The 2026 ACR Osteoarthritis Guideline Says No to PRP. Here’s What It Leaves Out

By Nikhil Verma, MD. Board-certified in Physical Medicine and Rehabilitation and Interventional Spine, fellowship-trained in Interventional Spine and Sports Medicine. Essential Sports and Spine Solutions, Columbus, OH.

This week the same graphic kept showing up in my feed. The 2026 update to the American College of Rheumatology osteoarthritis guideline, boiled down to five take-home points: exercise, weight loss, NSAIDs, steroid injections, and at the bottom, PRP and stem cell injections strongly recommended against.

And honestly, my first reaction wasn’t calm. That list reads almost like the opposite of how I practice. So I did what I’d want any physician to do before reacting publicly. I read the actual guideline summary, not the graphic.

Here’s the short version. The ACR now strongly recommends against PRP for knee and hip osteoarthritis, and it rated the certainty of the evidence behind that recommendation as low. The same low certainty earned steroid injections into the knee and hip a strong recommendation in favor. Meanwhile, there are multiple Level 1 randomized controlled trials showing PRP improves pain and function in knee osteoarthritis, a specialty society guidance statement from earlier this year supporting it in the right patients, and drug-free options like laser therapy and shockwave that the guideline doesn’t address at all.

I respect the ACR. I also think they got this one wrong. Both of those can be true. As an interventional spine and sports medicine physician in Columbus who treats knee arthritis every week, here’s what I actually know.

What does the 2026 ACR osteoarthritis guideline actually say?

The ACR Board approved a summary of its updated recommendations for knee, hip, and hand osteoarthritis in September 2026. The full manuscript, with the evidence tables, hasn’t been published yet. I’ll update this post once I’ve read it, because the details matter.

Here’s what the summary says, in plain language:

• Strongly recommended: exercise, weight loss if overweight, topical NSAIDs (knee and hand), oral NSAIDs, and steroid injections for knee and hip OA.
• Conditionally recommended: GLP-1 medications for knee OA with obesity, knee bracing, acupuncture, massage, tai chi, yoga, heat and cold, and radiofrequency ablation for the knee, among others.
• Strongly recommended against: PRP and stem cell injections for knee and hip OA, glucosamine and chondroitin, and several drugs that failed in trials.
• Conditionally recommended against: hyaluronic acid injections, dextrose prolotherapy, vitamin D, fish oil, and opioids, among others.

A few things are worth noticing. The guideline itself says treatment should start with the least toxic options, that decisions should be personalized through shared decision-making, and that specialized treatments should be delivered by people with the expertise to do them. I agree with all three of those. I just don’t think the PRP recommendation follows from them.

Why does “strong recommendation, low certainty” matter?

This is the part the graphic left out, and it’s the part that matters most.

Guidelines like this use a system called GRADE. Two separate things get rated: how strong the recommendation is, and how certain the evidence is. A strong recommendation means the panel is telling nearly every clinician to do (or not do) something for nearly every patient. Certainty of evidence tells you how confident you should be that the research actually supports it.

The GRADE framework itself treats a strong recommendation built on low-certainty evidence as something that should be uncommon, reserved for special situations. In this guideline, PRP got a strong recommendation against with low certainty. Steroid injections got a strong recommendation for, also with low certainty.

Same certainty. Opposite verdict.

I’m not the arbitrator of truth here, and I haven’t seen the full evidence tables yet. But when two treatments sit on the same evidence footing and one gets a green light while the other gets a red light, that decision is being driven by something other than certainty alone. Patients deserve to know that.

Is there Level 1 evidence for PRP in knee osteoarthritis?

Yes. Level 1 evidence means randomized controlled trials and meta-analyses of them, the highest tier of clinical research. PRP for knee OA has quite a bit of it.

• A randomized trial in The American Journal of Sports Medicine (Patel et al., 2013) compared PRP to saline in knee OA and found better pain and function scores in the PRP groups at six months.
• A randomized trial in Arthroscopy (Lin et al., 2019) compared leukocyte-poor PRP to hyaluronic acid and to saline. PRP outperformed both at 12 months.
• A 2021 meta-analysis of Level 1 trials in The American Journal of Sports Medicine (Belk et al.) found PRP produced better functional outcomes than hyaluronic acid.
• The American Academy of Orthopaedic Surgeons’ 2021 knee OA guideline concluded PRP may reduce pain and improve function.
• In April 2026, the American Academy of Physical Medicine and Rehabilitation released a guidance statement recommending that PRP be considered for patients with mild to moderate knee OA who are still symptomatic after conservative care, with expert consensus suggesting earlier treatment may do better.

So when someone tells you “there’s no evidence for PRP,” that’s just not accurate. There’s a lot of it. The honest question is how you weigh it.

What about the studies where PRP didn’t beat placebo?

I’m not going to pretend they don’t exist. The most important one is the RESTORE trial, published in JAMA in 2021. It compared three PRP injections to saline in knee OA and found no meaningful difference in pain or cartilage volume at 12 months. That’s a rigorous trial, and it was negative.

Here’s how I hold it. “PRP” is not one thing. The preparation, the platelet dose, the white cell content, the number of injections, and whether the injection was even guided into the joint all vary enormously from study to study. When you separate the studies with better outcomes, they tend to share higher delivered platelet doses. Work in the orthobiologics literature has pointed to roughly 10 billion platelets as an important threshold for sustained benefit in knee OA.

So a negative trial of one preparation doesn’t prove PRP fails, any more than one underdosed medication trial proves a drug class doesn’t work. If a guideline lumps every preparation together, the good and the underdosed, it will get a blurry answer. The nuance here is everything.

Why I don’t reach for NSAIDs

The guideline strongly recommends oral NSAIDs. I understand why. They’re cheap, they’re accessible, and they do reduce pain for a lot of people in the short term.

But I don’t like using them for chronic knee arthritis, and here’s why. Knee OA isn’t a six-week problem. It’s a years-long problem. And the long-term cost of daily NSAIDs is real:

• Heart and blood vessels. A large 2013 Lancet meta-analysis found that high-dose regimens of several common NSAIDs increased major cardiovascular events by roughly a third.
• Stomach. GI bleeding and ulcers are a well-established risk, and it climbs with age.
• Kidneys. NSAIDs are linked to kidney injury, especially in older adults, people with high blood pressure, and anyone already on certain blood pressure medications.

The people most likely to have knee arthritis are the same people most likely to be harmed by years of NSAIDs. That’s the tension. Topical NSAIDs carry much lower systemic exposure, and a short, deliberate course has its place. Reflexive, open-ended daily use is where I push back. I’ve written an entire series on alternatives to chronic NSAID use in my newsletter because this comes up constantly.

Why I avoid steroid injections in the knee

Cortisone works. For a few weeks. I get why patients like it and why it’s in the guideline.

But the long-term data is not kind. A randomized trial in JAMA (McAlindon et al., 2017) gave patients steroid injections into the knee every three months for two years. The steroid group lost more cartilage than the saline group, and they didn’t have less pain. A 2019 report in Radiology described patients who developed accelerated arthritis, subchondral fractures, and rapid joint destruction after steroid injections into the hip and knee. Steroid injections in the months before a knee replacement have also been associated with higher infection risk.

That’s why I rarely use them, and never as a reflex. If a steroid injection keeps wearing off, there’s a reason, and repeating it isn’t a plan.

Where MLS laser and shockwave therapy fit

Here’s something the guideline summary doesn’t mention at all: photobiomodulation (laser therapy) and extracorporeal shockwave therapy. They weren’t recommended for or against. They just aren’t in it.

MLS laser therapy. A 2019 systematic review in BMJ Open (Stausholm et al.) found that laser therapy at recommended doses reduced pain and disability in knee osteoarthritis. The MLS system I use is a dual-wavelength Class IV laser. To be honest, most of the published research is on laser therapy broadly, and the research specific to MLS is smaller. The mechanism is biologically sound: light energy influences mitochondrial activity, inflammation, and local circulation. I deliver these treatments myself, and I often use them before and after an injection to prepare the joint.

Shockwave therapy. A 2020 systematic review and meta-analysis of randomized trials in the International Journal of Surgery (Avendaño-Coy et al.) found moderate-quality evidence that shockwave reduced pain and improved function in knee OA in the short term. It’s non-invasive, requires no medication, and fits naturally alongside a loading program. Full transparency: I don’t currently have a shockwave device in my practice. I’m including it because the evidence is real and patients deserve to know it exists, not because I have something to offer you.

Neither of these is magic. Both are low-risk, drug-free tools with a real evidence base, and I’d rather a patient try them than take ibuprofen every day for five years.

Where I agree with the guideline

I don’t want to throw the baby out with the bathwater. A lot of this guideline is right.

Exercise is the foundation. Period. Weight loss matters for a loaded joint. I’m glad GLP-1 medications made it in as an option for knee OA with obesity. The guideline also conditionally recommends genicular nerve radiofrequency ablation for knee OA, which I do perform and think is an underused option for the right patient. And the good practice statements about education, physical therapy, and shared decision-making are exactly how I think care should work.

The injection is one piece. The protocol is the point. Every patient I treat for knee arthritis gets a plan built around strength, movement, body composition, sleep, and recovery. The biologics and the devices work better in a well-prepared joint. That part, the ACR and I agree on.

What this means if you have knee arthritis in Columbus

If your doctor showed you this guideline and said PRP is off the table, that’s a reasonable conversation to have. Guidelines exist for a reason. But you’re also allowed to ask what the certainty of the evidence was, why steroids got a pass on the same certainty, and whether anyone has looked at your imaging and your goals, not just a chart.

If you’re in Columbus, Dublin, Westerville, Upper Arlington, Gahanna, or anywhere in Central Ohio, that’s the conversation I have every week. I look at your imaging myself. Every injection is done under ultrasound guidance. And if you’re not a good candidate for PRP, I’ll tell you.

If you want to go deeper on this, including the specific protocols I use, how I think about system selection, and what I tell every patient after an injection, I cover all of that in my paid newsletter, Essentials of Healing. You can find it at nikhilvermamd.substack.com.

Frequently asked questions

Does the new ACR guideline mean PRP doesn’t work for knee arthritis? No. It means the ACR panel weighed the evidence and decided against recommending it. The panel rated the certainty of that evidence as low. Multiple Level 1 randomized trials show PRP improves pain and function in knee OA, and other physician organizations have reached different conclusions.

Why does the ACR recommend steroid injections but not PRP? The summary doesn’t fully explain it, and the full manuscript isn’t out yet. What we do know is that both recommendations are rated as low certainty of evidence, yet steroids received a strong recommendation for and PRP a strong recommendation against. In my view, that gap deserves a closer look.

Is there Level 1 evidence for PRP in knee osteoarthritis? Yes. Several randomized controlled trials and meta-analyses of randomized trials have found PRP outperforms saline or hyaluronic acid for knee OA pain and function. There are also rigorous negative trials. Differences in platelet dose and preparation likely explain a lot of the mixed results.

Are NSAIDs safe for long-term knee arthritis pain? They carry real long-term risks, including cardiovascular events, GI bleeding, and kidney injury, and those risks climb with age. Short, deliberate use has a place for some people, and topical NSAIDs have much lower systemic exposure. I don’t recommend open-ended daily use for a condition that lasts years.

Do cortisone shots damage the knee? They can. A randomized trial found repeated steroid injections every three months led to more cartilage loss than saline without better pain relief. Imaging reports have also described accelerated joint damage after steroid injections. One injection isn’t a catastrophe, but repeated injections aren’t a long-term plan.

Does MLS laser therapy work for knee arthritis? The evidence suggests laser therapy at proper doses can reduce pain and improve function in knee OA. Most of that research is on laser therapy broadly rather than the MLS system specifically. It’s drug-free, low-risk, and I often use it alongside injections.

Is shockwave therapy effective for knee osteoarthritis? A meta-analysis of randomized trials found moderate-quality evidence that shockwave improves pain and function in knee OA over the short term. It’s non-invasive and works well combined with a strengthening program.

Should I still consider PRP after this guideline? That’s a decision for you and a physician who has actually examined you and looked at your imaging. PRP is not right for everyone, especially in advanced arthritis with mechanical symptoms. For the right patient, with a properly dosed, image-guided preparation, the evidence still supports it as a reasonable option.

Ready to talk through whether this is right for your knee? You can request an appointment at https://www.essentialsportsspine.com/request-appointment/ or call 614-626-8707.

This is for educational purposes only and does not constitute medical advice.

References

1. American College of Rheumatology. 2026 Update of the ACR Recommendations for the Management of Osteoarthritis of the Knee, Hip, and Hand (summary). Approved September 8, 2026.
2. AAPM&R Guidance Statement on Platelet-Rich Plasma for Knee Osteoarthritis. PM&R. 2026. doi:10.1002/pmrj.70144.
3. Patel S, et al. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis. Am J Sports Med. 2013.
4. Lin KY, et al. Intra-articular injection of platelet-rich plasma is superior to hyaluronic acid or saline solution in the treatment of mild to moderate knee osteoarthritis. Arthroscopy. 2019.
5. Belk JW, et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021.
6. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Clinical Practice Guideline. 2021.
7. Bennell KL, et al. Effect of intra-articular platelet-rich plasma vs placebo injection on pain and medial tibial cartilage volume in patients with knee osteoarthritis: the RESTORE randomized clinical trial. JAMA. 2021.
8. Coxib and traditional NSAID Trialists’ (CNT) Collaboration. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs. Lancet. 2013.
9. McAlindon TE, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis. JAMA. 2017.
10. Kompel AJ, et al. Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought? Radiology. 2019.
11. Stausholm MB, et al. Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials. BMJ Open. 2019.
12. Avendaño-Coy J, et al. Extracorporeal shockwave therapy improves pain and function in subjects with knee osteoarthritis: a systematic review and meta-analysis of randomized clinical trials. Int J Surg. 2020.