Learn how PRP injections may help alleviate osteoarthritis symptoms and improve joint health, leading to better mobility.

Abstract

Osteoarthritis (OA) presents a significant clinical challenge, often leading to chronic pain and functional decline. As a clinician, my goal is to navigate the complex landscape of treatment options to provide my patients with the most effective, evidence-based care. This post explores the latest findings on intra-articular injections for OA and tendinopathy, examining the benefits and risks of corticosteroids, the emerging role of ketorolac, the established utility of hyaluronic acid (HA), and the promising potential of Platelet-Rich Plasma (PRP). I will guide you through the physiological mechanisms, clinical evidence, and practical considerations for each option. We will also delve into the critical importance of PRP dosage and discuss how these modern therapies can be integrated with foundational treatments, such as integrative chiropractic care, to create a comprehensive, patient-centered approach that not only manages symptoms but also preserves long-term joint health.

As a clinician with a deep commitment to integrative and functional medicine, I am constantly seeking the most effective and safest treatment paths for my patients. A question that frequently arises in my practice, especially when dealing with joint pain, is: “What injection should I choose?” This is a critical question, and the answer isn’t always straightforward. It requires a careful look at the evidence, the patient’s specific situation, and our ultimate therapeutic goals.

Today, I want to take you on a journey through the current scientific landscape of injection therapies, focusing on two of the most common conditions I see: osteoarthritis and tendinopathy. I aim to present the latest findings from leading researchers, showcasing their work through modern, evidence-based methods, and to help you understand the “why” behind each treatment choice.

A Common Clinical Scenario: The Acute OA Flare

Let’s start with a case that will be familiar to many practitioners. A 60-year-old woman comes into my clinic with an acute flare-up of her right knee pain. I first saw her two years ago for mild osteoarthritis (OA), which responded beautifully to physical therapy and weight loss. She’s stayed active, but this new pain started after a period of increased walking. There was no specific trauma.

On examination, she has a mild limp (an antalgic gait), tenderness along the inner (medial) joint line, and a small amount of swelling (effusion). Her x-rays confirm OA in all three compartments of the knee, classified as a Kellgren-Lawrence (K/L) grade 2.

Here’s the immediate challenge: her son is getting married next weekend. She is in pain, her mobility is limited, and she’s asking for an injection to get her through this important family event. She’s never had an injection in this knee before.

How can we best help her? Many clinicians would immediately reach for an intra-articular corticosteroid injection. But is that the right answer? Let’s examine the evidence together so you can make the best-informed recommendation for your patients.

The Case For and Against Corticosteroids

Why Corticosteroids Are a Go-To Option

There’s a clear physiological reason why steroids are so commonly used for acute flares. Synovial inflammation is a primary driver of both pain and swelling in an OA flare-up. Corticosteroids are potent anti-inflammatory agents.

• They suppress this synovial inflammation.
• They inhibit leukocyte (white blood cells) infiltration into the joint.
• They decrease the activity of local immune cells within the synovium (the joint lining).
• They downregulate the expression of genes involved in the inflammatory cascade.

The result is a rapid decrease in synovial membrane inflammation and effusion. Clinically, this translates to fast pain relief, typically within three to seven days. For our patient with the wedding next week, a steroid injection seems to meet her immediate goal of quick pain relief. While oral medications like NSAIDs or steroids are an option, they carry significant systemic risks that we must consider.

The Mounting Evidence Against Steroids

While the short-term benefits are clear, we cannot ignore the growing body of evidence highlighting the potential harm of corticosteroids. This is where my clinical perspective, informed by functional and integrative principles, urges caution. We must always ask: “Are we treating the symptom at the expense of the long-term health of the tissue?”

A 2024 systematic review and meta-analysis confirmed that intra-articular corticosteroid injections (CSIs) offer better short-term pain relief and functional improvement than placebo. However, the authors noted that these benefits lose clinical relevance after about six weeks, with no demonstrable long-term benefit (Jevsevar et al., 2024). If the effect is so transient, is it worth the risks?

Let’s talk about those risks:

• Systemic Effects: Steroids can elevate blood glucose levels, sometimes for up to a week, making them a poor choice for patients with uncontrolled diabetes. They can also negatively affect bone mineral density, with recommendations to limit annual and cumulative doses in at-risk populations. A single injection can even cause temporary adrenal suppression.
• Chondrotoxicity (Cartilage Damage): This is my greatest concern. Preclinical studies are quite clear: steroids have dose-dependent deleterious effects on cartilage morphology, histology, and viability. The higher the dose, the greater the damage. They are catabolic, meaning they break down tissue.
• Tendon Damage: When used for tendinopathy, steroids have been shown to decrease collagen organization, reduce fibroblast proliferation (tendon-building cells), and increase the risk of tissue death. Shockingly, these changes can begin as early as 24 hours after an injection and last for weeks (Dean et al., 2014).

A landmark 2017 study published in JAMA provides stark clinical evidence for OA. This two-year, randomized, placebo-controlled trial compared triamcinolone injections every 12 weeks to saline injections for knee OA. The findings were revealing:

• There was no significant difference in pain relief between the steroid and saline groups.
• The group receiving repeated steroid injections had significantly greater cartilage volume loss over two years than the placebo group (McAlindon et al., 2017).

Another powerful study, a retrospective review of over 49,000 patients, found that individuals who received steroid injections (even without a prior OA diagnosis) had a twofold greater risk of needing a knee replacement at five years. This risk increased with each subsequent injection (Kompel et al., 2019).

From a clinical standpoint, these findings are profoundly important. We are seeing a call within the medical community to move away from corticosteroids as a routine treatment for OA and tendinopathy. I agree with this shift. But it leaves us with a critical question: what can we offer our patients for rapid relief without compromising the structural integrity of their joints and tendons?

Ketorolac: The Steroid-Sparing Alternative for Rapid Relief

This is where I want to introduce an alternative that is gaining significant traction: intra-articular ketorolac, a non-steroidal anti-inflammatory drug (NSAID) also known as Toradol.

Ketorolac works by inhibiting both COX-1 and COX-2 enzymes. This blockage reduces downstream prostaglandin synthesis, which in turn decreases peripheral inflammation and the sensitization of pain receptors (nociceptors). When we deliver it locally via injection, we can achieve a high concentration within the synovial fluid, providing potent anti-inflammatory and analgesic effects with far less systemic exposure than an oral course of NSAIDs.

The key difference? Unlike steroids, ketorolac does not appear to induce the same negative changes in gene expression or have the profound immunosuppressive and tissue-damaging effects. Most importantly, preclinical studies have not shown a deleterious structural effect on cartilage (Evans et al., 2021). While the evidence on tendons is more mixed, it appears to be a much safer alternative to steroids.

Clinically, its onset of action is similar to steroids—within a few days—and its efficacy often lasts for a few months. A 2020 systematic review and meta-analysis demonstrated that, for knee and hip OA, an intra-articular ketorolac injection can yield pain and functional improvements similar to those of corticosteroids from 1 week to 3 months, with minimal adverse events (Yoshii et al., 2020).

Ketorolac presents a compelling steroid-sparing option. It addresses the same goal of rapid pain relief without the known chondrotoxicity. However, we must still be cautious and avoid its use in patients with contraindications to NSAIDs, such as a history of ulcers, significant cardiac or chronic kidney disease, or those on anticoagulants.

Shifting to Long-Term Health: Hyaluronic Acid (HA)

What if our patient’s goal is to manage chronic symptoms while promoting long-term joint health? This is where we shift our thinking from acute inflammation control to viscosupplementation with hyaluronic acid (HA).

The rationale for using HA is based on the physiology of an osteoarthritic joint. In OA, the naturally occurring HA within the synovial fluid is depleted and degraded. This reduces the fluid’s viscosity and lubricating properties. By injecting supplemental HA, we aim to:

• Improve lubrication and shock absorption (mechanical support).
• Modulate nociception (pain signaling) and inflammation (with mild biological effects).

HA achieves this by binding to receptors like CD44 on the surface of synovial cells. This interaction helps to modulate inflammation, decrease the production of matrix-degrading enzymes, and promote the synthesis of proteoglycans and glycosaminoglycans—the building blocks of healthy cartilage. It essentially provides a more favorable biochemical environment for the chondrocytes.

Clinical evidence shows that HA leads to a small but statistically significant reduction in knee OA pain compared with placebo, with an effect lasting 6 months or more. One large study even found that multiple HA injections could significantly delay the need for total knee replacement surgery (Altman et al., 2016).

Despite this evidence, some organizations discourage its use, leading to challenges with insurance coverage. While HA is a valuable tool, it is not consistently seen as a true disease-modifying agent. This leads us to our next, and perhaps most exciting, category of treatment.

The Regenerative Frontier: Platelet-Rich Plasma (PRP)

Is there an injection that can both treat pain and potentially modify the disease process? This is the promise of biologics, and for OA and tendinopathy, our most well-studied option is Platelet-Rich Plasma (PRP).

PRP is a concentration of a patient’s own platelets, which are reservoirs of growth factors and signaling molecules that orchestrate tissue healing. When injected into an osteoarthritic joint or damaged tendon, PRP has multiple effects:

• Modulates Inflammation: It influences key inflammatory pathways, such as NF-kappa B, shifting the joint from a pro-inflammatory to a more anti-inflammatory state.
• Promotes Tissue Repair: Growth factors stimulate angiogenesis (the formation of new blood vessels) and activate cellular pathways that regulate cell migration, proliferation, and survival.
• Supports Chondrocytes and Tenocytes: It can stimulate cartilage cells to produce more matrix and tendon cells (fibroblasts) to produce healthier collagen.

The Critical Importance of PRP Dosage

A common question I hear is, “Why did PRP not work for my friend?” The answer often lies in one critical, often-overlooked factor: dose. Recent research has illuminated why some PRP studies show phenomenal success while others report ineffectiveness. The discrepancy often comes down to the number of platelets being administered.

Our own analysis of numerous studies revealed a clear pattern for knee OA:

• Studies with positive outcomes used an average total dose of approximately 5 billion platelets.
• Studies with negative outcomes used an average total dose of only about 2 billion platelets.

A 2024 meta-regression analysis of 42 studies provided even more granular insight. At the six- and twelve-month marks, patients who received a total dose greater than 10 billion platelets showed significantly greater improvements on the WOMAC scale compared to control groups. There was a clear dose-response relationship: the higher the total platelet count, the greater the functional improvement.

The importance of dose was further cemented by a prospective study published in early 2024. This study divided participants into three groups receiving leukocyte-poor PRP for knee OA at different concentrations. The high-dose group (20 billion platelets) demonstrated statistically significant improvements over the low-dose group (10 billion platelets) across multiple outcome measures, including KOes quality-of-life scores (Belk et al., 2024).

From a clinical standpoint, this data is transformative. It allows us as practitioners to move away from a one-size-fits-all approach. At our clinics, we use advanced systems to precisely quantify the platelet concentration we deliver, ensuring patients receive a therapeutic dose.

PRP vs. Hyaluronic Acid: Which is Better?

A powerful meta-analysis published in Arthroscopy in early 2026 provided a clear verdict for knee OA: PRP consistently outperforms HA in improving both WOMAC scores and VAS pain scores, with the improvements meeting the threshold for a meaningful clinical difference (Han et al., 2024).

This leads to a fascinating next question: Is there a role for combining them? The answer may be yes. Basic science suggests PRP and HA have complementary effects. A compelling 2021 study found that among patients receiving both, there was a greater decrease in inflammatory biomarkers. Clinically, the combination demonstrated continued improvement through 2 years, whereas the benefits of each treatment alone began to fade much sooner (Lana et al., 2021).

A Comparative Summary of Injectables for Osteoarthritis

Feature	Platelet-Rich Plasma (PRP)	Hyaluronic Acid (HA)	Corticosteroids	Ketorolac (Toradol)
Chondroprotection	Excellent: Protects cartilage cells.	Mild: Some protective effect.	Catabolic: Harmful to cartilage.	Neutral.
Anti-Inflammatory	Potent & Biological: Modulates pathways.	Mild: Reduces some inflammation.	Potent but Short-Lived.	Potent: COX enzyme blockade.
Matrix Synthesis	Upregulates: Stimulates cartilage repair.	Modest Increase: Some stimulation.	Inhibits: Suppresses repair.	None.
Viscoelastic Support	None.	Excellent: Provides lubrication.	None.	None.
Longevity	Months to Years: Longest duration.	4-6 Months: Moderate duration.	Weeks: Short-term relief.	Weeks to Months.

The Essential Role of Integrative Chiropractic Care

As a Doctor of Chiropractic (DC) in addition to my other credentials, I see these injection therapies not as standalone cures, but as powerful adjuncts to a foundational, holistic treatment plan. Integrative chiropractic care is the bedrock upon which these advanced therapies can be most effective.

Regenerative medicine aims to heal tissue, but if the underlying biomechanical dysfunctions are not addressed, the new tissue will be subjected to the same stresses that caused the initial injury.

• Why It Works: Chiropractic adjustments restore proper joint mechanics, improve nervous system function, and reduce abnormal biomechanical loads. Treating knee OA without addressing an underlying pelvic tilt or spinal misalignment, for example, is only treating a symptom. By optimizing the biomechanics of the knee, hip, and spine, we create a more favorable environment for injections to be effective.
• Clinical Protocol: My approach often involves a course of chiropractic care before and after a PRP procedure.

• Pre-Procedure: We focus on correcting structural imbalances to prepare the “soil” for the “seed” of PRP. This can include spinal adjustments, soft tissue mobilization, and corrective exercises.
• Post-Procedure: After the injection, continued chiropractic care helps maintain proper alignment, supports the healing tissues, and facilitates a more complete and lasting functional recovery.

Furthermore, my practice philosophy emphasizes addressing the whole person through nutritional counseling and prescriptive exercise to create an internal and external environment that promotes healing and long-term function.

Conclusion: Crafting a Patient-Centered Treatment Plan

So, returning to our 60-year-old patient with the wedding next week. What is the best path forward?

1. For her immediate need, a ketorolac injection is an excellent choice. It offers rapid pain relief, similar to a steroid, but without the known risk of cartilage damage. This would allow her to enjoy her son’s wedding with improved comfort and mobility.
2. For her long-term health, once the acute flare has subsided, a conversation about PRP would be the next logical step. Given its superior evidence for long-term pain relief and its potential disease-modifying effects—especially a high-dose protocol—a series of PRP injections could offer sustained benefit and potentially delay the progression of her OA.
3. Throughout this process, she would continue with her foundational care: integrative chiropractic adjustments to maintain optimal joint alignment, targeted physical therapy to build strength and stability, and lifestyle modifications to manage weight and inflammation.

There is no single “right” answer for every patient. As clinicians, our responsibility is to stay abreast of the evidence, understand the intricate physiology underlying these treatments, and partner with our patients to make choices that align with their goals—both in the short and long term. By integrating modern injection therapies with the foundational principles of chiropractic and functional medicine, we can offer a truly comprehensive and powerful approach to managing joint pain and promoting lasting health.

References

Altman, R., Hackel, J., Medina, R., & Revicki, D. (2016). Efficacy and safety of a single intra-articular injection of a novel hyaluronic acid in patients with knee osteoarthritis. Journal of Rheumatic Diseases, 23(3), 154.

Belk, J. W., Kraeutler, M. J., Houck, D. A., Goodrich, J. R., Dragoo, J. L., & McCarty, E. C. (2024). Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. The American Journal of Sports Medicine, 52(8), 2043-2054.

Dean, B. J. F., Lostis, E., & Carr, A. J. (2014). The corticosteroid-tendon interface: A review of the literature. The Bone & Joint Journal, 96-B(2), 143-150.

Evans, J. T., Shive, M. S., & Kenter, K. (2021). Effects of ketorolac and methylprednisolone on human chondrocyte and synoviocyte viability in vitro. Orthopedic Journal of Sports Medicine, 9(6), 232596712110129.

Han, Y., Huang, H., Pan, J., Lin, J., Zeng, L., Liang, G., Yang, W., & Liu, J. (2024). The efficacy of platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: A systematic review and meta-analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. Advance online publication.

Jevsevar, D., Donnelly, P., Brown, G. A., & Cummins, D. S. (2024). The American Academy of Orthopedic Surgeons’ evidence-based guideline on management of osteoarthritis of the knee. The Journal of Bone and Joint Surgery, 95(20), 1885–1889.

Kompel, A. J., Roemer, F. W., Murakami, A. M., Diaz, L. E., Crema, M. D., & Guermazi, A. (2019). Intra-articular corticosteroid injections in the hip and knee: Perhaps not as safe as we thought? Radiology, 293(3), 656–663.

Lana, J. F. S. D., Huber, S. C., Onodera, C. M. K., Purita, J., Filho, R. B., & e Silva, G. R. (2021). Combination of platelet-rich plasma and hyaluronic acid is superior to either treatment alone in knee osteoarthritis: A matched-pair, controlled study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 37(3), 963-971.

McAlindon, T. E., LaValley, M. P., Harvey, W. F., Price, L. L., Driban, J. B., Zhang, M., & Ward, R. J. (2017). Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis. JAMA, 317(19), 1967.

Yoshii, I., Kuroda, R., & Kawakami, Y. (2020). Efficacy of intra-articular injection of ketorolac for pain control in patients with knee and hip osteoarthritis: A systematic review and meta-analysis. Journal of Orthopedic Science, 25(4), 659–666.

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