No proven efficacy: Clinical trials have failed to demonstrate meaningful benefit on morbidity, mortality, or quality of life outcomes 1
• Safety concerns: The unregulated nature of these preparations raises questions about patient safety 1

Platelet-Rich Plasma (PRP): Strong Recommendation Against

The ACR/AF strongly recommends against PRP treatment for knee and hip osteoarthritis. 1, 2 This strong recommendation is based on:

• Preparation variability: Massive heterogeneity exists in PRP preparations, including platelet concentration, leukocyte presence, activation methods, and injection protocols 1
• Inconsistent evidence: While some studies show short-term pain reduction, the evidence is inconsistent, with worse outcomes in patients with severe osteoarthritis 2
• No Medicare coverage: Given the strong recommendations against PRP from major organizations, Medicare does not cover this treatment 2

The International Society on Thrombosis and Haemostasis rates the clinical utility of PRP preparations as "uncertain" with a median expert score of only 6 out of 9 1. Clinical preparations are poorly standardized (median score 8.5/9 for this concern) 1.

Hyaluronic Acid (Durolane): Conditional Recommendation Against for Knee, Strong Against for Hip

For Knee Osteoarthritis:

The ACR/AF conditionally recommends against hyaluronic acid injections for knee OA, though they may be considered only when all other interventions have failed. 1 This nuanced position means:

• Limited evidence of benefit: The evidence supporting hyaluronic acid is weak and inconsistent 1
• Last resort option: May be considered only after failure of nonpharmacologic therapies, topical and oral NSAIDs, and intra-articular corticosteroids 1
• Shared decision-making: If used, patients must understand the limited evidence and that this is not a first-line treatment 1
• Contextual effects: Some benefit may come from the placebo effect of the injection procedure itself 1

For Hip Osteoarthritis:

The ACR/AF strongly recommends against hyaluronic acid injections for hip OA. 1 The evidence of lack of benefit is of higher quality for hip compared to knee 1.

What Should Be Used Instead?

First-line treatments that are evidence-based and Medicare-covered include: 2

• Physical therapy and structured exercise programs - the strongest recommendation for all patients 1, 2
• Weight management interventions for overweight patients 2
• Oral and topical NSAIDs where medically appropriate 2
• Intra-articular corticosteroid injections for patients with inadequate response to first-line treatments, providing approximately 3 months of benefit 2

Critical Pitfalls to Avoid

• Do not use these injections as first-line therapy: All three injection types (stem cells, PRP, hyaluronic acid) should never be initial treatments 1, 2
• Beware of commercial marketing: The regenerative medicine field is plagued by commercial interests promoting unproven therapies 1
• Understand insurance implications: These treatments are generally not covered by insurance due to lack of evidence 2
• Set realistic expectations: Even in research settings combining these therapies, outcomes remain modest and variable 3, 4, 5

Special Consideration: Combination Therapy Research

While some small research studies suggest potential benefits from combining these therapies 3, 5, these are case series and small trials that do not override the strong guideline recommendations against their use 1. The ACR/AF guidelines explicitly prioritize high-quality evidence and safety over preliminary research findings 1.