Hyaluronic Acid Injection For Joints And Tendons: Is It Useful?

Arthritis and tendonitis are common in the general public. For those actively involved in sports or running, arthritis and tendonitis can cause pain and swelling that prevent them from participating. One option for treating arthritis and tendonitis is a hyaluronic acid gel or viscosupplementation injection. Are hyaluronic acid injections effective for arthritis and tendonitis?

What is Hyaluronic Acid?

Hyaluronic acid, also called viscosupplementation, is a naturally occurring substance in the body. It forms part of the building blocks and nourishment for cartilage and bone. You can consume hyaluronic acid as a tablet, but we believe it works more effectively when injected directly into a joint.

How Does a Hyaluronic Acid Gel Injection Work?

We are not entirely sure, but we have some ideas. One theory suggests that hyaluronic acid gel injection acts as a lubricant, allowing the joint to function more smoothly. Alternatively, we believe that a gel injection can help reduce joint inflammation, pain, and swelling. However, we are sure that hyaluronic acid does not regenerate joint cartilage.

Does the molecular weight of hyaluronic acid matter?

Generally, molecular weight refers to the mass of the hyaluronic acid molecules. Viscosupplementation can be high- or low-molecular-weight. High-molecular-weight products only need one injection because they are more potent and last longer in the joint.

An example of a higher-molecular-weight hyaluronic acid is Durolane.

There is some debate about whether high- or low-molecular-weight is better. However, recent evidence suggests that high-molecular-weight hyaluronic acid is more effective. In one study, the effect of high molecular weight was at least twice that of low molecular weight. Additionally, the Arthroscopy Association of Canada recommends that high-molecular-weight hyaluronic acid has a beneficial effect on knee and hip arthritis pain.

What Can Be Treated with Viscosupplementation Injections?

The most common condition we treat with hyaluronic acid is knee arthritis. However, other conditions are also treated, including:

• Ankle arthritis
• Hip arthritis
• Thumb arthritis
• Hip impingement

Overall, the most evidence supports the use of gel injections for knee arthritis.

Cortisone vs Hyaluronic Acid Injections for Knee Pain: Which is Better

We know that cortisone injections can help alleviate pain and swelling in knee joint arthritis. However, the effect of cortisone is small and short-lived. Additionally, we have several concerns regarding side effects, including cartilage damage. Also, there are limits to the number of cortisone injections. Generally, we recommend no more than three injections into a single joint within 12 months.

Gel injections offer a different option. Generally, hyaluronic acid injections take longer to take effect than cortisone (up to 4 weeks), but the effect is often longer-lasting, lasting up to 12 months. However, these shots are not for everyone. Research suggests that the evidence of effectiveness is mixed. They appear to be more effective for younger patients with less advanced arthritis. Moreover, older patients with more advanced diseases are less likely to experience pain relief.

There are different brands of viscosupplementation. We are not sure which brand is the best. However, some groups suggest the best form of hyaluronic acid has the following characteristics:

• high molecular weight
• high cross-links
• non-animal products

High molecular weight indicates that hyaluronic acid is more effective. A non-animal product means the reaction rate is lower. The brands with these characteristics include Durolane. Other brands, such as Ostenil Plus or Synvisc 1, do not possess these characteristics.

How Long Does a Viscosupplementation Injection Last?

Generally, higher-concentration gel injections last 6 to 12 months.

A recent study sheds light on the duration of Durolane injections. Generally, the effect of one single injection lasted, on average, about 466 days. However, in some cases, Durolane lasted for more than 100 days. Also, subsequent injections lasted as long as the first injection for up to 6 injections in a row. Ultimately, 70% of individuals who received a Durolane injection reported satisfaction.

Are There Other Points to Consider about Gel Shots for Knee Arthritis?

Usually, people consider these gel injections when they fail to respond to exercise, tablets, and cortisone injections. For example, some people can’t take common anti-inflammatories like ibuprofen due to stomach ulcers or previous heart attacks. In addition, as the side effects of viscosupplementation injections are minimal, some people consider these injections an alternative to surgery.

You need to understand that a gel injection should be performed under ultrasound guidance. Ultrasound ensures that hyaluronic acid is injected directly into the joint, not into surrounding tissues. If you inject hyaluronic acid into the soft tissue, there is a chance that you may experience severe pain and swelling. A recent study found that hyaluronic acid injections performed with ultrasound have a significantly greater effect than those performed without ultrasound. In a survey of over 1,000 patients who received hyaluronic acid injections for knee arthritis, those who underwent ultrasound-guided injections had significantly lower rates of knee replacement (over 30% lower) than those who received blind injections. Moreover, patients who underwent an ultrasound-guided hyaluronic acid injection were 27% less likely to require a subsequent cortisone injection for pain.

Recently, a new type of injection called platelet-rich plasma (PRP) has shown more promise in treating arthritis. PRP is extracted from whole blood and centrifuged, separating the plasma from the red blood cells. As a result, the plasma contains many growth factors and platelets. Recent studies suggest that PRP may be more effective than hyaluronic acid or cortisone for treating knee arthritis.

Side effects of hyaluronic acid gel injections?

Like all medications, gel injections have side effects. You should consult your doctor about these side effects. The most common side effects include pain at the injection site, fluid build-up in the knee, and allergic reactions. Generally, you should use other options if you have an allergy to hyaluronic acid-based products. For example, in a recent study on Durolane injections, the rate of allergic reactions ranged from 1% to 2%. Additionally, we are aware that hyaluronic acid derived from animal products is more likely to react.

Typically, after a hyaluronic acid gel injection, it is recommended to rest the affected joint for at least 48 hours. Additionally, avoid prolonged standing or walking.

What about combining hyaluronic acid and PRP?

There is some evidence that combining PRP and hyaluronic acid is more effective than using them separately.

A recent review found that combining PRP with hyaluronic acid is better than PRP alone. This positive effect was found at 3, 6, and 12 months. Additionally, incorporating hyaluronic acid into PRP reduces the risk of a flare after a PRP injection.

Perhaps this combination will be the norm in the future.

Another Use in Plantaris-associated Achilles Tendinopathy

In some cases of Achilles tendinopathy, the plantaris tendon interferes with the inside of the Achilles tendon. Some people have a specific anatomical configuration that predisposes them to friction between the two tendons. Recent evidence suggests that injecting hyaluronic acid between the two tendons reduces friction and improves pain.

Frequently Asked Questions about Viscosupplementation Injections:

Do gel injections in the knee hurt?

Generally, no if the knee injection is done with ultrasound guidance. If a knee gel injection is excruciating, it probably has not gotten into the joint. Also, failing to get in the joint means the risk of a severe reaction, such as ‘pseudo-sepsis’, increases. Having an experienced doctor perform your ultrasound-guided injection would be best.

Additionally, you should avoid animal-based hyaluronic acid due to the increased risk of an allergic reaction.

I’ve heard that Durolane is more likely to cause a severe reaction than other hyaluronic acids. Is this true?

No. Durolane is a high-molecular-weight hyaluronic acid, which is more potent. We believe it also exhibits a slightly increased reaction rate. The vast majority of these reactions are mild and settle quickly.

Can synvisc be injected into the shoulder?

Yes, but the shoulder joint should be the target. However, there is less evidence supporting the use of a gel shot for shoulder arthritis.

What should I do after a Synvisc injection?

Generally, we recommend resting the joint for at least three days after a gel shot. Exercise after injection increases the risk of a reaction, including pain and swelling.

We suggest using ice and simple medication, such as ibuprofen, for 5-7 days if you experience a reaction. Most cases settle in time. However, you should see your doctor if your knee pain or swelling doesn’t resolve. Occasionally, we might need to drain the swelling and inject cortisone into the knee to settle it.

Does Synvisc raise blood sugar levels?

No. Gel shots do not affect blood sugar levels, making them entirely safe for individuals with diabetes.

How long does gel injection in the knee last?

Generally, viscosupplementation injections should last up to 12 months with the use of higher-molecular-weight hyaluronic acid. Therefore, we think having a repeat injection every 6-12 months is safe. However, a recent study found that HA injections lasted an average of 450 days, with some lasting more than 1000 days. In the same study, repeated shots remained as effective as the first shot for up to 6 doses.

Knee gel injection side effects: Are they common?

Like any joint injection, viscosupplementation injections have side effects. These side effects include:

• Mild pain and swelling after a knee gel injection, which lasts for 1-2 weeks (10-20%)

• Severe allergic reaction that occurs within 1-2 days after an injection (2-3%)

• infection (1:10000)

My knee pain is worse after a gel injection. What do you do?

Sometimes, gel injections could worsen the pain. This increase in pain may be short-term only. We recommend anti-inflammatory measures, such as applying ice and taking oral NSAIDS (e.g., ibuprofen).

However, in some cases, the knee becomes swollen and inflamed. In these cases, you might have experienced an allergic reaction. Approximately 1-2% of patients experience an allergic reaction. You should speak to your doctor if you’ve experienced an allergic reaction. In some cases, you’ll need to have the knee drained.

I’ve heard of this new hydrogel called Arthrosamid. Is this injectable the same as viscosupplementation?

No, Arthrosamid is not a hyaluronic acid.

Arthrosamid is a unique hydrogel of water molecules attached to a polyacrylamide backbone. The injectable is non-degradable, meaning the body does not break it down. It works by coating the synovial lining of the knee joint, reducing inflammation and providing lubrication. Recent studies have shown improvement in pain scores that lasts for up to 5 years. Additionally, compared with hyaluronic acid, it is more effective in younger, slimmer patients.

Final Word from Sportdoctorlondon about Hyaluronic Acid Injection

Overall, hyaluronic acid injections are a beneficial addition to arthritis treatment. Generally, the best evidence is in knee arthritis, although injections into other joints are possible.

Dr Masci performs hyaluronic acid injections for arthritis and tendonitis. For further information on this procedure, including costs, please get in touch with his staff. Please review his fees here.

More injection information:

• Injections by body part
• Ultrasound-guided injection
• Durolane injection for knee arthritis
• What should I do after a knee gel injeciton? Post-injection care
• Platelet-rich plasma injection
• Cortisone vs hyaluronic acid for knees: Which is better?
• Combined hyaluronic acid and PRP injection
• Arthrosamid injection for knee arthritis
• Fees for ultrasound-guided injections for self-paying patients