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Hyaluronic Acid Injections

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combined steroid & Hyaluronic Acid

Cingal®

Cingal® contains monovisc HA and steroid

Hyaluronic acid injections have been shown in several studies, including meta-analyses (where data from several similar studies is combined), to be safe and provide improvements in function and pain caused by osteoarthritis (OA). The beneficial effects typically last around 6 months although for some this may be shorter or much longer. For many patients, periodic treatments with HA injections allows them to live with more manageable pain levels and improved function, allowing more invasive treatments like joint replacement to be delayed or even avoided altogether.

HA injections are used mainly for joint pain. The most common joints injected are the knee, ankle, shoulder, hip and big toe joint. However, HA can also be injected next to painful tendons (into the tendon sheath) or into the bursa that lye between tendons to improve pain caused by inflammation or impingement.  Importantly injections of all nature generally work best when supported by a program of structured, and initially supervised exercise rehabilitation guided by an experienced physiotherapist.

Numerous studies have investigated the efficacy of HA injections in knee OA, with several systematic reviews and meta-analyses providing valuable insights. For example, a meta-analysis by Bannuru et al (2015)* examined 7 eligible trials including 606 patients and concluded that 8 weeks after HA injection, patients reported significant pain relief and improved function compared to steroid injection.

More recently Zhu et al (2023) examined the use of HA for hip OA in a systematic review of 40 studies totalling 3350 patients. Although there were some concerns about the quality of studies included in this review, the authors concluded that there is evidence to suggest that HA injection into the hip joint improves patient-reported pain and function. Clearly, an important next step is for further higher quality research to be performed to enable regulatory bodies like NICE to make their recommendations.

*Bannuru, R. R., et al. (2015). Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis & Rheumatology, 67(11), 331-340.

**Zhu J, Lim A, McCaskie AW, Khanduja V. Viscosupplementation Is Effective for the Treatment of Osteoarthritis in the Hip: A Systematic Review. Arthroscopy. 2023 Nov 23:S0749-8063(23)00939-8. doi: 10.1016/j.arthro.2023.11.010. Epub ahead of print. PMID: 38000487.
So what does the evidence suggest?

Conclusion are certainly far from clear at this stage regarding the effectiveness of Hyaluronic Acid (HA). Many clinicians have seen their patients benefit significantly following treatment, but this alone cannot be considered strong medical evidence.

There are studies however that have found patients with knee OA had improved pain at six months when treated with HA injection versus steroid injections. Take a look at this graph taken from a meta-analysis in 2020(1). The circled points at six months are fully left of the centre line, indicating that pain scores are better in those treated with HA compared to steroid and placebo.

1) Chevalier X, Sheehan B, Whittington C, Pourrahmat MM, Duarte L, Ngai W, de Campos GC. Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis. Clin Med Insights Arthritis Musculoskelet Disord. 2020 Nov

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