Regenerative (Biological) and Non-surgical Joint Treatments

One of the comments we hear most often in the clinic is: 'I was advised to have a joint replacement, but I do not want surgery.' There are two different situations, and the decisions differ accordingly. The first is that the patient does not want surgery because of apprehension, work or caring responsibilities, or timing. The second is that the patient cannot undergo surgery because of conditions that increase surgical risk, such as heart or lung disease, uncontrolled diabetes, bleeding disorders or active infection. In the first group, the aim is usually to postpone surgery safely; in the second, it is to manage pain and movement through non-surgical approaches.

The foundation is the same in both groups and comes before injections: weight control, muscle-strengthening exercises, activity modification, appropriate shoes or walking-stick use, and medication. Joint injections are added to this foundation; without it, any benefit is likely to be short-lived. Osteoarthritis itself, including its stages, exercise programme and replacement decisions, is explained on the relevant joint page rather than here.

• Knee Osteoarthritis (Gonarthrosis)
• Hip Osteoarthritis (Coxarthrosis)
• Shoulder Conditions
• Orthopaedics for Older Adults (Geriatric Orthopaedics)

Intra-articular and peri-tendinous treatments are selected according to diagnosis rather than from a single standard list. Below is a summary of options considered for common diagnoses. Each row is a set of options discussed during consultation, not a recommendation; the linked page explains the diagnosis.

• Knee osteoarthritis: hyaluronic acid, PRP, corticosteroids; expectations are limited in advanced disease → knee osteoarthritis
• Hip osteoarthritis: injections are image-guided because the joint is deep → hip osteoarthritis
• Rotator cuff and shoulder impingement: the choice between corticosteroids and PRP depends on tendon condition → rotator cuff tear, shoulder impingement syndrome
• Tennis elbow: PRP is discussed for persistent tendon pain despite treatment → tennis elbow
• Heel spur / plantar fasciitis: exercise and insoles come first; injection for persistent symptoms → heel spur
• Avascular necrosis of the femoral head: bone-marrow-derived treatments in early disease are under investigation → avascular necrosis of the femoral head
• Sports injuries (muscle–tendon): planned according to healing and incorporated into return-to-sport rehabilitation → sports injuries
• Frozen shoulder: range-of-movement exercises are the main treatment; injections are supportive → frozen shoulder

Corticosteroids are powerful medicines that rapidly suppress inflammation around a joint or tendon. They are not regenerative treatments: they do not repair tissue, but suppress inflammation and the associated pain. Their effect begins within a few days in most patients and lasts from weeks to months, depending on the person and diagnosis. They are most useful during marked pain flare-ups that prevent an exercise programme from starting. Once pain settles, the aim is to move on to the main treatment: exercise, weight management and activity modification.

The answer to 'Is cortisone harmful?' depends on the frequency and injection site. Frequent repeat injections into the same joint are considered detrimental to cartilage and tendon tissue; an interval is therefore left between injections and the total number is limited. Cortisone injections into weight-bearing tendons such as the Achilles tendon are avoided. Blood glucose may rise for several days in people with diabetes, so monitoring is advised during this period. Cortisone is not injected if a joint is red and warm and there is fever, in other words, if infection is suspected.

Corticosteroids and biological treatments should not be presented as interchangeable. Corticosteroids may be considered when rapid suppression of inflammation is needed, whereas biological treatments may be discussed when supporting tissue repair is the aim; a time interval between them is preferred. The diagnosis at examination determines which treatment, when and how often.

Local collagen applications involve injecting collagen, the main structural protein of tendons and connective tissue, into the painful area; they are generally used for tendon- and ligament-related pain. Local ozone involves applying a medical ozone–oxygen mixture around a joint or to a muscle–tendon region. Evidence for the orthopaedic use of both methods is limited: studies involve small patient groups, treatment protocols are not standardised, and there are insufficient data on long-term outcomes. They are therefore not first-line treatments, but adjunctive options considered only in selected patients after expectations have been discussed clearly; this is also why they do not have separate treatment pages on this site.

Not every painful joint is suitable for an injection. If there is a retained foreign body, bone or joint infection, a growing mass or leg malalignment, inflammation is not the underlying source of the problem; an injection may offer no benefit and delay diagnosis. An intra-articular procedure can worsen the condition when infection is suspected. These subjects have dedicated pages on the site, linked here.

• Foreign Body Embedded in Tissue
• Bone and Joint Infections
• Bone and Soft Tissue Tumours
• Deformity Correction (Bow Legs and Knock Knees)

The following procedures are also frequently discussed during consultation. Detailed pages are being prepared; suitability is assessed according to your diagnosis.

• Exosome treatment (joint applications)
• Intra-articular hyaluronic acid (rooster comb) and hydrogel injections
• Chitosan and polynucleotide (PN) injections