Hyaluronic Acid Injections for Knee Osteoarthritis

Hyaluronic acid injections are used to treat knee osteoarthritis and improve the functions of the knee joint. This treatment method is called viscosupplementation.

During a hyaluronic acid injection (viscosupplementation), a small amount of hyaluronic acid, often just 2 mL, is injected directly into the knee joint capsule.¹Abate M, Vanni D, Pantalone A, Salini V. Hyaluronic acid in knee osteoarthritis: preliminary results using a four months administration schedule. International Journal of Rheumatic Diseases. 2015;20(2):199-202. doi:10.1111/1756-185x.12572

The goals of treating knee osteoarthritis with hyaluronic acid injections are to:

• Reduce pain
• Improve joint movement by increasing joint lubrication and reducing joint friction and inflammation
• Perhaps slow osteoarthritis progression

Hyaluronic acid injections are usually given at a doctor’s office. Depending on the brand used, this treatment involves 1, 3, 4, or 5 injections. If more than one injection is needed, injections are given one week apart.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534

What Does Hyaluronic Acid Do in the Knee Joint?

A healthy knee joint contains up to 4 mL of joint fluid.³Kraus VB, Stabler TV, Kong SY, Varju G, McDaniel G. Measurement of synovial fluid volume using urea. Osteoarthritis Cartilage. 2007;15(10):1217-20. Hyaluronic acid is a key component of the joint fluid. It gives the joint fluid its viscous, slippery quality, which does the following:

• Enables the bones' cartilage-covered surfaces to glide against each other, thereby reducing joint friction
• Adds cushion to protect joints during impact (e.g. weight-bearing activity)

Joints affected by osteoarthritis typically have a lower concentration of hyaluronic acid in their joint fluid than healthy joints, and therefore less protection against joint friction and impact.⁴Altman RD, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskelet Disord. 2015;16:321. Published 2015 Oct 26. doi:10.1186/s12891-015-0775-z Experts believe this further accelerates the joint degeneration process, setting in place a vicious cycle.

Who Can Get Hyaluronic Acid Injections for Knee Osteoarthritis?

Hyaluronic acid injection is not a first-line treatment for knee osteoarthritis.⁵Cooper C, Rannou F, Richette P, et al. Use of Intraarticular Hyaluronic Acid in the Management of Knee Osteoarthritis in Clinical Practice. Arthritis Care Res (Hoboken). 2017;69(9):1287-1296. This treatment may be considered for those who:

• Have moderate knee osteoarthritis with symptoms that affect daily living.⁶Maheu E, Rannou F, Reginster JY. Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Semin Arthritis Rheum. 2016;45(4 Suppl):S28-33.^,7Henrotin Y, Raman R, Richette P, et al. Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis. Seminars in Arthritis and Rheumatism. 2015;45(2):140-149. doi:10.1016/j.semarthrit.2015.04.011

  See Knee Osteoarthritis Symptoms

• Do not take pain medication because they:
  • Have little or no benefit from pain relieving medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), and/or steroids (tablets or injectable).⁴Altman RD, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskelet Disord. 2015;16:321. Published 2015 Oct 26. doi:10.1186/s12891-015-0775-z^,5Cooper C, Rannou F, Richette P, et al. Use of Intraarticular Hyaluronic Acid in the Management of Knee Osteoarthritis in Clinical Practice. Arthritis Care Res (Hoboken). 2017;69(9):1287-1296. Some people may also choose to avoid these medications.
  • Are at a risk of side effects such as kidney damage, heart problems, and/or abdominal bleeding with long-term use of NSAIDs.⁵Cooper C, Rannou F, Richette P, et al. Use of Intraarticular Hyaluronic Acid in the Management of Knee Osteoarthritis in Clinical Practice. Arthritis Care Res (Hoboken). 2017;69(9):1287-1296.^,6Maheu E, Rannou F, Reginster JY. Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Semin Arthritis Rheum. 2016;45(4 Suppl):S28-33.^,8Smith C, Patel R, Vannabouathong C, et al. Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy. July 2018. doi:10.1007/s00167-018-5071-7
  • Have other conditions, such as diabetes or high blood pressure, and cannot take medications such as steroids.

  See Pain Medications for Arthritis Pain Relief

• Show improvement after the first round of treatment. Such cases may benefit from additional hyaluronic acid injections when the osteoarthritis symptoms reappear.⁵Cooper C, Rannou F, Richette P, et al. Use of Intraarticular Hyaluronic Acid in the Management of Knee Osteoarthritis in Clinical Practice. Arthritis Care Res (Hoboken). 2017;69(9):1287-1296.^,6Maheu E, Rannou F, Reginster JY. Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Semin Arthritis Rheum. 2016;45(4 Suppl):S28-33.
• Are not eligible for surgery, want to postpone surgery, or do not want to have surgery.

  See Types of Knee Surgery for Arthritis Treatment

While people of any age can get hyaluronic acid injections, this treatment may be more effective in people under 65 years of age.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534

When Are Hyaluronic Acid Injections Not Appropriate?

Hyaluronic acid injections may not be appropriate in some people, including, but not limited to:

• Women who are pregnant or breast-feeding.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534
• Children and adolescents.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534
• Those with bacterial and other infections in and/or around the osteoarthritic knee.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534
• Those with a known allergy to hyaluronate products.²Hunter DJ. Viscosupplementation for Osteoarthritis of the Knee. Jarcho JA, ed. New England Journal of Medicine. 2015;372(11):1040-1047. doi:10.1056/nejmct1215534

Additionally, those who are allergic to eggs or other bird products (e.g. poultry) are advised to inform their doctor.⁴Altman RD, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskelet Disord. 2015;16:321. Published 2015 Oct 26. doi:10.1186/s12891-015-0775-z This is because certain hyaluronate products are made from rooster combs and may not be suitable for such patients.

Questions to Ask When Choosing Hyaluronic Acid Injection Treatment for Knee Osteoarthritis

While deciding to choose hyaluronic acid injections for the knee, it may help to ask the doctor a few questions regarding the treatment. Asking relevant questions will help weigh the potential risks and benefits of these injections and set reasonable expectations.

A few examples of questions that can be asked are:

• What is the typical outcome for a patient like me?
• Will there be an immediate reaction in my knee after the injection?
• What are the risks associated with this injection?
• How long will my recovery be?
• Is it recommended to take time off work?
• How might this injection affect the chances of postponing my knee replacement surgery?
• Do I need to do anything to prepare for the injection?
• What other treatments can be considered?

By asking these questions, patients can discuss concerns specific to their health and lifestyle and make the necessary adjustments for a better treatment outcome.

Read about Lubricating Injections Can Soothe Knee Osteoarthritis