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Should You Get A Lube Job for Your Arthritic Knee?

Reviewing the science of injecting artificial synovial fluid, especially for patellofemoral pain

updated (first published 2008)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

It’s now common for orthopaedic surgeons and sports medicine specialists to recommend the injection of artificial “lubricant” into knees and other arthritic joints, or for a “pseudo-arthritis” like patellofemoral syndrome (PFPS).1 The actual substances are “hyaluronan” and “hylan” (Durolane®) which are basically synthetic replacements for the slippery component of the fluid in your joints. It’s fairly clear that the procedure is common simply because the idea of adding some lube to your knees really sounds like a good idea — so good that it’s done in spite of the fact that it barely works!

I’m no surgeon or scientist myself, and I don’t even play one on TV … but I can certainly quote them. The authors of a 2003 summary of this subject for the Journal of the American Medical Association2 said that injecting synovial fluid into your knee …

… has a small effect when compared with … placebo. The presence of publication bias suggests even this effect may be overestimated.

Emphasis mine.

That 2003 assessment is supported by a bigger 2012 one.3 Nearly 90 trials were reviewed and determined that this treatment is associated “with a small and clinically irrelevant benefit and an increased risk for serious adverse events.” take-home message? Combining injections and wishful thinking is bad news.

No honest person could possibly look at the available scientific evidence and fail to come to the conclusion that the value of injecting artificial joint fluids into your knees is, in a word, underwhelming. At best. I’m inclined to say that these injections are simply all washed up scientifically. Case closed.

Risks of hyaluronan injection

Many patients are justifiably cautious about accepting the prescription of invasive procedures, even “just” an injection. Even when the risks are relatively low — which they are here — things can still go wrong any time you stick a needle into a knee. There is still a considerable personal and social “overhead” to such procedures. We should generally avoid any kind of invasive medical procedure unless the benefits are really quite clear. Really, like a charge of murder, it should probably be proven “beyond a reasonable doubt.” Such proof is simply not present in this case. And I have heard reports of nasty reactions. They are clearly uncommon, but they do occur. No injection is ever completely risk-free.

Important perspective: you can treat osteoarthritis with a placebo surgery

Bear in mind when you consider this treatment method that in 2002 a (now famous) study showed a truly spectacular placebo effect.4

In this landmark and fascinating study, people with osteoarthritis improved equally well regardless of whether they received a real surgical procedure or a sham, which is a particularly striking example of the placebo effect and implies that belief can have an effect even on a “mechanical” knee problem. From the abstract: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”

In 2008, these findings were fully supported by a Cochrane Collaboration review (Laupattarakasem) which concluded that “there is ‘gold’ level evidence that arthoscopic debridement has no benefit,” and by New England Journal of Medicine (Kirkley) which reported that “surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.”

This study inspired more comparisons of orthopedic surgeries to shams. By 2016, at least four more popular surgeries have been shown to have no benefit (Louw 2016).

The point is that the conditions inside your knee are probably not nearly as important as you might think.

What about other joints?

Maybe this stuff works for shoulder pain? A 2008 study in Journal of Bone & Joint Surgery (American) found that injections of sodium hyaluronate into stubbornly painful shoulders were pretty helpful. It is, of course, completely possible that shoulders respond differently to this treatment than knees. It’s also possible there was something wrong with the study. But it’s worth noting.

Perhaps for the jaw? It’s also worth noting that a review found “insufficient evidence to either support or refute the use of hyaluronate for treating patients with temporomandibular joint disorders.”5

Related surgeries are also useless

The effectiveness of many orthopedic surgeries has been under seige since the early 2000s. It’s clear that many of them do not work,6 and popular knee surgeries in particular are scandalously ineffective. In addition to the failures of injecting lubricant, two other extremely common knee surgeries have also condemned by one scientific test after another:

Medical guidelines now recommend against these procedures even when the need seems “obvious.”9

In addition to their futility, of course all surgeries involve risk: Thorlund et al reported 4 harmful outcomes per thousand surgeries, including symptomatic deep venous thrombosis, pulmonary embolism, infection, and death.

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About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

2016Added a section about other surgical procedures for context. Started proper update logging (the article has been around since 2008, updated occasionally).

Related Reading

This article is a free abridged chapter from PainScience.com’s huge patellofemoral pain syndrome (PFPS) tutorial, one of 95 chapters in all. The full book contains more thorough analysis of knee “lube jobs,” plus practical advice, tips, and tricks for managing patellofemoral pain. There are also several other articles on PainScience.com about patellofemoral pain and related topics:

What’s new in this article?

NovemberScience update, cited Siemieniuk.

Notes

  1. Patellofemoral pain syndrome is not osteoarthritis, although they do get confused, because of the way typical patellar pain feels — a nagging ache — and a loose correlation with a slight degeneration of the kneecap cartilage (chondromalacia patellae). But, because it is perceived as being arthritis-y, it is a popular target for artificial synovial fluid injection. BACK TO TEXT
  2. Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis: a meta-analysis. JAMA. 2003;290(23):3115–3121. BACK TO TEXT
  3. Rutjes AW, Jüni P, da Costa BR, et al. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta-analysis. Ann Intern Med. 2012 Aug;157(3):180–91. PubMed #22868835. BACK TO TEXT
  4. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81–8. PubMed #12110735. PainSci #56845.

    In this landmark and fascinating study, people with osteoarthritis improved equally well regardless of whether they received a real surgical procedure or a sham, which is a particularly striking example of the placebo effect and implies that belief can have an effect even on a “mechanical” knee problem. From the abstract: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.”

    In 2008, these findings were fully supported by a Cochrane Collaboration review (Laupattarakasem) which concluded that “there is ‘gold’ level evidence that arthoscopic debridement has no benefit,” and by New England Journal of Medicine (Kirkley) which reported that “surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.”

    This study inspired more comparisons of orthopedic surgeries to shams. By 2016, at least four more popular surgeries have been shown to have no benefit (Louw 2016).

    BACK TO TEXT
  5. Shi Z, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders. Coch. 2002. PainSci #56202. BACK TO TEXT
  6. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957. PainSci #53458.

    This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

    Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.

    The surgeries that failed their tests were:

    • vertebroplasty for osteoporotic compression fractures (stabilizing crushed verebtrae)
    • intradiscal electrothermal therapy (burninating nerve fibres)
    • arthroscopic debridement for osteoarthritis (“polishing” rough arthritic joint surfaces)
    • open debridement of common extensor tendons for tennis elbow (scraping the tendon)

    BACK TO TEXT
  7. www.nytimes.com [Internet]. Kolata G. The Right to Know That an Operation Is ‘Next to Useless’; 2016 August 3 [cited 17 Oct 26].

    An excellent plain language overview of the scandalous futility of meniscectomy, from the relentless Gina Kolata at the NY Times. For a formal scientific review, see Thorlund.

    BACK TO TEXT
  8. PS Ingraham. Knee Surgery Sure is Useless! Evidence that arthroscopic knee surgery for osteoarthritis is about as useful as a Nerf hammer. PainScience.com. 1564 words. For a scientific review, see BACK TO TEXT
  9. Siemieniuk RA, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017 May;357:j1982. PubMed #28490431. PainSci #52778.

    These guidelines “make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease…” regardless of “imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.” The authors believe this is the last word on the subject: “further research is unlikely to alter this recommendation.”

    BACK TO TEXT