The newest arthritis guideline says no to treatments clinics still sell

Picture a mailer for a cash-only knee injection made from your own cells, promising no surgery, no downtime and a joint that repairs itself. In September 2026 the American College of Rheumatology, the professional society for US arthritis specialists, put stem-cell injections for knee and hip osteoarthritis on its strong-against list. The Food and Drug Administration (FDA) has not approved any stem-cell product for osteoarthritis, or for any other orthopedic condition.

That gap between what is sold and what is supported runs through arthritis care, starting with the word itself. Arthritis is not one disease, and about one in five American adults who have it don’t know which kind they have.

Here is what the label covers, what the newest osteoarthritis guideline backs and rejects, and what trials of knee surgery and injections found.

Arthritis is a label for more than 100 conditions

The Centers for Disease Control and Prevention (CDC) files more than 100 conditions under arthritis, from osteoarthritis and rheumatoid arthritis to gout and lupus. Its surveys count anyone a health professional ever told they had one of several of them.

By that measure the numbers are large. Pooling its 2019 to 2021 National Health Interview Survey, the CDC estimated that 53.2 million US adults, or 21.2%, had diagnosed arthritis (18.7% after adjusting for age). The 2022 round put the age-adjusted share at 18.9%.

It is not only a condition of old age: 5.4% of adults aged 18 to 44 reported it, against 47.3% of those 65 and older.

A second federal survey, the National Health and Nutrition Examination Survey, found 27.9% of adults 20 and older in 2017 to March 2020. That is not a contradiction; the surveys differ in design, years and age cutoffs. Its more striking finding, published by CDC researchers in 2025, is about knowledge. Among adults with arthritis, 21.6%, about 14.4 million people, said they did not know which type they had. Among the uninsured, it was closer to one in three. The types people named were never checked by a clinician, so the 10.6 million who reported rheumatoid arthritis reflects what people believed, not what a rheumatologist confirmed.

Osteoarthritis is not simple wear and tear

Osteoarthritis was the type named most often, by about half of all adults with arthritis. The CDC estimates it affects about 33 million US adults and says it is not a regular part of aging. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) describes joint tissue breaking down through changes that build up over time, and it explicitly rejects the idea that the cause is simple wear and tear.

If a joint were a worn tire tread, rinsing it out, refilling it or regrowing it would make sense. Much of what current evidence rejects rests on that picture.

What the 2026 osteoarthritis guideline recommends

On September 14, 2026, the American College of Rheumatology (ACR) posted a summary of updated recommendations for osteoarthritis of the knee, hip and hand. Approved by the college’s board on September 8, it replaces the 2019 guideline the ACR wrote with the Arthritis Foundation. The full paper has not been published yet, so everything here comes from the summary.

Each graded item carries a strength (strong or conditional, for or against) plus a certainty rating for the evidence behind it. The ACR’s announcement says the conditional ones are meant to prompt a discussion with each patient that weighs benefits and harms along with burden, cost and access.

The strong-for list is short and unglamorous:

• Exercise for knee and hip osteoarthritis (moderate certainty).
• Weight loss for people with knee or hip osteoarthritis who have overweight or obesity (moderate certainty).
• Nonsteroidal anti-inflammatory drugs (NSAIDs), as gels or creams for the knee and hand and as pills for the knee, hip and hand (moderate certainty).
• Steroid injections into the knee or hip (low certainty), with ultrasound guidance strongly recommended for hip injections.

Three ungraded good practice statements add education and self-management, referral to physical or occupational therapy, and canes or other mobility aids for people whose walking is limited.

Look again at the steroid line. A strong recommendation can rest on low-certainty evidence, and this one does.

A longer conditional-for list includes knee braces, hand splints, taping, yoga for the knee, heat or cold, acupuncture, cognitive behavioral therapy, acetaminophen, duloxetine (an antidepressant also used for pain) and radiofrequency ablation, which applies heat to nerves around the knee. Tai chi, rated strong in 2019, now sits in this tier on very low certainty evidence; the trials behind it are laid out in our tai chi piece.

One entry is brand new. GLP-1 receptor agonists, the drug class used for type 2 diabetes and obesity, are conditionally recommended for knee osteoarthritis in people with obesity (moderate certainty). Whether one suits a particular person is a prescribing decision. The weight-loss trials are weighed in the diet-claims article, and NSAID label warnings are summarized in our piece on inflammation.

The no list, and what changed since 2019

The strong-against list, which also covers interleukin-1 blocking drugs for the hand, is where the distance from the marketplace shows:

• Platelet-rich plasma (PRP), a concentrate made from your own blood and injected into the joint, for the knee and hip (low certainty).
• Stem-cell injections for the knee and hip (moderate certainty).
• Glucosamine and chondroitin, alone or combined, for the knee, hip and hand.
• Hydroxychloroquine, bisphosphonates and TNF-alpha inhibitors, drugs borrowed from lupus, osteoporosis and inflammatory arthritis care.

The conditional-against tier holds hyaluronic acid injections (moderate certainty for knee and hip), electrical nerve stimulation units known as TENS (low certainty), opioids (low certainty), wedged shoe insoles, fish oil, vitamin D, colchicine, botulinum toxin and dextrose prolotherapy.

What moved since 2019

Besides tai chi, these are among the positions that changed, so anything written before September 2026 shows the old versions:

• Massage for the knee and hip went from conditional against to conditional for (low certainty). In 2019 the panel had faulted the trials as small and at high risk of bias.
• Methotrexate for erosive hand osteoarthritis, a form that shows bone erosions in the finger joints on X-rays, flipped from strongly against to conditionally for (low certainty). The 2019 panel had cited well-designed trials in that very group showing no benefit, so the full paper’s reasoning will matter.
• TENS softened from strongly against to conditionally against.
• Hyaluronic acid for the hip eased from strongly against to conditionally against, the same as the knee.
• Chondroitin for the hand, conditionally supported in 2019, now falls under the strong-against line for all glucosamine and chondroitin products.
• Braces for the main knee joint and splints for the base of the thumb dropped from strong to conditional recommendations, and canes and self-management programs, strongly recommended in 2019, became ungraded good practice statements. NSAID gels and creams for the hand moved the other way, from conditional to strong.

Why the supplements landed where they did

The largest US test, a federally funded 24-week trial of 1,583 people with knee osteoarthritis published in the New England Journal of Medicine in 2006, holds a reframing number: 60.1% of people taking a placebo met its bar for pain relief. Glucosamine, chondroitin and the pair beat that by 3.9 to 6.5 percentage points, and none of those gaps was statistically significant. Celecoxib, an NSAID included as a check, beat placebo by 10 points, and that gap was. A better result in people with worse pain came from an analysis the authors called exploratory.

The National Center for Complementary and Integrative Health (NCCIH), in its October 2023 fact sheet, adds the cautions: glucosamine may raise blood sugar in some people, and both supplements have been linked to bleeding risk in people taking warfarin. Its bottom line is that benefit for knee symptoms remains uncertain.

US experts do not agree on all of it

The American Academy of Orthopaedic Surgeons (AAOS) adopted its own knee osteoarthritis guideline on August 31, 2021. It matches the ACR on exercise and NSAIDs, and is stricter on opioids, rating its advice against tramadol and other oral opioids as strong.

On several items the two bodies part ways. The AAOS rates the evidence as limited but says PRP may reduce pain and improve function, that glucosamine and chondroitin may help in mild to moderate disease, and that TENS may be used. The ACR now puts PRP and the supplements in its strongest category against. On hyaluronic acid they sit closer: the AAOS calls it not recommended for routine use.

The NCCIH fact sheet lays out the same split for the supplements.

Some of the gap is timing. The AAOS said it would update or withdraw its guideline within five years, and in late October 2026 its website still listed the 2021 edition. Some is judgment about thin evidence. Either way, a clinic that says guidelines support PRP is citing one US body and leaving out the other.

The knee clean-out that lost to sham surgery

For decades a common answer to a painful, worn knee was arthroscopy. A surgeon passes a camera and small tools through keyhole cuts to rinse the joint, smooth rough cartilage or trim a frayed meniscus, the rubbery cushion between the thigh and shin bones.

In 2002 a team at the Houston Veterans Affairs Medical Center tested it against a fake operation. They randomly assigned 180 people with knee osteoarthritis to an arthroscopic rinse, a rinse plus smoothing, or placebo surgery with skin incisions and a simulated procedure, the scope never entering the joint. Over two years, neither real operation beat the placebo for pain or function at any point, the team reported in the New England Journal of Medicine.

Supporters then pointed to meniscal tears as the better target. A Finnish team led by Sihvonen tested that idea in a double-blind trial published in 2013. It enrolled 146 people aged 35 to 65 who had symptoms of a degenerative meniscus tear and no knee osteoarthritis, and assigned them to partial meniscectomy, removing the torn piece, or a sham procedure. A year later both groups had improved by similar amounts: 21.7 points on a 100-point knee score after the real surgery, 23.3 after the sham.

In 2017 an international panel that included orthopedic surgeons and people who had lived with the condition pooled 13 randomized trials covering 1,668 patients. “We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease…” the panel wrote in The BMJ.

Its numbers explain why. Fewer than 15% of patients got a small or very small improvement at three months, and it was gone by one year. Recovery takes two to six weeks, often starting on crutches. Meniscus tears, the panel noted, are common, usually incidental and unlikely to be what is causing the pain. The one possible exception it named was a truly locked knee that cannot fully straighten.

Yet the panel reported that arthroscopy for degenerative knees was the most common orthopedic procedure in countries with data, done more than 2 million times a year worldwide at a US cost above $3 billion a year.

The AAOS stops short of the panel’s position. It advises against arthroscopic rinsing or smoothing for knee osteoarthritis, but says partial meniscectomy can be used for a meniscal tear with mild to moderate osteoarthritis once nonsurgical care has failed. The ACR’s 2026 summary does not address arthroscopy at all. Whether a particular knee fits the narrow locked-knee exception is a question for the surgeon, asked directly.

What the injection trials found

Steroid shots

The ACR (strong, low certainty) and the AAOS (moderate, short-term relief) both support steroid injections. Repeating them for years looks less reassuring. In a 2017 Tufts Medical Center trial in JAMA, 140 people with knee osteoarthritis and ultrasound signs of an inflamed joint lining got steroid or salt-water injections every 12 weeks for two years. The steroid group lost slightly more cartilage thickness on MRI and had no less pain. How steroid shots stack up against a course of physical therapy is a question for our physical therapy entry.

Hyaluronic acid, the gel shots

Hyaluronic acid injections, also called viscosupplementation, are meant to add lubricating fluid to the knee. A 2022 review led by researchers in Toronto gathered 169 trials with 21,163 participants, then focused on the 24 largest placebo-controlled ones. Pain improved by about 2 points on a 100-point scale more than with placebo, well below the smallest difference the team counted as meaningful to patients. In the 15 large trials that tracked them, serious adverse events were 49% more common with the injections. “The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis,” the authors wrote in The BMJ.

Practice has been slow to follow. In 2007 to 2015 claims from a national insurer covering more than 1 million people with knee osteoarthritis, 12.9% received hyaluronic acid. After the AAOS’s earlier guidelines, its use fell among orthopedic surgeons and pain specialists but not among primary care doctors.

Platelet-rich plasma

In an Australian trial published in JAMA in 2021, 288 people aged 50 and older with mild to moderate knee osteoarthritis received three weekly injections of PRP or salt water. After a year, pain had dropped 2.1 points on a 0-to-10 scale with PRP and 1.8 with placebo, a difference that was not statistically significant. Cartilage volume was no different, and 29 of 31 secondary outcomes showed no gap.

Stem cells and other biologic products

The FDA says it has received reports of blindness, tumor formation and infections from unapproved regenerative products, including fat-derived cell mixtures, cord blood, amniotic fluid and exosomes. As of April 2024, its consumer pages said the only stem-cell products it had approved were blood-forming cells from umbilical cord blood, for blood disorders. In December 2024 it approved its first therapy made from mesenchymal stromal cells, taken from the bone marrow of healthy adult donors, for children with a life-threatening complication of blood stem-cell transplants. None of these approvals covers osteoarthritis or any other orthopedic condition.

The agency adds two warnings. Being charged for one of these products outside a clinical trial means you are likely being deceived. And a listing on the federal trials registry, or a clinic’s FDA registration, does not make a product legal. Injuries can be reported to its MedWatch program.

Questions to ask before paying for an injection or a scope

Prompts for the conversation with whoever is offering the treatment:

1. What do the ACR (2026) and AAOS (2021) guidelines say about this for my joint? If they disagree, which is the clinic relying on?
2. What happened in placebo or sham-controlled trials? Ask for the gap in points on a pain scale, since placebo groups improve too.
3. Is this product FDA-approved for this use? For any cell or tissue product, is this an FDA-overseen clinical trial, and if so, why am I being charged?
4. For surgery, what would it fix that time and exercise would not? Is my knee truly locked, or is the plan based on a tear seen on an MRI?
5. What are the recovery time and the harms?
6. What will I pay out of pocket, and for how many sessions?
7. If I take more time to decide, what changes? Pressure to decide today is worth noticing.

Gout and rheumatoid arthritis, briefly

Gout is driven by uric acid. The CDC describes flares of sudden pain, swelling, redness and heat, usually in one joint and often the big toe, lasting days or weeks. Uncontrolled, it can form joint-damaging lumps called tophi, though not everyone with high uric acid gets gout. A 2019 analysis of national survey data put gout at 3.9% of US adults, about 9.2 million people, with only one-third of them on urate-lowering drugs. The ACR’s 2020 gout guideline strongly recommends those drugs for people with tophi, joint damage on X-rays or frequent flares, with allopurinol preferred first and blood tests guiding treatment toward a uric acid target. For flares, its strong recommendations are colchicine, NSAIDs or steroids.

Rheumatoid arthritis is an autoimmune disease, one in which the immune system attacks the body’s own tissues. The CDC says women are two to three times as likely to develop it, the highest risk falls between ages 50 and 59, and smoking raises it. NIAMS notes it often strikes matching joints on both sides and can bring fatigue and low-grade fever. The CDC says rheumatologists should diagnose and treat it, and that early treatment helps prevent joint damage. Stiffness patterns and blood markers are explained in our article on inflammation; autoimmune disease as a group comes in a later entry.

When to get seen promptly: a joint that suddenly turns hot, red and swollen; swelling in several joints, especially on both sides, that has lasted more than six weeks, which the ACR calls a sign of persistent inflammation. Whether either calls for a rheumatology referral is the referring clinician’s decision, and a fair question to ask.

The takeaway

The current osteoarthritis guideline’s strong yes list is short: exercise, weight loss where it applies, anti-inflammatory gels and pills, and steroid shots. Its strong no list includes injections and supplements still offered to patients. Before paying for anything on the second list, the three facts most worth having are which type of arthritis you have, what the sham and placebo trials showed, and whether the product is FDA-approved for that use.

Sources

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