Hyaluronic acid joint injections: what NICE advises for osteoarthritis

Hyaluronic acid, which NICE calls hyaluronan, is a substance that occurs naturally in joint fluid. Preparations of it are injected into a joint, a procedure described as an intra-articular injection. The idea behind the treatment is to improve the lubricating and cushioning properties of the fluid and so reduce pain in an osteoarthritic joint, which is why it is also called viscosupplementation. The knee is the joint most often treated.

Osteoarthritis itself is, in the NHS description, a condition that causes joints to become painful and stiff and is the most common type of arthritis in the UK. In osteoarthritis the protective cartilage on the ends of the bones breaks down, causing pain, swelling and problems moving the joint. Injections do not rebuild cartilage, and the NHS says there is no cure for the condition, but treatments can relieve symptoms and it does not necessarily get worse over time.

NICE guideline NG226, Osteoarthritis in over 16s: diagnosis and management, published in October 2022, makes a clear recommendation: do not offer intra-articular hyaluronan injections to manage osteoarthritis. The recommendation covers all joints. The guideline sets out the evidence in a separate review, which the recommendations page links to, and the page read for this guide does not itself summarise that evidence.

This is guidance for NHS care in England, but it also informs what many clinicians in other parts of the UK advise. It does not stop a person from choosing to pay for treatment, and some private providers offer hyaluronic acid injections. If you are considering them, it is reasonable to ask the clinician to explain how their advice compares with NICE guidance, what the expected benefit is, how long it lasts and what the cost will be.

NICE puts exercise and weight management at the centre of treatment. It recommends therapeutic exercise tailored to the person for everyone with osteoarthritis, which can be local muscle strengthening or general aerobic fitness, and says that although joint pain may increase when you start, regular and consistent exercise will be beneficial for the joints in the long term. For people living with overweight or obesity, any amount of weight loss is likely to be beneficial and losing 10% of body weight is likely to be better than 5%.

Medicines are used alongside these measures, at the lowest effective dose for the shortest possible time. NICE recommends offering a topical NSAID to people with knee osteoarthritis, and considering an oral NSAID with gastroprotection if topical medicines are ineffective or unsuitable. It does not routinely recommend paracetamol, because there is no strong evidence of benefit, and does not recommend glucosamine or strong opioids. Walking aids such as sticks can be considered for lower limb osteoarthritis.

A corticosteroid injection is the injection treatment that NICE does leave room for. The NHS explains that steroids contain manmade versions of the hormone cortisol and are sometimes used for particularly painful musculoskeletal problems; some people with osteoarthritis may be offered a steroid injection when other treatments have not worked, and a local anaesthetic may be given first. They work quickly and can ease pain for several weeks or months, according to the NHS. NICE is more specific, advising people that they provide only short-term relief, 2 to 10 weeks.

That short window is sometimes used to support exercise, for example to make it easier to start a strengthening programme. A steroid injection is not a treatment on its own, and your clinician should discuss the number and timing of injections for your joint.

NICE says osteoarthritis can be diagnosed clinically without imaging in people who are 45 or over, have activity-related joint pain, and either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. It says not to routinely use imaging unless there are atypical features. The NHS says a GP may arrange X-rays or blood tests to rule out other causes such as rheumatoid arthritis or a fracture.

NICE suggests considering patient-initiated follow-up for most people, so you can arrange a review when symptoms or function change. It also says management should be guided by symptoms and physical function and that information should challenge common misconceptions, including about flares and progression.

The NHS says surgery for osteoarthritis is only needed in a small number of cases where other treatments have not been effective or daily life is seriously affected, and that it cannot be guaranteed to get rid of symptoms altogether. NICE recommends considering referral for joint replacement for hip, knee or shoulder osteoarthritis when symptoms such as pain, stiffness, reduced function or progressive deformity substantially affect quality of life and non-surgical management has not helped.

If a clinician suggests hyaluronic acid injections, a few questions can help you decide. They are not a substitute for medical advice but help structure the conversation.

• What do you expect the injection to achieve for me, and over what time frame?

• How does this fit with NICE guidance on osteoarthritis?

• What would I be doing alongside it, such as an exercise programme?

• What are the risks, and what is the total cost, including follow-up and repeat injections?

• What would be the next step if it does not work?

On the NHS, osteoarthritis care starts with your GP or an NHS musculoskeletal (MSK) service, often with physiotherapy and exercise advice. Private physiotherapists, sports medicine doctors and orthopaedic surgeons also see people with osteoarthritis. Whichever route you take, ask for a plan that includes exercise and weight management as the core of treatment, as NICE recommends.