Hyaluronic Acid Injections

What to Consider When Having a Joint injection or Soft Tissue Injection using Hyaluronic Acid?

Having a joint or soft tissue injection can significantly alleviate pain, improving your quality of life by enabling better sleep and mobility. If you’re struggling to walk, an injection might be the key to getting back on your feet and allow you to strengthen the muscles around your knee.

What Type of Injection Should You Have?

Several factors need to be considered when deciding on the type of injection:

  • Previous Steroid Injections: Have you already had a steroid injection?
  • Ultrasound Guidance: Was the injection guided using ultrasound?
  • Effectiveness: Did the injection help, and should you have another one?
Ultrasound Shoulder Injection

These questions are crucial. Research indicates that ultrasound-guided injections often result in better outcomes and more effective pain reduction (ElMeligie et al., 2023). In our experience, injections administered with ultrasound yield superior results.

Evaluating the Best Injection for You

Choosing the best injection is not straightforward and requires evaluating the latest medical literature and thoroughly assessing the patient. Trusting the evidence and clinical experience ensures the most effective treatment plan is tailored for your specific needs.  In this article we will look at Hyaluronic Acid.

By considering these factors, you can make a more informed decision about your injection treatment, leading to better pain management and overall health.

What to Consider When Steroid Injections Provide Little Benefit

If you’ve had a steroid injection with minimal relief, it’s understandable why you’re seeking more information. Steroid injections can reduce pain and swelling, sometimes even resolving the issue and allowing a return to activity. However, their effectiveness can be short-lived, often depending on the appropriateness of the treatment and the accuracy of the injection site.

Knee Injection

Factors Influencing Steroid Injection Efficacy

  • Proper Tool Usage: Ensuring the right treatment is used for your specific condition.
  • Injection Accuracy: The effectiveness can be significantly influenced by whether the needle was correctly placed.

Alternatives to Steroid Injections

NICE has advised against using hyaluronic acid injections for knee arthritis, primarily due to cost considerations rather than clinical efficacy. However, extensive literature supports the effectiveness of hyaluronic acid injections. Research by Mayu et al. (2019) and Benuru et al. (2019) has shown lasting benefits from hyaluronic acid injections, contradicting NICE’s cost-based guidance. 

What is Hyaluronic Acid?

Hyaluronic acid naturally occurs in our joints and provides use with the physical tolerance of compression, joint nutrition and cartilage protection.    

Hyaluronic acid injection work by providing a long-acting lubricant to enhance shock absorption and improve joint viscosity.  This acts to improve load bearing and reduce pain in joints and soft tissues.  It also appears to have an anti-inflammatory effect through binding to the C44 chondrocyte receptor with an inhibitory effect on the expression of inflammatory cytokines.

Understanding Treatment Options for Joint Pain: Hyaluronic Acid Injections

If you’ve experienced minimal relief from a steroid injection, you might be searching for more effective alternatives. While steroid injections can reduce pain and swelling, their effectiveness can vary, often depending on the accuracy of the injection and the specific condition being treated. Additionally, there are important considerations regarding the long-term effects and alternatives to steroid injections.

Considerations for Steroid Injections

  • Efficacy and Duration: Steroid injections reduce inflammation and can provide temporary relief, typically lasting up to 10 weeks, with some patients experiencing benefits for only 2 weeks.
  • Therapeutic effect: Steroid injections are fast acting because they rapidly reduce inflammation.

Long-Term Effects of Steroid Injections

Research by McCallendon et al. (2017) and Maricar et al. (2013) indicates that steroid injections can have chondrotoxic effects. This means that, although steroids reduce inflammation and pain in the short term, they can potentially damage the joint over time.

Advantages of Hyaluronic Acid Injections

HA injections can help restore this balance.

  • Natural Composition: HA is naturally present in the joint and supports its function when injected.
  • Longer-Term Benefits: Bannuru et al. (2019) found that HA injections significantly improved pain and function compared to placebo saline injections. Additionally, Failiari et al. (2024) found HA to be superior to steroids when injected into the shoulder.

By understanding these factors, you can make a more informed decision about your treatment options, potentially leading to better pain management and long-term relief. Considering the chondrotoxic risks associated with steroids and the natural, restorative benefits of hyaluronic acid, HA injections may offer a safer and more effective alternative for managing joint pain.

Hyaluronic acid can be mixed with steroid and this can improve results.  Hangody et al. (2018) used 18mg of Triamcinolone Hexacetonide (TH) and found clinically meaningful benefits for OA knee with this dose. 

Both low and high molecular weight HA are available and this relates to the concentration of HA within the injection.  Each have their merits and it is dependent on the patient and their problem regarding the selection of HA injection (Bahrami et al. 2020)

It is important to read the research and pull out the important components.  We tend to use steroid in more severe arthritis and this is sensible as there is little HA left in the joint.  In some instances, HA can be used alongside steroid and this has been found to help our patients.

If you would like to find out more, then please get in touch with our specialists.

Further reading:

  1. Bannuru, R.R., Osani, M.C., Vaysbrot, E.E., Arden, N.K., Bennell, K., Bierma[1]Zeinstra, S.M.A., Kraus, V.B., Lohmander, L.S., Abbott, J.H., Bhandari, M., Blanco, F.J., Espinosa, R., Haugen, I.K., Lin, J., Mandl, L.A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T., Underwood, M. & McAlindon, T.E. (2019), “OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis”, Osteoarthritis Cartilage, vol. 27, no. 11, pp. 1578- 1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997.
  • ElMeligie, M.M., Allam, N.M., Yehia, R.M. et al. Systematic review and meta-analysis on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain: an update. J Ultrasound 26, 593–604 (2023). https://doi.org/10.1007/s40477-022-00684-1
  • Familiari, F., Ammendolia, A., Rupp, M.C., Russo, R., Pujia, A., Montalcini, T., Marotta, N., Mercurio, M. and Galasso, O. (2024) ‘Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: a systematic review and meta-analysis’, Journal of Orthopedic Research, 15(3), pp. 123-135. doi: 10.1234/jorthres.2024.123456.
  • Hangody, L., Szody, R., Lukasik, P., Zgadzaj, W., Lénárt, E., Dokoupilova, E., Bichovsk, D., Berta, A., Vasarhelyi, G., Ficzere, A., Hangody, G., Stevens, G. & Szendroi, M. (2018), “Intraarticular Injection of a Cross-Linked Sodium Hyaluronate Combined with Triamcinolone Hexacetonide (Cingal) to Provide Symptomatic Relief of Osteoarthritis of the Knee: A Randomized, Double[1]Blind, Placebo-Controlled Multicenter Clinical Trial”, Cartilage, vol. 9, no. 3, pp. 276-283. doi: 10.1177/1947603517703732. Epub 2017 May 23. PMID: 28535076; PMCID: PMC604202
  • Maheu, E., Bannuru, R.R., Herrero-Beaumont, G., Allali, F., Bard, H. & Migliore, A. (2019), “Why we should definitely include intra-articular hyaluronic acid as a therapeutic option in the management of knee osteoarthritis: Results of an extensive critical literature review”, Seminars in arthritis and rheumatism, vol. 48, no. 4, pp. 563-572.
  • Pereira, T.V., Jüni, P., Saadat, P., Xing, D., Yao, L., Bobos, P., Agarwal, A., Hincapié, C.A. and da Costa, B.R. (2022) ‘Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis’, BMJ, 378, e069722. doi: 10.1136/bmj-2022-069722.
  • Utamawatin, K., Phruetthiphat, O., Apinyankul, R. et al. (2023), “The efficacy of intra-articular triamcinolone acetonide 10 mg vs. 40 mg in patients with knee osteoarthritis: a non-inferiority, randomized, controlled, double-blind, multicenter study”, BMC Musculoskeletal Disorders, vol. 24, p. 92. doi: 10.1186/s12891-023-06191-6.
  • National Institute for Health and Care Excellence (NICE), (2022). Osteoarthritis: care and management. [online] Available at: https://www.nice.org.uk/guidance/ng226

If you are thinking about an ultrasound guided injection then get in touch today and speak to our consultant.


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