Patient case (clinical description): A 47-year-old woman comes to the office complaining of pain in the calf and knee when she bends down. The pain limits her activity. Her medical history is significant for osteoarthritis, for which she uses nonsteroidal anti-inflammatory drugs (NSAIDs) for the past two years. She is living with her husband and has 3 children. She doesn't smoke but drinks alcohol occasionally. Her vital signs are normal. On physical examination, there is a small effusion in the right knee. The effusion grew a little larger and she developed a tender swelling in the popliteal fossa and calf. Both the pain and swelling worsened as she bent and straightened her knee.

Patient's own account: I'm a 47-year-old woman, married with 3 kids. I don't smoke and I drink occasionally. I went to the doctor because of pain in my calf and knee when I was bending down. This has been limiting my daily activities. I have been diagnosed with osteoarthritis for which I have taken anti-inflammatory drugs for the past 2 years. The doctor saw a small fluid buildup in my right knee. This buildup became a bit bigger and I have a swollen calf. The pain is worse when I bend and straighten my knee.

Clinical trial: Study of Cingal® and Triamcinolone Hexacetonide for the Relief of Knee Osteoarthritis Pain

Eligibility criteria:
Inclusion Criteria:

          1. Subject is 40-75 years old.

          2. Body Mass Index (BMI) ≤ 40 kg/m2.

          3. Subject has Kellgren-Lawrence (K-L) severity grade II or III in the Index knee as
             determined by X-Ray. Contralateral knee: K-L severity grade 0, I or II.

          4. Subject has had at least two signs and at least two symptoms of OA disease (based on
             the European League Against Rheumatism (EULAR) recommendations for diagnosing knee OA)
             in the Index knee for at least 6 months despite conservative treatment (weight
             reduction, physical therapy, pain medications, etc.). The EULAR signs and symptoms are
             as follows:

               -  Signs: crepitus, restricted movement and bony enlargement

               -  Symptoms: persistent knee pain, limited morning stiffness and reduced function

          5. Subject must be willing to abstain from other IA treatments of the knee for the
             duration of the study.

          6. Subject is willing to discontinue all analgesics including nonsteroidal
             anti-inflammatory drugs (NSAIDs), except acetaminophen before the treatment injection
             and through the completion of the study. NSAIDs should be discontinued through the
             Screening period.

          7. Subject is willing to use only acetaminophen (up to a maximum of 3.0 grams per day)
             for the treatment of joint pain for the duration of the study. At least forty-eight
             hours prior to the Baseline Visit and each follow-up visit, the Subject is willing to
             discontinue use of acetaminophen

          8. Subject is willing to maintain a stable dose of oral glucosamine and/or chondroitin
             sulfate products throughout the study, if taken prior to signing ICF.

          9. Subject is able to understand and comply with the requirements of the study and
             voluntarily provides consent.

        Baseline Inclusion Criteria 24 Subject has a Western Ontario and McMaster Universities
        Osteoarthritis Index (WOMAC) pain-sub-score ≥ 50 mm and ≤ 90 mm in the affected knee and ≤
        30 mm in the contralateral knee on a 100 mm Visual Analog Scale (VAS) scale.

        Exclusion Criteria:

          1. Subject received an IA injection of Hyaluronic Acid (HA) and/or steroid in either knee
             within 6 months of signing the ICF. A Subject will be excluded if they are planning to
             receive an HA or steroid injection (other than the study injection) in either knee
             during the course of this study.

          2. Subject had an arthroscopy of either knee within 3 months of signing the ICF.

          3. Subject had an open surgical procedure of either knee or hip or any surgery of the
             spine within 12 months of signing ICF. Subject plans to have knee, hip or spine
             surgery within the study period.

          4. Subject has intra-articular trauma to the Index knee. Subject has concurrent
             multi-system or multi-limb trauma.

          5. Subject has evidence or medical history of the following diseases in the Index knee:
             septic arthritis; inflammatory joint disease; history of Reiter's syndrome; gout;
             chondrocalcinosis associated with recurrent episodes of acute synovitis of the knee
             consistent with pseudogout; osteochondritis dissecans, Paget disease of the bone;
             ochronosis; acromegaly; hemochromatosis; primary osteochondromatosis; known history of
             Wilson disease; heritable disorders or collagen gene mutations.

          6. Subject has a history of cartilage repair surgery in the Index knee within 3 years of
             signing the ICF.

          7. Subject has a history of Anterior cruciate ligament (ACL) repair, reconstruction or
             injury in the Index knee within 3 years of signing the ICF.

          8. Subject has X-Ray findings of acute fractures, severe bone loss, avascular necrosis,
             severe bone or joint deformity in the Index knee.

          9. Subject has significant varus or valgus deformity greater than 8 degrees in either
             knee.

         10. Subject has a clinically apparent tense effusion of the Index knee.

         11. Subject has knee instability in either knee per the Investigator's assessment.

         12. Subject requires consistent use of an assistive device (e.g. wheelchair, walker, etc.)
             Occasional use of a cane is acceptable.

         13. Subject has medical condition(s) which could affect study assessments or may adversely
             affect the safety and/or success of the study treatment. This includes but is not
             limited to the following: a. Peripheral neuropathy severe enough to interfere with
             evaluation of the subject, b. Vascular insufficiency severe enough to interfere with
             evaluation of the subject, c. Active fibromyalgia, d. Hemiparesis involving either
             lower extremity, e. Immunocompromised or immunosuppressive disorder or receiving
             medications to treat immunosuppressive disorders, f. Systemic bleeding disorder(s), g.
             Current malignancy or treatment within the last 5 years, except for non-melanoma skin
             cancer, h. Significant psychiatric disorder, i. Active drug and/or alcohol abuse
             within the past year, j. Uncontrolled diabetes with a Screening Hemoglobin A1C (HbA1c)
             of >7% k. contraindication to Triamcinolone Hexacetonide (TH) including active
             tuberculosis, herpes simplex keratitis, acute psychoses and systemic mycoses and
             paracitoses.

         14. Subject is taking medications at the time the subjects signs the ICF which could
             interfere with the treatment procedure, healing and/or assessments. This includes but
             is not limited to oral or injectable anticoagulant treatments, anti-aggregant platelet
             treatment, chronic opioid analgesics. Low dose aspirin used for cardiovascular
             protection is allowed if a stable regimen is maintained for the duration of the study.

         15. Subject is receiving treatment using electromagnetic stimulation and/or low intensity
             ultrasound in the Index knee at the time of signing the ICF, within 3 months of
             signing the ICF or plans to receive treatment any time during the study period.

         16. Subjects who had an oral, intramuscular, intravenous, rectal suppository or topical
             (excluded in Index knee only) corticosteroid within 30 days of signing the ICF are
             excluded. Topical corticosteroid use at any site other than the Index knee is allowed.

         17. Subject has a pre-treatment contraindication to IA injections or aspiration of the
             Index knee, including cutaneous infection in the injection site area, active IA
             infection (as suggested by moderate or marked effusion), knee deformity or condition
             which, in the opinion of the Investigator could jeopardize the sterility or delivery
             of the IA injection.

         18. Subjects with a history of hypersensitivity to any of the ingredients in the
             hyaluronan or previous hypersensitivity to the administration of corticosteroids or an
             inability to tolerate acetaminophen.

         19. Subject has any contraindication to the receipt of a corticosteroid.

         20. Subject is receiving or in litigation for worker's compensation.

         21. Subject is a woman who is pregnant or breastfeeding at the Screening Visit or a woman
             of child bearing potential who refuses to use effective contraception during the
             course of the study.

         22. Subject was involved in any other research study involving an investigational product,
             or a new application of an approved product, within 60 days of signing the ICF.

         23. Subject previously treated with Cingal for knee osteoarthritis.

        Baseline Exclusion Criteria 25. Subject has a decrease of ≥ 20 mm in the WOMAC
        pain-sub-score (average of 5 pain scales) from Screening to Baseline in the Index knee on a
        100 mm Visual Analog Scale (VAS) scale.

        26. Subject has a synovial fluid aspirate volume > 10 mL in the Index knee. 27. Subject has
        a contraindication to continue with the study treatment injection based on the visual
        appearance of the synovial fluid aspirate unless the fluid is examined microscopically
        prior to injection with no clinically significant findings (e.g. bacteria, crystals or
        blood).

        28. Subject has range of motion of less than 100° flexion in either knee.
No condition on gender to be admitted to the trial.
No healthy subjects accepted to join the trial.
Subject must be at least 40 Years old.
Subject must be at most 75 Years

Eligibility (NLI label): Entailment