Hyaluronic acid injections

Hyaluronic acid is a natural component of the fluid that lubricates and cushions your joints. In osteoarthritis this fluid can lose some of its normal thickness and elasticity. A hyaluronic acid injection places a gel-like preparation of the same substance directly into the joint to supplement its own fluid; you may also hear the approach called viscosupplementation. It is used most often for the knee, and sometimes for other large joints such as the shoulder.

It is a different idea from a steroid injection. A steroid is an anti-inflammatory medicine, at its most useful when a flare of inflammation needs settling quickly. A hyaluronic acid preparation contains no steroid and is not designed to damp down a flare: the aim is slower and gentler, to improve the day-to-day comfort of a worn joint over a longer period. It is also classed as a medical device rather than a medicine.

Studies of hyaluronic acid in osteoarthritis have produced mixed results: some people report worthwhile relief, others notice little or no benefit, and the average effect across trials is modest. The evidence is genuinely not clear-cut, and it is right to be open about the strongest voice against. NICE, which advises the NHS, recommends against these injections: its guideline says "Do not offer intra-articular hyaluronan injections to manage osteoarthritis", because across the trials it reviewed it found no convincing evidence of benefit on quality of life, physical function or pain, and a possible harm signal at the hip. That is a firm recommendation, and it deserves stating plainly rather than explaining away.

It is equally worth understanding what sits behind it. In NICE's own analysis of the knee, pooling six trials in 489 people, the injections did reduce pain on average: the effect was statistically real, simply smaller than the difference NICE treats as clinically important, and the evidence was of low certainty. At the knee NICE found no evidence of harm; the hip, where the harm signal sat, is a joint we do not inject. So for the knee, NICE found a small average effect that fell short of its threshold, not an absence of any effect. And averages hide variation: the largest independent analysis of these injections, while concluding against their broad use, accepts that its findings "do not exclude the possibility that selected osteoarthritis patient populations could benefit". The American College of Rheumatology, which also recommends against routine use, states that its recommendation is consistent with using hyaluronic acid injections through shared decision-making, with the limited evidence understood, when other options have been exhausted or have not helped. That is exactly the basis on which they are offered here.

None of that changes where the personal question sits. In private care you pay for the treatment yourself, and the decision is whether a modest chance of worthwhile relief is worth the cost to you. It is offered here as a self-pay option, and we are not aware of any private medical insurer that currently covers it. Because individual responses vary so widely, a treatment with a modest average effect can still prove genuinely worthwhile for a particular person; it cannot be promised in advance, and no test reliably predicts who will benefit. It is most worth considering where a steroid injection is unsuitable or has stopped helping, or where you want to explore what can reasonably be done short of surgery. Dr Borukhson will give you a frank, balanced view of whether it is worth trying in your situation, and will say so just as honestly if she thinks it is not.

No one is offered an injection on the strength of a sore knee alone. The starting point is a proper assessment: your history, an examination and, where helpful, point-of-care ultrasound during the same consultation. The scan helps establish what is actually going on in the joint, and sometimes shows that a different approach would serve you better. If, after an honest discussion, you decide to go ahead, the injection can usually be given in the same visit as an ultrasound-guided injection, so the preparation is placed accurately inside the joint.

The preparation used at the practice is OSTENIL PLUS, made by TRB Chemedica. The manufacturer describes it as a solution of highly purified sodium hyaluronate (hyaluronic acid) developed specifically for the treatment of osteoarthritis, with added mannitol to help stabilise the hyaluronic acid chains. It is designed to be given as a single injection per treatment cycle in large joints such as the knee, hip and shoulder, rather than as a course of weekly injections, and the manufacturer states that repeat treatment cycles may be given as required. The practice is a registered Ostenil Approved Clinic, part of the manufacturer's UK scheme that exists to reassure patients that the preparation they receive is an authentic OSTENIL product.

Do not judge the injection on the day it is given. There is nothing in the preparation designed to work quickly, so any benefit tends to build gradually over several weeks. When the treatment works, the usual reward is a more comfortable joint for some months, and the manufacturer allows for the treatment cycle to be repeated if a worthwhile benefit later wears off.

Not everyone benefits, and there is no test that reliably predicts who will, so it is sensible to treat the first injection as a trial: give it several weeks, judge the result against how the joint felt beforehand, and repeat it only if it has clearly helped. Whatever the outcome, the core measures for osteoarthritis, such as exercise, strengthening and weight management where relevant, remain worthwhile alongside it, and are covered in the osteoarthritis guide.

Afterwards you can usually go straight home. It is sensible to rest the joint and avoid strenuous activity for a day or two, then build back up gradually; any specific aftercare for your joint is explained at the time.

A few people notice a temporary flare of pain or swelling in the injected joint for a day or two; this settles on its own. Infection after a joint injection is rare, but it matters: if the joint becomes increasingly hot, swollen and very painful in the days afterwards, or you develop a fever or feel unwell, seek medical advice urgently rather than waiting for it to pass.

Point-of-care ultrasound is part of the consultation with Dr Borukhson, which is why a single appointment can usually take in the examination and the scan, and then the injection itself if you decide to go ahead, placed in the joint under the scan's guidance. The decision comes first and is yours: the evidence, the cost and the realistic prospects are talked through openly, and an injection follows only where it makes sense for your joint.

How is it decided whether a hyaluronic acid injection is right for me?

No one is offered an injection on the strength of a sore joint alone. It starts with a proper assessment of your history and an examination, and where helpful Dr Borukhson uses point-of-care ultrasound during the same consultation to see what is actually happening in the joint. Sometimes the scan shows a different approach would serve you better. You then have a frank, balanced discussion before deciding together whether it is worth trying.

Why does the NHS not offer this if it can still help?

NICE, which advises the NHS, recommends against hyaluronic acid injections for osteoarthritis: the benefit seen in trials was too small and too uncertain for NICE to count it as clinically meaningful. Averages are not the whole story, though. At the knee, NICE's own analysis found a real average reduction in pain, just smaller than the threshold it applies, and no evidence of harm at that joint. Other specialist bodies weigh the same evidence more generously, and the American College of Rheumatology accepts these injections through shared decision-making once other options have been tried. In private care the question becomes personal: whether a modest chance of worthwhile relief is worth the cost to you. It is offered here on exactly that basis, as a self-pay option, after a frank discussion.

How soon will I notice a difference, and how long might it last?

Do not judge it on the day it is given. There is nothing in the preparation designed to work quickly, so any benefit tends to build gradually over several weeks. When it works, the usual reward is a more comfortable joint for some months. Not everyone benefits, and no test reliably predicts who will, so it is sensible to treat the first injection as a trial and repeat it only if it has clearly helped.

How is this different from a steroid injection?

A steroid is an anti-inflammatory medicine, most useful when a flare of inflammation needs settling quickly. A hyaluronic acid preparation contains no steroid and is not designed to damp down a flare; the aim is slower and gentler, supplementing the joint's own lubricating fluid to improve day-to-day comfort over a longer period. It can be worth considering particularly where a steroid injection is unsuitable or has stopped helping.

What should I do afterwards, and when should I seek help?

You can usually go straight home. Rest the joint and avoid strenuous activity for a day or two, then build back up gradually. A few people notice a temporary flare of pain or swelling that settles on its own. Infection is rare but matters: if the joint becomes increasingly hot, swollen and very painful in the days afterwards, or you develop a fever or feel unwell, seek medical advice urgently rather than waiting.