In this clinical setting, the pain is due to immune mediated synovitis and will respond very well unless the patient has patellofemoral pain syndrome that is being overlooked, which is often the case. To exclude, look for it first, then confirm not an issue with Insall ratio and TT-TG measurements.

Consider getting a T2 wetmap sequence of the joint to indirectly assess the proteoglycan content of the cartilage. If it looks dessicated, which it will, then you have your etiology and know what you are treating. You are describing a very common clinical finding that is easily explained with Cartigram® imaging. The same is true for spine discs that look 'normal' on routine sequences. Get the diffusion weighted (DWI/EDC) images of the disks on the MR and the T2 wetmaps in the appendicular joints.

Any increased dark signal in the subchondral bone is a dead giveaway in the appendicular or axial skeleton. Consider unloading the joint to REMARKABLY increase the lifetime of your treatments. The key to all of these treatments in the setting of arthritis, whether primary(RA) or secondary (OA), since they are the same disease from a purely molecular standpoint (G Livshits, Rheumatol, January 2018) and should be treated as such, is to unload both the chondral and the subchondral structures WHILE treating the cytokine mayhem in the joint. At least that has been our experience with orthopedic immunobiologics over the last 12 years.

Practically we have noticed good short term improvement to allow pain relief and lifestyle modifications in cases of early Arthritis. Long acting high molecular weight hyaluronic acid injections thus may be an adjunct in early OA cases. We prefer annual doses as these are reported to have better outcome.

But these supplements can not replace the activity and posture modifications, exercises , weight reduction etc that have cumulative impact.

Most chondroprotective substance available in our country are under foot supplement section and their long term efficacy and quality is not backed by strong data thus it is solely based on practitioner's discretion to prescribe them or not.

Dear

There must be a cause for this pain, It is mostly early OA. Injection could have short effect period. Injection that treat OA are not fully tested. It may have some damage to the joint when it is repeated for long time. I think better than injection is to improve knee joint stability and alignment by strengthen the muscles around the joint.

In this clinical setting, the pain is due to immune mediated synovitis and will respond very well unless the patient has patellofemoral pain syndrome that is being overlooked, which is often the case. To exclude, look for it first, then confirm not an issue with Insall ratio and TT-TG measurements.

Consider getting a T2 wetmap sequence of the joint to indirectly assess the proteoglycan content of the cartilage. If it looks dessicated, which it will, then you have your etiology and know what you are treating. You are describing a very common clinical finding that is easily explained with Cartigram® imaging. The same is true for spine discs that look 'normal' on routine sequences. Get the diffusion weighted (DWI/EDC) images of the disks on the MR and the T2 wetmaps in the appendicular joints.

Any increased dark signal in the subchondral bone is a dead giveaway in the appendicular or axial skeleton. Consider unloading the joint to REMARKABLY increase the lifetime of your treatments. The key to all of these treatments in the setting of arthritis, whether primary(RA) or secondary (OA), since they are the same disease from a purely molecular standpoint (G Livshits, Rheumatol, January 2018) and should be treated as such, is to unload both the chondral and the subchondral structures WHILE treating the cytokine mayhem in the joint. At least that has been our experience with orthopedic immunobiologics over the last 12 years.

The Halawa question is interesting: in patient with unknown age and other background with painful knee without apparent cause with MRI and normal biomechanics, what should be done? I think the observation is the most advisable

Viscous injections according to the manufacturer are proposed for patients with stage 1 or 2 degeneration. We run an audit of 80 patients some years ago after staging the degenerative changes with an arthroscopy and we found that the benefit was for patients of stage 3 or 4 than the lower grades. Then as is was unethical to offer a different injection we compared the cases with patients who had only a washout of the joint via an arthroscopy. The findings shown that severe degeneration had more benefit than the early presented wear and tear. Our conclusion was that viscous injections had mainly a placebo effect and to the expense of the insurers. We have not published the results but other did. The tendency is not to used them anymore.

In the cases of the patients you have described the cause of pain has to be found potentially in different areas than the knee or as part of more systemic condition (rheumatoid, obesity, non immune conditions) than a simple "osteoarthritis".

Ha injection has outphased in latest WHO concensus. Tka nsaids and physio recommend