Overall, exercise therapy is the best form of medicine for knee arthritis. Also, other factors such as weight loss and reducing cholesterol and sugar are essential. However, some people find that treating these lifestyle factors is not enough. Yet, they don’t want to resort to costly and invasive joint replacement surgery. Instead, some turn to injections such as cortisone or hyaluronic acid. So, cortisone vs. hyaluronic acid for knee pain: which is better, and what should we use?

Cortisone injections

cortison injections

Cortisone is an anti-inflammatory that reduces pain, swelling, and inflammation. They are the most common injections for knee arthritis.

Cortisone injections are usually administered with the help of imaging such as ultrasound.

There is good evidence to suggest that cortisone improves pain and function for up to 3 months. However, cortisone injections don’t work for all. Also, some people are concerned that repeated injections lead to cartilage loss. In addition, there is some added evidence that having repeated injections lead to faster joint replacements. Overall, there are some question marks about the use of cortisone in arthritis. In general, we should limit cortisone in arthritis to those cases with severe pain and swelling.

Generally, you should have a cortisone shot in the knee by ultrasound guidance. These are the four questions you should ask before having an injection under ultrasound. 

Hyaluronic acid injections 

hyaluronic acid injection

Hyaluronic acid is a naturally occurring substance found in joints and bones. It forms part of the synovial fluid in joints and acts as a lubricant and shock absorber. However, in a diseased joint, the amount of hyaluronic acid reduces.

Hyaluronic injections, also known as gel injections, involve injecting joints with hyaluronic acid to decrease pain and improve function. It is vital to ensure the hyaluronic acid is injected into the joint like cortisone. So, ultrasound guidance is recommended.

Unlike cortisone, the effect of hyaluronic acid is not immediate. It often takes up to 4 weeks to notice an impact. However, the result usually lasts longer than cortisone averaging 6 to 12 months. For example, in a recent study on a high molecular weight hyaluronic acid (Durolane), the average effect lasts about 15 months.

Research suggests that the results of hyaluronic acid for knee arthritis are at best mixed. Many studies have reported reduced pain, but others have shown no effect. However, the results seem better with the high molecular weight hyaluronic acid. Also, there are few adverse outcomes and no potential negative impact like cortisone.

So cortisone vs. hyaluronic acid for knee pain: which is better?  

In deciding which one to use, you need to consider several factors.

Hyaluronic or gel injections work best for people with little or no swelling and a grumpy joint—for example, a 45-year-old recreational footballer with mild arthritis of the knee. People need no significant downtime after gel injections. Also,  these gel injections are suitable for people who are allergic to steroids or can’t use steroids for medical reasons.

On the other hand, cortisone injections work best for those people who need a quick pain-relief fix. Usually, people with a swollen and painful joints are most suitable for a cortisone injection. A perfect example would be a swollen knee joint from acute gout. However, cortisone is not ideal for a longer-lasting effect on a grumpy joint. Also, there is evidence that repeated cortisone injections lead to more significant wear and tear in the cartilage and a faster conversion rate to knee replacement.

Finally, some people choose to have both injections. For example, people with a swollen joint choose to have cortisone first, followed by a hyaluronic injection four weeks later. In some cases, people choose to have both injections together simultaneously. Your doctor can speak to you about the best option for your particular case.

Do you have alternatives to cortisone shots in knees? 

Yes. Platelet-rich plasma, also known as PRP, is obtained from your blood. This blood is spun in a centrifuge to concentrate the platelets and separated from the other cells. We then inject this plasma into a joint. Platelets release growth factors, which induce healing and pain reduction.

Recent evidence comparing PRP, hyaluronic acid, and cortisone suggests that PRP might have a better effect at 6 and 12 months – although the differences with hyaluronic acid are minor.

Another option is Arthrosamid, a hydrogel material with water molecules attached to a polyacrylamide backbone. It is non-degradable, meaning the body can’t break it down. When injected into the knee joint, the hydrogel is taken up by the synovial cells and incorporated into a new synovial lining. We think the hydrogel reduces inflammation in the synovial lining, thereby reducing pain and swelling in the joint. It also provides cushioning of the inner joint capsular tissue.

New studies show that Arthrosamid positively affects pain and function in knee arthritis from 12 weeks.


Frequently asked questions

What is the best gel injection for the knee?  

We think that higher molecular hyaluronic acid such as Durolane is better. Generally, they are more cross-linked, making them bigger so they last longer. Also, recent evidence suggests that 75% of people who have a Durolane injection for arthritis are satisfied.

Do gel injections in the knee hurt? 

Generally not. But these injections should be done under ultrasound to make sure the gel gets into the joint. If the gel is injected into the fat near the joint, there is a chance of developing a severe reaction called ‘pseudosepsis.’ You should ask these four questions before having an ultrasound-guided injection.

Can you combine both cortisone and hyaluronic acid for knee pain? 

Yes. Some people choose to have a cortisone injection first to produce an immediate effect. Then about four weeks later, we use a gel shot to give a longer-lasting result. Others choose to have cortisone and hyaluronic acid together.  A recent review suggested that combining cortisone with a gel for knee pain is better than gel alone.  However, other studies suggest adding cortisone to hyaluronic acid reduces the effect of hyaluronic acid.

Also, some doctors combine PRP and hyaluronic acid for a better effect. For example, one study found that combining PRP with hyaluronic acid reduced pain at 3, 6, and 12 months and with fewer side effects than PRP alone.

Final word from Sportdoctorlondon about cortisone vs. hyaluronic acid for knee pain

Given recent evidence suggesting cortisone is harmful to joints, we recommend avoiding cortisone injection unless you have a swollen joint. Both hyaluronic acid and PRP are good options for knee arthritis. Sometimes, combination therapy using cortisone and hyaluronic acid is justified.

More topics on injections related to cortisone vs. hyaluronic acid for knee pain:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.

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