We use hyaluronic acid injections to reduce arthritis pain. Durolane is a type of hyaluronic acid widely used by doctors. Some reports suggest Durolane has more side effects than other types of hyaluronic acid. However, a new study contradicts this claim. What are Durolane side effects, and is severe pain after Durolane injection common? If your knee pain is worse after a Durolane injection, what should you do?  

What is Durolane?  

Durolane is a particular type of hyaluronic acid. Hyaluronic acid is found in the lining of joints to help with lubrication and shock absorption. Generally, in arthritic joints, the concentration of hyaluronic acid drops, so the joint has less cushioning. 

Unlike other types of hyaluronic, such as Synvisc, which is made from egg protein, scientists make Durolane through a unique bacteria process. Scientists modify the hyaluronic acid molecule to make it bigger (high molecular weight) and link the molecules (cross-link). 

How does Durolane work? 

Durolane reduces pain through several mechanisms. First, injecting Durolane into an arthritis joint restores shock absorption and lubrication like a normal joint. Second, Durolane binds to the joint’s lining, reducing toxic substances found in arthritic joints.

However, Durolane has a few differences from other hyaluronic acids on the market. The larger molecule binds to the joint’s lining more powerfully, increasing the anti-inflammatory effect and removing toxic chemicals. Also, linking the molecules slows the natural breakdown of Durolane, meaning it stays in the joint longer. These differences in the hyaluronic acid molecule are why we see better effects in Durolane than in other hyaluronic acid types. For example, in one study comparing different injections for knee arthritis, the bigger-sized hyaluronic acid, such as Durolane, was the most effective compared to other hyaluronic acid types and cortisone. 

Durolane Side Effects 

All injections have potential side effects like cortisone or platelet-rich plasma. Hyaluronic acid injections also have side effects, some commonly shared by other injections and some specific to the drug. 

Common Durolane Side Effects

Some of the more common side effects of Durolane include:

  • Mild joint swelling 
  • Mild joint pain 
  • Muscle stiffness around a joint

These milder side effects occur in about 15-20% and last only 1-2 weeks. They often don’t need medical management. However, anti-inflammatory treatment such as regular icing or NSAIDs such as ibuprofen, Aleve or Naproxen will help the joint settle faster. 

A recent study suggests these mild side effects may not directly relate to hyaluronic acid. When scientists compared Durolane with sterile water in a group with knee arthritis, they found similar rates of mild side effects. The scientists proposed that needle trauma from the injection rather than hyaluronic acid could cause these mild side effects.   

Rare and Severe Durolane Side Effects 

swollen knee joint in man with Durolane side effects

Severe Durolane side effects are very infrequent. 

In less than 1% of cases, the joint may swell and cause intense pain. Some doctors refer to an allergic reaction or ‘pseudo-sepsis’, which (means it looks like an infection). This reaction usually starts on the day of the injeciton but can be delayed by a few days. Generally, these reactions last for a few days to weeks. Sometimes, doctors drain the knee to reduce the pressure from joint swelling. Occasionally, cortisone is injected into the knee to settle the pain and swelling. 

Even rarer is the risk of infection. It occurs in about 1:10,000 cases. The joint looks swollen and is extremely painful to move. Frequently, people have fever, sweats, and chills. Joint infection needs urgent medical treatment. Luckily, it is scarce. 

A new study sheds light on the severe side effects of Durolane injection

A recent study reviewed all the evidence for severe reactions after hyaluronic acid. The study findings have helped us understand this reaction more. The findings include the following:

  • Severe reactions usually start after six hours.
  • These reactions can occur in any hyaluronic acid and not just Durolane. 
  • Severe reactions are more common if the hyaluronic acid is accidentally injected outside the joint. 
  • If you experience a severe reaction, you should see your doctor. Sometimes, a watch-and-wait approach is all that is needed. Other times, your doctor may remove some fluid from the knee and perform a blood test to ensure you don’t have an infection. Gout or Pseudogout is another possibility for a severely inflamed joint. 

How can we reduce the risk of a severe reaction to a Hyaluronic acid injection? 

We know that accidentally injecting hyaluronic acid outside the joint into muscle, tendons, or fat increases the risk of a severe reaction. Most doctors suggest using ultrasound-guidance to improve accuracy and avoid missing the joint. There is good evidence that ultrasound-guided injections are more accurate. Also, missing the joint means the hyaluronic acid is less effective. So, overall, you should have your injection done with ultrasound to improve the positive impact and reduce the chance of severe reactions. 

Other commonly asked questions related to side effects of Durolane injection:

Knee pain worse after Durolane injeciton. What does this mean? 

Generally, worsening symptoms may be due to a mild reaction if they occur within a few days. Severe pain and swelling in the joint may indicate a severe reaction. However, in other cases, increasing joint pain can be due to arthritis, especially if the pain lasts for longer than a few weeks. 

Durolane vs Synvisc: Which is better?

Both Durolane and Synvisc are high-molecular-weight hyaluronic acids. However, Synvisc is made from egg protein, whereas Durolane comes from harmless bacteria. 

A study compared these two brands for treating knee arthritis. Scientists found that Durolane had a better effect than Synvisc at six months post-injection. 

Is an ultrasound-guided Durolane injection better? 

Yes, we think so. The evidence points to greater accuracy and improved hyaluronic acid with ultrasound guidance. Recent evidence suggests that using ultrasound may reduce the risk of a severe reaction to hyaluronic acid. 

What should you do after a knee gel injection? 

You must manage your knee activity after a knee gel injection. Generally, we recommend resting from all activities for a few days. If you develop pain or discomfort, apply regular ice every 2-3 hours and take NSAIDs until the flare settles. After 3-4 days, you can restart the activity but should avoid loading the injected joint. Please see this blog on post-injection treatment after a knee gel injeciton for further tips. 

How long does it take for Durolane to work? 

Durolane usually takes four weeks to start working, although some people report reduced pain after two weeks. Sometimes, it can take up to six weeks for an effect to occur. 

Final word from Sportdoctorlondon about Durolane side effects

A Durolane injection is safe and effective for knee arthritis. Severe side effects are rare, and most will settle with simple treatments. The risk of severe side effects is not higher in Durolane than in other hyaluronic acid brands. As the risk of severe reactions is higher with inaccurate injections, we suggest you get your injection done by an expert, preferably with ultrasound-guided experience.  

Related topics: