Most people who come to my office don't need surgery on the first visit. What they need is a clear diagnosis and a sensible order of treatments. Here is how I think about the options, from the simplest to the more involved.
Start with the right diagnosis
Before any treatment is chosen, we need to know just what we are treating. A good history and a hands-on exam are the foundation. Imaging fills in the picture, but it does not replace the exam. The same MRI finding can mean very different things depending on your age, activity level, and symptoms.
Home exercises and supervised physical therapy
For most chronic conditions without trauma, movement is medicine. I usually start with a targeted home exercise program or a referral to supervised physical therapy. The goal is not generic strengthening — it is restoring the specific motion and correcting the loading pattern that is irritating your joint.
A good physical therapist can watch how you move, correct mechanics, and progress loading safely. For shoulders, that often means restoring rotation and scapular control. For knees, it may mean core, hip and quadriceps coordination. The exercises you do at home between visits are just as important as the visits themselves.
Activity modification
This sounds simple, but it is often the hardest part. Activity modification does not mean stopping everything. It means temporarily changing the load on the irritated tissue so it can calm down or avoiding movement patterns that are harmful. For a tennis shoulder, that might mean avoiding the serve for a few weeks. For a runner's knee, it might mean cross-training on a bike or in the pool. We match the restriction to the tissue and the person.
Pain relief: acetaminophen
For many patients, acetaminophen (Tylenol) is the safest first-line pain medicine. It does not inflame the stomach or thin the blood the way anti-inflammatories can, and it does not blunt the healing response the way ibuprofen or naproxen might. I often recommend it for the first few days after an injection or flare, when the goal is comfort while the underlying treatment takes hold.
Injections: what they can and cannot do
Injections are a tool, not a plan. Used at the right time, they can calm a flare, confirm a diagnosis, or deliver a treatment directly to the source. Used too often or in the wrong joint, they can do more harm than good. There are several different types of injections used to treat joint pain.
Corticosteroid injections
Cortisone and similar steroids are powerful anti-inflammatories. They can break a painful cycle quickly — a frozen shoulder that will not move, a knee flare that is blocking therapy, an inflamed bursa. The relief can be dramatic, and that has real value.
But there are downsides that are not discussed enough. Steroid injections do not strengthen or heal damaged tissue and do not restore vascularity (blood supply) to degenerative tissue. Repeated corticosteroid injections into a tendon or young joint can weaken tissue over time. More recent data suggest that corticosteroid injections can be detrimental to tendon and cartilage health in the long run, especially when they are used repeatedly. That is why I use them sparingly, and almost never as the only treatment.
Viscosupplementation
Viscosupplementation — a hyaluronic acid injection — is FDA-approved for knee osteoarthritis. Some patients get meaningful relief, particularly when the knee is still relatively aligned and the arthritis is not end-stage. It is also used off-label for shoulders, hips, and other joints. The evidence is more mixed outside the knee, but in selected patients it can be a reasonable option when other measures have not been enough.
Prolotherapy
Prolotherapy is an injection-based treatment that uses a concentrated sugar solution to create a controlled, low-grade inflammatory response. The idea is to stimulate the body's own repair mechanisms in ligaments and tendons that have become lax or painful. It is generally considered a biologic-type intervention, though it is less well studied than PRP. For patients with certain tendon or ligament problems who want a conservative option, it is worth a conversation.
Orthobiologics
Using your own tissue in the form of blood/plasma (PRP), bone marrow and cells (BMAC), or adipose tissue and cells (micro fat) to treat arthritis and other joint conditions such as tendon injury/tear, ligament injury, and sprains/strains. This is a relatively safe and natural alternative that offers potential to relieve pain and also improve the health of your injured tissue.
Alternative treatments
Patients often ask about massage, acupuncture, chiropractic care, and similar therapies. I am not opposed to any of them. My job is to make sure they are safe with your specific diagnosis, and that they are aimed at the goal that matters to you.
Sometimes the goal is pain relief, and these modalities can help. Sometimes the goal is restoring function, and they are not enough on their own. We have a real conversation in the office about your diagnosis, what the treatment evidence supports, and what you are willing and able to do.
My philosophy
Treating pain is a legitimate goal. The important part of the encounter is figuring out what the patient needs and what their goals are, then building a plan that gets them there safely.
When to take the next step
If conservative care — therapy, activity modification, targeted medication, and the right injection — is not moving the needle, we revisit the diagnosis and consider the next layer. That might be an orthobiologic such as PRP, BMAC, or microfat. It might be focused shockwave. And in some cases, it might be surgery.
The order matters. Start with the least invasive option that has a real chance of working, and escalate only when the diagnosis and your response tell us to.