Exercise therapy is the best medicine for knee arthritis, alongside weight loss and managing cholesterol and blood sugar. But when lifestyle measures aren’t enough, and joint replacement feels too big a step, many people turn to injections. So, for cortisone vs hyaluronic acid for knee pain — which is better, and when should each be used?
Cortisone injections
Cortisone is an anti-inflammatory that reduces pain, swelling, and inflammation. It’s a synthetic version of the corticosteroid your adrenal glands make naturally. For the knee, cortisone is the most commonly used injection, ideally given with ultrasound guidance.
How effective is cortisone?
Cortisone works quickly — good evidence shows it improves pain and function within 1–2 weeks. But the effect is short-lived, typically lasting up to about 3 months, and sometimes it doesn’t work at all.
The concern is cartilage. Several studies link repeated cortisone injections to faster cartilage loss, and possibly earlier joint replacement. So we now limit cortisone in arthritis to joints with significant pain and swelling, and we follow proper aftercare to get the most from it. (For the full risk picture, see Are Cortisone Injections Bad for You?)
Hyaluronic acid injections
Hyaluronic acid occurs naturally in the joint, forming part of the synovial fluid that lubricates and cushions it, and its levels are reduced in a diseased joint. A hyaluronic acid (gel) injection helps to do this, reducing pain and improving function. Like cortisone, it should be injected into the joint under ultrasound guidance.
How effective is hyaluronic acid?
Hyaluronic acid works more slowly — often taking up to 4 weeks — but lasts longer, averaging 6 to 12 months. In one study of a high-molecular-weight hyaluronic acid (Durolane), the average effect lasted about 15 months. Results across studies are mixed, but they’re better with high-molecular-weight options such as Durolane. Crucially, hyaluronic acid has few adverse effects, no negative impact on cartilage (unlike cortisone), and some evidence that it delays the time to knee replacement. Around 65–70% of people respond to a Durolane injection for arthritis. Manage your activity afterwards to get the most from it.
Cortisone vs hyaluronic acid: which is better?
The right choice depends on the joint and the person.
Hyaluronic acid suits a “grumpy” joint with little or no swelling — for example, a 45-year-old recreational footballer with mild knee arthritis. There’s no real downtime, the effect lasts 6–18 months, and it suits people who can’t have steroids.
Cortisone suits a swollen, acutely painful joint needing quick relief — for example, a swollen knee from acute gout. It’s less suited to a chronic, grumpy joint, and repeated cortisone injections are linked to greater cartilage wear and faster progression to replacement.
Some people have both — cortisone first for fast relief, then hyaluronic acid four weeks later for durability. We don’t advise injecting the two together in one sitting, as mixing them accelerates hyaluronic acid breakdown.
Which is better for cartilage health?
Hyaluronic acid. One study found more cartilage damage on MRI after cortisone than after hyaluronic acid, and arthritis progressed faster in those with a history of cortisone. Hyaluronic acid, by contrast, appears to delay joint replacement — so it’s probably protective.
Other alternatives to cortisone in the knee
Beyond the cortisone vs hyaluronic acid question, two other injections are worth knowing about.
PRP (platelet-rich plasma) uses your own concentrated platelets to reduce pain and aid healing. Evidence suggests it may edge ahead of hyaluronic acid at 6 and 12 months, with around 65–70% of people responding. Higher-concentration “second-generation” PRP, such as Arthrex ACP Max, may be more effective. Dr Masci offers Arthrex ACP Max for £1,350.
Arthrosamid is a non-degradable hydrogel injected into the knee, taken up by the synovial lining to reduce inflammation and cushion the joint. Its benefit builds over about six months and, recent data suggest, can last up to four years — longer than PRP or hyaluronic acid. Around 75% of people respond (ranging from 80–95% in younger, slimmer patients with more joint swelling). It’s more expensive than the alternatives. Dr Masci offers Arthrosamid for £2,500. Arthrosamid is approved in Europe and the UK, and is awaiting approval in Canada, Australia, and the US.
We compare these directly on the combined PRP and hyaluronic acid and Durolane pages.
Frequently asked questions about cortisone vs hyaluronic acid
What is the best gel injection for the knee?
A higher-molecular-weight hyaluronic acid, such as Durolane, tends to be best — more cross-linked, so larger and longer-lasting. Around 65–70% of people are satisfied after a Durolane injection for arthritis.
Do gel injections in the knee hurt?
Generally not. But they must be done under ultrasound to ensure the gel reaches the joint — if injected into the surrounding fat, there’s a risk of a severe reaction called ‘pseudosepsis’.
Can you combine cortisone and hyaluronic acid for knee pain?
Yes, sequentially. Cortisone first for immediate relief, then a gel shot about four weeks later for durability. One review found cortisone-then-gel better than gel alone, though other studies show that mixing them reduces the hyaluronic acid’s effect — so we don’t inject both at once. Some doctors instead combine PRP and hyaluronic acid, which reduces pain at 3, 6, and 12 months with fewer side effects than PRP alone.
How long should I wait for knee surgery after a cortisone shot?
About six months. The infection risk is elevated for at least 3 months, and possibly up to 6 months, so, to be safe, wait 6 months before having knee surgery after a cortisone shot. (More on cortisone and surgery timing.)
Is cortisone or hyaluronic acid better long-term?
For a chronic, grumpy knee, hyaluronic acid generally wins — it lasts longer, doesn’t harm cartilage, and may delay replacement. Cortisone is better reserved for short-term relief of an acutely swollen, painful joint.
Final word from Sport Doctor London about cortisone vs hyaluronic acid
Given evidence that repeated cortisone injections may harm the joint, we generally reserve cortisone for a swollen, acutely painful knee and favour hyaluronic acid (or PRP) for a chronic, grumpy joint. Occasionally, sequential cortisone-then-hyaluronic-acid is justified. The right choice is individual, and any of these injections should be done under ultrasound guidance.
To discuss the best injection for your knee with Dr Masci in London, contact the team here or view the injection fees.
Thankyou, this information was extremely informative and I’ve shared it with another suffering friend.
I asked my GP if there was a more beneficial treatment for my knee arthritis than cortisone. He said that Harley Street London may give hyaluronic acid but that cortisone works best for 99.9% of patients. I asked him if he should use a scan to be sure of where he was placing the needle and he said he didn’t need to.
In my opinion, cortisone and hyaluronic acid injections should be done with ultrasound guidance.
Cortisone may give more pain relief, in the short run. But there is increasing evidence it accelerates deterioration of cartilage in the long run.