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Table of Contents

Magill’s Medical Guide, 9th Edition

Hyaluronic acid injections

by Joanne R. Gambosi, , BSN, MA

Category: Procedure/Treatment

Anatomy or system affected: Knees, face, joints

Specialties and related fields: Orthopedic surgery; family medicine/primary care; physician assistant/nurse practitioner under physician supervision; plastic surgery; dermatology

Definition: Hyaluronic acid is a gel-like substance that is found in high amounts in joints to lubricate and help joints move smoothly. It is also found in skin to help increase elasticity, as well as other tissues in the body.

Key terms:

arthralgia: joint pain

arthrofibrosis: scar tissue in a joint that develops after surgery, implant, or joint replacement

arthropathy: disease of a joint in the body

arthroscopy: a procedure where a surgeon uses an instrument called an arthroscope to look inside a joint

articulating: where a joint or juncture between bones or cartilages is present for motion

hyaluronan: a naturally occurring gel-like material that is found primarily in synovial fluid

hyaluronic acid: a substance present in body tissues, such as in skin and cartilage. In joints, it serves to help lubricate the joints

intra-articular: occurring within a joint

joint effusion: a collection or buildup of fluid in a joint

kneecartilagedefect: an area of damaged cartilage in the knee

osteoarthritis: a progressive disorder of the joints caused by gradual loss of cartilage which can result in the development of bone spurs and cysts at the margins of joints

synovialfluid: a clear fluid that serves as a lubricant in a joint, tendon sheath, or bursa

viscosupplementation: a therapeutic treatment typically involving injection(s) of hyaluronic acid or related compounds; used in the treatment of osteoarthritis

INDICATIONS AND PROCEDURES

Hyaluronic acid injections (in a treatment group called viscosupplementation) were approved by the United States Federal Drug Administration (FDA) in 1997 to treat osteoarthritis of the knee. It is a gel-like material made from hyaluronan which is found in the combs on the tops of the heads of chickens, or manufactured synthetically. Brand names include: Euflexxa®, Gel-One®, GelSyn-3®, GenVisc 850®, Hyalgan®, Hyalgan L/L®, Hymovis®, Monovisc®, Orthovisc®, Supartz®, Supartz FX®, Synvisc®, and Visco-3®.

In March 2005, injectable hyaluronic acid injections were also approved to increase skin elasticity and decrease wrinkles in the face, enhance lips, and replace soft-tissue volume loss associated with aging facial wrinkles, etc. It is injected into facial tissue to smooth wrinkles and folds, especially around the nose and mouth. The hyaluronic acid gel works by temporarily adding volume and increasing elasticity to facial tissue to restore a smoother appearance to the face. The effect of the hyaluronic acid gel can last approximately six months. Most patients need one injection of hyaluronic acid to achieve the most favorable benefits of wrinkle smoothing; about one-third of patients need more than one injection to get a satisfactory result.

Hyaluronic acid filler injections are usually given by a plastic surgeon, dermatologist, esthetician, or other trained healthcare professional. Brand names include: Restylane®, Juvederm, Belotero®, Hylaform®, and Captique®, as well as others.

Although hyaluronic acid filler injections are now commonly used by healthcare professionals today to smooth wrinkles at the request of the aging, young-appearance-oriented population, the primary use of hyaluronic acid injections is for treatment of knee osteoarthritis.

Hyaluronic acid injections are used in individuals with knee pain caused from osteoarthritis of the knee that has not responded to physical therapy, anti-inflammatory drugs, or other treatment. They can also be used to control pain symptoms from damage to knee cartilage caused by repeated knee trauma, or in individuals that have had prior arthroscopic surgery or cleaning of the defective cartilage that has not been successful.

However, hyaluronic acid injections are not recommended for use in individuals with allergies to hyaluronan, chicken eggs or feathers, sensitivity to bacterial proteins, or in patients who have bleeding disorders, severe inflammation, infection or joint effusion of the affected knee, or skin problems near the knee. However, once the inflammation or infection is treated and resolved, the injection may be possible based on an examination and evaluation by the physician.

Some brands of hyaluronic acid are not derived from animal proteins (e.g., Euflexxa®), and patients may be eligible for injection with these brands.

The use of hyaluronic acid injections has not been studied in children or breastfeeding women. Currently, the relationship of age to the effects of hyaluronic acid injection in geriatric patients is not available.

Individuals should also check with their health insurance company to inquire about coverage for hyaluronic acid injection.

The largest study and review of the use of hyaluronic acid injections for knee pain from osteoarthritis was done by Nicholas Bellamy, MD, and his team in 2006. They found that pain levels in the average patient who received these injections were reduced by 28 to 54 percent, which is about the percentage of relief from an individual taking non-steroidal anti-inflammatory drugs (NSAIDs) for knee pain relief. However, the researchers also found that hyaluronic injections improved the ability of patients who received them to move about and perform daily activities by 9 to 32 percent. They also noted in their review that although cortisone injections for the knee may work more quickly for relief of knee pain and possibly improve function, hyaluronic acid injections tend to take longer to work (can be five to eight weeks for full effectiveness), but yield longer-lasting improvement.

Injectable hyaluronic acid injections are also used to increase skin elasticity and decrease wrinkles in the face, enhance lips, and replace soft-tissue volume loss associated with aging facial wrinkles, etc.

MMG2022_p1476_001.tif

Image via iStock/be_moll. [Used under license.]

A later analysis of treatments for knee osteoarthritis by Bannuru and others in 2015 reviewed research studies in which randomized trials of adults with knee osteoarthritis comparing two or more of the following—non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, hyaluronic acid injections and oral NSAIDs and hyaluronic acid injection placebos for treatment of osteoarthritis—were studied. Bannuru and his colleagues’ analysis noted that articular treatments (cortisone and hyaluronic injections) improved the movement and functional ability of patients who received them and were superior to NSAIDs. All treatments except acetaminophen (Tylenol®) improved pain control.

PROCEDURE

An orthopedic surgeon, primary care physician, or other healthcare professional trained and supervised to provide the hyaluronic acid injection(s) will first clean the knee to be injected with an alcohol swab. Sometimes a local anesthetic spray or lidocaine injection is used to lessen any patient discomfort before the physician inserts the needle with the hyaluronic acid. The needle is first placed in the intra-articular space of the affected knee, and a small amount of synovial fluid is withdrawn to assure correct placement.

Once the hyaluronic acid is injected into the knee, the healthcare provider usually has the patient flex their knee three or four times to help circulate the hyaluronic acid in the knee. Depending on the hyaluronic acid brand used for the procedure, one injection or a series of three to five injections one week apart are given. Both the multi-injection and single-dose repeat injections can be given after six months if needed.

Strenuous exercise, e.g., jogging, heavy lifting, racquetball, or prolonged standing should be avoided for 48 hours or as advised by the healthcare provider. Any moderate swelling or pain of the injected knee should have ice packs applied. However, any sharp or increased pain, locking or increased swelling of the injected knee should be reported to the individual’s healthcare provider.

It can take five to eight weeks for a hyaluronic acid injection(s) to work to relieve knee pain and symptoms, with peak effectiveness at eight weeks.

USES AND COMPLICATIONS

The most common side effects reported after hyaluronic acid knee injections are minor pain at the injection site, swelling, and a small buildup of fluid in the affected knee joint. These symptoms usually disappear within a few days.

Other issues that are less common but may occur include joint stiffness, warmth at the injection site, arthropathy, and gait disturbance.

As individuals grow older, joint issues—especially in the knees—can be challenging. In addition to the use of hyaluronic acid injections, other new procedures are being studied to restore or replace damaged knee cartilage and improve function and mobility while decreasing pain from osteoarthritis. Among treatments being researched are stem cells used to promote cartilage growth, novel anti-inflammatory drugs that inhibit inflammation in osteoarthritis, and growth factors for cartilage regrowth.

See also: Aging; Cartilage repair; Meniscus repair; Osteoarthritis; Knee surgery; Non-steroidal anti-inflammatory drugs (NSAIDs); Torn cartilage; Hyaluronic acid fillers; Viscosupplementation.

For Further Information:

1 

Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Annals of Internal Medicine 2015; 162(1):46-54. doi: 10.7326/M14-1231.

2 

Cleveland Clinic. “New study finds injections are best for your knee arthritis pain.” Health Essentials. January 2015.

3 

“Knee injections.” DePuy Synthes. www.depuysynthes.com/patients/knee/patient-treatment-center/knee-injections.

4 

Gold M. Use of hyaluronic acid fillers for the treatment of the aging face. Clinical Interventions in Aging 2007; 2(3): 369-376.

5 

Gower T. Hyaluronic Acid Injections for Osteoarthritis. The weight of evidence suggests that a shot in the knee may bring some OA patients relief. Arthritis Foundation.

Citation Types

Type
Format
MLA 9th
Gambosi, Joanne R. "Hyaluronic Acid Injections." Magill’s Medical Guide, 9th Edition, edited by Anubhav Agarwal,, Salem Press, 2022. Salem Online, online.salempress.com/articleDetails.do?articleName=MMG2022_0683.
APA 7th
Gambosi, J. R. (2022). Hyaluronic acid injections. In A. Agarwal, (Ed.), Magill’s Medical Guide, 9th Edition. Salem Press. online.salempress.com.
CMOS 17th
Gambosi, Joanne R. "Hyaluronic Acid Injections." Edited by Anubhav Agarwal,. Magill’s Medical Guide, 9th Edition. Hackensack: Salem Press, 2022. Accessed October 22, 2025. online.salempress.com.