If physical therapy, pain medications and commonly used injections of cortisone or hyaluronic acid (Synvisc) no longer relieve your knee pain, don't assume that you need surgery.

Knee replacement is widely known to significantly reduce pain, but 15% of knee-replacement patients still have severe pain several years later. In some cases, scar tissue from the surgery can irritate the surrounding knee structure, which leads to lasting pain.

What's more, the recovery period after knee replacement can be very difficult for some people-for example, it usually takes four to six weeks after the operation before you can drive again, go shopping and do most of your everyday activities. And some knee-replacement patients can never again participate in high-impact sports, such as tennis, jogging or downhill skiing

Fortunately, there are some highly effective nonsurgical alternatives to knee replacement.

Less Invasive Than Surgery

The procedures that show promise for long-term relief are less painful and have a quicker recovery time than knee-replacement surgery. Nonsurgical approaches…

  • Platelet-rich plasma (PRP) therapy. This is rapidly emerging as one of the most popular remedies for knee pain. It's been successfully used by professional athletes, including the golfer Tiger Woods, to improve healing after a knee injury.

How it's done: A small amount of blood is withdrawn from the patient. The blood is then spun in a centrifuge to concentrate platelets, which are then injected back into the knee to stimulate healing, Injections given in the open space inside a joint are only slightly painful...those given directly into a ligament or tendon typically require a local anesthetic to reduce discomfort. The procedure takes about an hour. Moderate to significant soreness lasts a few days.

How it works: Platelets are small cells in blood that initiate clotting. More importantly, they produce growth factors that stimulate, and accelerate, the body's natural healing process. An injection of PRP stimulates the movement of collagen-producing cells to the injured area. The body uses collagen to repair cartilage and other tissues.

My clinical experience: I've found that about 90% of my patients given PRP treatment for knee osteoarthritis report at least a 50% reduction in knee pain after two to four injections given at four to eight-week intervals. PRP can heal damaged cartilage, but it won't stop the progression of osteoarthritis. Many patients need a booster shot every couple of years.

*To find a physician with expertise in evaluating and treating musculoskeletal disorders, click on "Find a Doc tor' at the Web site of the American Association of Orthopaedic Medicine (www.adomed.org).

Best candidates: PRP can potentially be helpful for anyone with mild-to-severe arthritis who wants to avoid knee-replacement surgery, but seems to work best in younger patients with less severe arthritis.

Typical cost: Each injection ranges from $500 to $1,000. Most patients need at least two injections. PRP usually is not covered by insurance. Risks are minimal but include infection and injury to surrounding tissue.

  • Prolotherapy. Using sugar (dextrose) injections to treat knee pain sounds like a scam. But this approach, known as prolotherapy, has been extensively researched.

Scientific evidence: In a recent study of arthritis patients published in Alternative Therapies in Health and Medicine, patients who received dextrose injections had a 44% decrease in pain, 63% decrease in swelling and 85% fewer episodes of knee buckling after one year.

How it's done: Dextrose solution is injected into the painful area. A topical anesthetic can be used to reduce discomfort from the injections. Most patients get several injections during each session. It takes about 15 minutes. Prolotherapy injections are given every three to six weeks. It usually takes one to three months to notice results, which can last for several years.

How it works: The sugar solution stimulates production of collagen fibers, the body's natural healing response. Sometimes other solutions are used, including sodium morrhuate or phenol.

Best candidates: Most effective for patients with mild-to-moderate knee pain from arthritis or ligament and tendon injury.

Typical cost: $150 to $500 per session. The average patient needs five to seven sessions. It probably won't be covered by insurance. Prolotherapy has a small risk for infection, temporary or permanent nerve irritation or injury, or allergic reaction.

  • Stem cell therapy. Stem cells are undifferentiated cells that have the ability to turn into specialized cells in different parts of the body. They also have the unique ability to repair damaged tissue by dividing and multiplying almost indefinitely. Stem cell therapy is often used to repair damaged cartilage.

How it's done: Stem cells are "harvested" from the patient, often from fatty tissue or from bone marrow. The cells are spun in a centrifuge to separate stem cells and get a high concentration of them. Patients are given a local anesthetic to reduce discomfort, then the cells are injected into the injured/painful area.

How it works: When stem cells are injected into specific parts of the knee, they transform themselves into chondrocytes, or cells that build cartilage. They can also be transformed into cells known as fibroblasts for soft-tissue repair) or osteoblasts (for building bone).

Unlike PRP and prolotherapy, which mobilize the body's repair mechanisms, stem cell therapy directly repairs damaged areas. I've seen arthritis patients with severe bone damage, who I thought would require joint-replacement surgery, improve dramatically enough from this therapy to not need surgery.

Best candidates: People with severe osteoarthritis who didn't get significant pain relief from PRP or prolotherapy.

Typical cost: About $2,000 to $3,000 per treatment. One treatment might be enough—patients with more severe joint damage may need more. The therapy is not covered by insurance.

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