Hyaluronic Knee Injections - do they work?

Hylauronic Knee Injections – Do they work?

Intra-articular hyaluronic knee injections (also known as viscosupplementation) have been used since the 1970s to treat painful joint osteoarthritis conditions. Knee osteoarthritis is a chronic condition that involves inflammation and structural changes of the joints, resulting in joint pain and limitations to physical movement. It is one of the leading causes of disability among older people, with an estimated 560 million people living with the condition globally.

Hyaluronic acid is a naturally occurring substance in the body that helps lubricate and cushion our joints. Injections of the acid have soared in popularity both for elite sports people and everyday sufferers. They are believed to ease the pain of osteoarthritis in the knee by adding extra lubrication and a layer of cushioning between the articular surfaces of the joint (cartialage). It is important not to confuse these injections with cosmetic treatments using the same substance, where Hyaluronic acid is used on the face to enhance the plumpness of the skin.

The procedure is fast and relatively painless, with a local anesthetic administered to the upper side of the knee, and the injection taking seconds. Common brand names of hyaluronic acid are

  • Durlane
  • Euflexxa
  • Gel-One
  • Hyalgan
  • Hyalgan LL
  • Monovisc
  • NeoVisc
  • Orthovisc
  • Supartz
  • Supartz FX
  • SynVisc
  • SynVisc One

When are the injections given?

In many cases, they are administered to those for whom first-line conventional treatments have not succeeded, like physiotherapy and NSAIDs. They might also be used when more traditional glucocorticosteroid injections have not worked. Although they can be used in the shoulders and hips, they are most commonly used to treat osteoarthritis in the knee.

Hyaluronic Knee Injections – do they work? What does the science say?

Hyaluronic injections are  controversial in the medical and research communities. A quick search on google will bring up many conflicting results but with the majority claiming that they are no better than a placebo, with increased risk of side effects and adverse reactions. In the US, the American College of Rheumatology and Arthritis Foundation actually recommend against hylauronic acid injections for the treatment of osteoarthritis because of insufficient evidence of their effectiveness.

A 2022 review of 24 studies with a total of 8,997 participants found that hyaluronic acid injections had no clinically meaningful improvements in knee osteoarthritis pain compared with a placebo.

Earlier,  research from 2018 on osteoarthritis in the hip also found that hyaluronic acid injections led to no significant improvements in pain scores compared with a placebo. Another  2019 research review had similar findings in that the injections were of little or no benefit.

In the UK one of the largest reviews of 50 years’ worth of study data featured in the renowned British Medical Journal – it concluded that there is scant evidence to recommend the use of Hyaluronic injections for knee osteoarthritis. In England, the National Institute for Health and Care Excellence (NICE) – the body that decides what to spend and what medicines to approve for patients – recommends against its use, but it is worth noting that healthcare systems in other countries including the USA still offer it to patients.In the study published in the BMJ, they covered 196 trials involving 21,163 patients, no small number.

The authors concluded:

“there is strong, conclusive evidence that among patients with knee osteoarthritis, viscosupplementation, compared with placebo, is associated with a clinically irrelevant reduction in pain intensity and with an increased risk of serious adverse events. The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis.”

But, some experts argue the case for the treatment and its effectiveness in alleviating symptoms of osteoarthritis. In Europe, the position is more favourable, with the European Experts on Osteoarthritis group recommending it as a treatment for mild-to-moderate osteoarthritis pain. Another  2019 randomised trial found that hyaluronic acid injections may help with mild-to-moderate osteoarthritis pain.

But, the clinical significance and interpretation of these studies remain a hot topic for debate amongst scientists, with those against the treatment claiming that even a statistical improvement in pain scores in studies does not mean any meaningful difference in real life.

My personal Experience

In 2012 I suffered a partially torn ACL – walking the dog of all things. Although declared stable, in the MRI my ACL looks like a mop head with just a tiny few strands in continuation. Although fully functional, it remained achey, prone to slight swelling and discomfort, especially if subjected to  heavy squatting or fast, twisting lunging activities like squash. It remained bothersome but working. Then in 2022 I suffered a small posterior meniscus tear – kitesurfing, so at least doing something extreme! That got better on its own, but my knee then become more persistently painful. I would describe it as a stiff ache that was painful even in non weight bearing activities like rowing – at this point all strength training for the legs was out of bounds due to pain and I was getting pretty worried about needing a replacement knee.

So I had another MRI and then went to see one of the UKs top knee specialists Martin Logan, an orthopaedic consultant specialising in professional sports injuries to the knee. My diagnoses was severe, full thickness fissuring of the trochlear (the groove that the kneecap runs over at the bottom of the femur or thigh bone). He recommended a conservative treatment of a hyaluronic injection to smooth out the action of the knee – he said I’d need one anually.

Despite his advice that it would start to work straight away, nothing really happened for a few weeks- I was having doubts as to its effectiveness. But slowly my knee started to get better, in a very gradual way. the persistent pain had gone, and at times I would forget it was injured at all. 3 months later and it remains improved by about 60-70%. I can row on a c2 with no pain at all and do gym work in a conservative way. Leg work like weighted squats still aggravate it as does squash – but weirdly despite feeling injured again after pushing it, in a day or two of sensible activity or rest it comes back up to about 8/10, with 10/10 being perfect. Online research led me again and again to quad locking as a rehabilitation exercise, which I do 3 times a week for 5 sets of 5 seconds.

So did it work for me? Admittedly this is a study of just one person, but yes it did. It’s not 100%, but at a certain point in life we all receive injuries from which we will never quite fully recover. Even surgery would not have my knee back to 100%. But YES it really did. I’m looking forward to my next one and wonder of I can’t sneak it in a little early!

For those suffering knee pain or who have had the Hylauronic injection, this video was invaluable for me.

Adam Atkinson