The Best Hyaluronic Acid Injections For Joints

Compare Hyaluronic Acid Injection Brands

We have developed our own, bespoke treatment scoring system called the Resoken Treatment Potency Rating (TPR) which allows you to see how efficacious each treatment is, at a glance.

And we have reviewed all of the top Hyaluronic Acid (HA) injection brands, made specifically for joints.

Compare Cingal, Ostenil, Ostenil Plus, Ostenil Mini, Monovisc, Durolane, Synvisc and Synvisc-One. They are presented in the comparison table below. Each one has been assigned a TPR.

Check under the table, for further explanation.

Scroll ⬅️ left & right ➡️ to view the entire table.

Name	Composition	Weight	Crossed	Total HA	Origin	Resoken TPR
Cingal	HA + Steroid	1900	Yes	88	Bacteria	7.8 / 10
Ostenil	HA Only	1,200-1,400	No	20	Bacteria	7.5 / 10
Ostenil Plus	HA Only	1600	No	40	Bacteria	7.5 / 10
Ostenil Mini	HA Only	150	No	20	Bacteria	7.5 / 10
Monovisc	HA Only	1000-2900	Yes	88	Bacteria	7.3 / 10
Durolane	HA Only	>10,000	Yes	60	Bacteria	7.2 / 10
Synvisc	HA Only	6000	Yes	16	Avian	6.8 / 10
Synvisc-One	HA Only	6000	Yes	48	Avian	6.8 / 10

The columns in the table above, mean the following:

• Name: The name of the hyaluronic acid injection product (or brand). If you want to learn more about any of the injection brands, simply click on their name to view our respective in-depth articles.
• Composition: The constituents of the product. Is Hyaluronic Acid the only API (active pharmaceutical ingredient) or does the product contain something additional.
• Weight: The molecular weight (also known as molar mass) of the Hyaluronic Acid, written in kDa (kilo Daltons). Daltons are an atomic mass unit.
• Crossed: Whether the Hyaluronic Acid inside the respective product is cross-linked or not.
• HA Total: The total amount of Hyaluronic Acid for a single injection of the respective treatment, written in mg (milligrams).
• Origin: From what has the Hyaluronic Acid been derived – either bacteria fermentation or avian (primarily chicken) sources.
• Resoken TPR: The Resoken Treatment Potency Rating shows you at a glance how efficacious each treatment is. The higher the rating, the more efficacious the treatment and the fewer the chances of side effects.

Sources: (1), (2), (3), (4)

The Role of Hyaluronic Acid in Joint Health

Hyaluronic acid injections, as the name suggests, contain hyaluronic acid (HA).

HA is a naturally occurring substance found throughout our body – in the skin, blood vessels, eyes, tendons, and the synovial fluid of our joints.

Synovial fluid is a viscous (thick), slippery fluid which acts as a lubricant and shock absorber. It enables smooth movement while protecting the cartilage from wear and tear.

Think of it as oil in a car’s engine. Just like the machine oil helps the engine’s moving parts glide smoothly, the synovial fluid does a similar thing, but within our joints.

And one of the key components of synovial fluid is hyaluronic acid, which gives it these unique, cartilage-preserving properties.

So here’s exactly how hyaluronic acid preserves joint health:

• Lubrication: Hyaluronic acid acts as a lubricant. It reduces the friction between the joint’s articulating (or moving) surfaces. This helps minimise cartilage wear and tear, prolonging optimal joint functionality (1).
• Shock Absorption: Hyaluronic acid contributes to synovial fluid’s viscoelastic (stretchy and spongy) properties. Basically, it’s like the shock absorbers in a car or a bike, which help smooth out the bumps and jolts when you drive over rough roads. The hyaluronic acid in the synovial fluid helps distribute the load evenly across the joint surface and absorbs the shock, so to speak, whenever you walk, run, or jump (2).
• Cartilage Protection: Besides lubrication and shock absorption, hyaluronic acid forms a pericellular matrix around the chondrocytes. Think of it as similar to a protective coating but at the molecular level. This was shown to potentially shield the joint from degradative enzymes and free radicals (3).
• Nutrient Transport: Hyaluronic acid facilitates the transport of nutrients to cartilage cells (chondrocytes) and helps remove waste products. Which is quite important for maintaining healthy cartilage tissue (4).
• Anti-inflammatory: Interestingly, hyaluronic acid seems to exhibit some minor anti-inflammatory properties. In a mouse model study by Campo et. al. (5) HA was shown to mitigate inflammation by interacting with the CD44 receptor. And since inflammatory mediators like interleukin-1beta (IL-1beta) also bind to the same CD44 receptor, HA acid prevents them from doing so due to its apparent higher binding affinity. Essentially, HA helps soothe inflammation by preventing the over-activation of these inflammatory pathways within the cells. However, since this was only shown in a mouse study, we can’t readily extrapolate the same conclusions for humans. Further investigation needs to be done. And of course, the HA anti-inflammatory effect isn’t comparable to targeted anti-inflammatory agents like corticosteroids which, on average, are much more potent.

Below is a video demonstrating how hyaluronic acid attaches to the CD44 receptor on a molecular level.

You can see the long hyaluronic acid chains, displayed in blue, docking onto the CD44 receptor shown in yellow.

This interaction with CD44 receptors can also trigger synovial cells to produce more endogenous (your own) HA, potentially prolonging the effects of the injection (6).

Efficacy of Hyaluronic Acid Injections

Does hyaluronic acid really work for joints?

We wanted to answer this question via an earnest piece of research.

That’s why we looked into all of the available clinical data on hyaluronic acid injections, and didn’t just cherry-pick studies.

Our consensus is:

Hyaluronic acid injections have shown enough therapeutic merit to be worthy of consideration. However, they are still debated in the medical community due to some conflicting data.

The success rates can vary significantly depending on various factors:

• The hyaluronic acid product (brand) being used
• The target joint being treated
• The proficiency of the injection specialist or doctor
• Are the injections landmark or ultra-sound guided
• Patient individual characteristics
• And more…

In a large-scale meta-analysis by Bannuru et al. (7), HA injections showed significant improvement in knee osteoarthritis pain compared to placebo.

The study reported an effect size of 0.63 at 8 weeks post-injection, which is considered a moderately positive effect.

However, we noted that the efficacy tended to decrease over time, with the effect size reducing to 0.21 by 24 weeks.

Effect size (0-1) is a statistical measure of how helpful a given treatment is. Where 0 means it isn’t helpful at all, and 1 means extremely helpful.

Another comprehensive review by Rutjes et al. (8) analysed 89 trials involving 12,667 patients, and the findings were slightly more modest.

The effect size for pain reduction was 0.37.

It still represents a small to moderate improvement, just not as prominent as the 0.63 in study 7.

However, we also found studies that questioned the clinical significance of HA injections.

For instance, a meta-analysis by Johansen et al. (9) showed that intra-articular hyaluronic acid injections are better than placebo, but only slightly.

Hence these improvements were too small to be clinically meaningful.

So our inference is that hyaluronic acid injections fall in the category of ‘positive or neutral’ effect, for the most part.

Meaning, the vast majority of people experience one of the following:

• Perceived positive effect: a positive pain-relieving effect and improvement in joint function. The word ‘perceived’ here means you’re actually feeling a noticeable improvement.
• Unperceived positive effect: no perceivable pain relief or improvement in joint function, but still helpful due to reducing the rate at which osteoarthritis is progressing. The word ‘unperceived’ here means you’re not feeling a noticeable improvement, but the hyaluronic acid is still helping by slowing down the degeneration of the joint.
• Net neutral effect: no benefits and no adverse reactions.

These are the most common outcomes.

But of course, like any other medical intervention or therapeutic, there are potential side effects you should be mindful of.

They are quite rare, but nonetheless, we’ve covered them in depth (here). And we’ve also discussed how you can minimise or prevent these side effects (here). So you can make your own educated decision.

Knee Osteoarthritis

If you have knee osteoarthritis (OA), based on the findings we cited above and our inference, hyaluronic acid injections can be a viable form of treatment.

Specifically, if traditional therapies have failed to provide sufficient pain relief.

A study by Moheu et al. (10) investigated viscosupplementation for knee osteoarthritis.

And found exogenous (or injected) hyaluronic acid a safe and effective treatment, which improved joint function and reduced pain.

This makes hyaluronic acid a worthwhile treatment, especially for those with less severe knee OA.

It can prolong the need for knee replacement surgery, or in some cases, eliminate it entirely.

Hip Osteoarthritis

Similarly, hyaluronic acid injections have shown clinical merit in the treatment of hip joint osteoarthritis (OA).

A long-term study by Perna et. all (11) showcased that HA injections can be equally effective for the hip joints, as in the knee.

In the study, 167 patients with hip osteoarthritis received ultrasound-guided, hyaluronic acid injections (both with and without corticosteroids).

And both groups achieved statistically significant improvements in pain and mobility scores over a 12-month period, shown via VAS and GLFS scores.

A one-year follow-up study by Battaglia et al. (12) found that HA injections aren’t effective for severe hip OA, but are effective for mild to moderate states.

So our conclusion here is similar to what we said above regarding knee OA.

Hyaluronic acid injections are worthwhile for those with less severe forms of hip OA, since for the most part, such injections fall in the category of ‘positive or net neutral’ effect.

How Long Do Hyaluronic Acid Injections Last?

The duration of hyaluronic acid (HA) injections can vary among patients.

On average, the effectiveness typically peaks around 6 – 8 weeks.

Meaning for up to 8 weeks, your injected joint will continuously feel better and better.

After that, you can still retain the majority of pain relief for 6 months or longer.

But the effectiveness will most likely begin to wear off as time progresses (13).

There are several factors which influence the duration.

And you should consider them when deciding which injection brand to go with:

• Cross-linked status: Cross-linking is a chemical process that binds the HA molecules together. This creates a more stable and durable structure. In very simple terms, think of it as grabbing a lot of sticks and creating a lattice. But on a molecular level, it’s a network of intertwined HA molecules. This makes them more resistant to breakdown. So cross-linked HA products last longer and theoretically should provide longer relief. But interestingly, only the soluble portion of these cross-linked products has been shown to interact with the CD44 receptor. We have a video explanation of this above, (click here) in case you missed it. For this reason, cross-linked HA injections are dissimilar to the linear chain structure of normal, healthy endogenous HA (14).

• Molecular weight: Molecular weight refers to the size of the HA molecules. Higher molecular weight HA (>3,000 kDa) generally remains in the joint longer than lower molecular weight products (<1,000 kDa). The molecular weight is related to the cross-linking. Typically, cross-linked HA has a higher molecular weight and vice versa. Think of it as larger molecules being more difficult to break down, hence remaining in the joint for longer. However, some low-to-moderate weight HA products, which aren’t cross-linked (100 – 2,000 kDa) can still provide significant relief. That’s because they more closely mimic the natural HA found in healthy synovial fluid. Healthy joint synovial fluid HA has a linear chain structure (meaning it’s not cross-linked). And a molecular weight of 500 – 6,000 kDa. In some cases even under 500 kDA (15).

• Biological Origin: From where has the HA been derived. The main origins are Avian (usually derived from chicken combs), Bacterial fermentation (usually derived from Streptococcus zooepidemicus), and a newer promising but yet to-be-fully tested version – called Bioengineered HA. The Bacterial fermentation origin is currently the gold standard, as this method produces highly pure HA that is structurally identical to human HA. And it has longitudinal safety data. Whereas, Avian-based HA injection products have a small probability of causing allergic reactions due to immunogenicity and inflammation. Specifically for those patients with poultry allergies. Plus, some religious or ethical considerations may make this source less acceptable to certain people (16), (17), (18).

So these are the 3 main variables you should take into consideration when choosing the best hyaluronic acid injection for your use case.

As for how are hyaluronic acid injections administered – it’s typically a minimally invasive, outpatient procedure.

The doctor or injection specialist will first apply a local anaesthetic to completely numb the area.

They should use ultrasound to accurately guide and inject the hyaluronic acid into the affected joint.

Some doctors may use landmark guidance (physical touch, palpation) but ultrasound is vastly superior.

Most patients typically experience minimal or no discomfort at all during the procedure.

Hyaluronic Acid Injections – Price

In the UK, Hyaluronic Acid injections can vary quite a lot in price.

It mainly depends on the brand, the clinic and the injection specialist.

But the cost can sometimes depend on the target joint.

Whether it’s a knee hyaluronic acid injection or the much smaller metacarpophalangeal (MCP or finger) joints, which require much more precision to administer the injection correctly.

Though to give a broad estimate, the usual range is £200 – £500 per injection.

It’s always advisable to choose a clinic or specialist with a lot of experience in intra-articular injections, i.e. joint injections.

Preferably someone who does Ultrasound-guided Hyaluronic Acid injections, which ensures accuracy in delivering the hyaluronic acid directly into the affected joint space.

And are Hyaluronic Acid Injections available on the NHS?

Unfortunately, rarely.

As per the NHS commissioning decision:

“Hyaluronic Acid injections are considered a low priority for funding and will only be considered in exceptional circumstances. Funding approval must be sought from the local integrated care board (ICB) via the Individual Funding Request process prior to treatment.” (NHS Decision)

This specific statement is taken from an NHS Gloucestershire document but is effectively the same for the entirety of the UK.

If you fall within these “exceptional circumstances” and manage to get Hyaluronic Acid injections via the NHS, great.

But if you wish not to waste time, it’s best to seek private treatment.

Hyaluronic Acid Injections – Patient Reviews

Since Hyaluronic Acid injections come in many different brands, types and dosages, we compiled and analysed and compiled all top-performing ones to write this section.

Let’s break down the patient data into two groups – empirical (scientific) and anecdotal (word of mouth).

Empirical:

The empirical group is further subdivided into two – evidence for, and against hyaluronic acid injections for joints.

Arguments Supporting The Effectiveness

• Pain Relief and Functional Improvement: A large-scale meta-analysis by Bellamy et al. (19) analysed all available research on Hyaluronic Acid (HA) in relation to joint pain. The conclusion was that HA injections provide significant improvement in pain and function compared to placebo. On average, peak effectiveness was 5-13 weeks post-injection. But some patients had relief for 24 weeks or longer.

• Delayed Need for Total Knee Replacement: Another large retrospective study by Altman et al. (20) concluded that patients who had HA joint injections, delayed total knee replacement surgery by an average of 3.6 years compared to those who did not receive HA treatment.

• Quality of Life Improvements: A systematic review by Miller et al. (21) reported that patients experienced significant improvements in physical function after having HA injections, which lead to an overall better quality of life.

Arguments Against The Effectiveness

• Minimal Clinical Significance: A meta-analysis by Rutjes et al. (22) concluded that Hyaluronic Acid (HA) joint injections showed statistically significant positive effects on pain relief. However, these effects were too small to be clinically meaningful for most patients.

• Inconsistent Results: A network meta-analysis by Bannuru et al. (23) found that the effectiveness of HA injections varied widely across different studies. Meaning, the benefits for patients were quite inconsistent.

• Placebo Effect: Some researchers argue that the perceived benefits of HA injections may be largely due to a placebo effect. A study by Zou et al. (24) found no significant difference between HA and saline injections in terms of pain relief and functional improvement.

Here’s what we think:

Hyaluronic acid injections have shown enough therapeutic merit to be worthy of consideration.

The problem is that there are many confounding variables which make it difficult to standardise. That’s why these large meta-analyses cannot provide sufficiently conclusive claims.

The success rates can vary significantly depending on:

• The hyaluronic acid product (brand) being used
• The target joint being treated
• The proficiency of the injection specialist or doctor
• Are the injections landmark or ultra-sound guided
• Patient individual characteristics
• And more…

We expanded this topic further in one of the earlier sections above. If you’ve missed it and would like to read it (click here).

Anecdotal:

There are thousands of word-of-mouth (or anecdotal) patient reviews.

We sifted through all tagged with Sodium Hyaluronate, Hyaluronan as well as individual injection brand names.

And just like the empirical data we presented above, the anecdotal reviews are mixed – you can verify this for yourself.

Some patients have had tremendous pain relief from Hyaluronic Acid injections, while others haven’t had much improvement.

Individual responses can vary significantly due to differences in joint morphology, genetic predispositions, the stage and severity of osteoarthritis, as well as overlapping effects of previous treatments.

So our inference is that Hyaluronic Acid injections, for most people, produce either a net-positive or net-neutral effect.

Some patients do experience side effects, but it’s difficult to ascertain why.

Are the HA injections causing the side effects? Is it the method of administration? Does the injection specialist they chose lack sufficient care/precision? Or is it a mixture of all these factors?

We discuss these topics further in the Side Effects and Preventing Side Effects sections below.

What Are The Side Effects?

Hyaluronic Acid (HA) has been used as a treatment for osteoarthritis (OA) since the 1970s.

So it’s not a new or unproven treatment modality. And it has a well-established side-effect profile based on a lot of empirical and anecdotal data.

Most people don’t get any serious side effects.

However, like any other medical procedure, there are potential risks you should be mindful of.

We’ll list the side effects below. And in the next section, we’ll discuss how to minimise or eliminate them entirely.

These side effects can happen with any hyaluronic acid injection brand. That’s because all HA injections have the same mechanism of action and similar excipients. Therefore similar side effect profiles can be expected. Most of these adverse reactions depend primarily on the skillfulness and care of the injection specialist or doctor.

Common MILD side effects (10-20% of patients):

• Pain at the injection site: Some patients may experience temporary discomfort or mild pain where the injection was administered. This shouldn’t last more than 1 week.
• Swelling and redness: Minor swelling or erythema (redness) around the injection area can occur. This typically resolves on its own within a week.
• Joint and muscle stiffness: A temporary increase in stiffness at the target joint, or the muscles around it. You might notice this immediately after the procedure but it should subside within 1-2 weeks.

Rare SEVERE side effects (≤1% of patients):

• Allergic reaction: In very rare cases, patients may have an allergic reaction to the components of the HA injection. This can involve symptoms such as swelling, redness, and itching at the injection site.
• Pseudosepsis: Which combines “Pseudo” + “sepsis” = it mimics the symptoms of sepsis. Such as fever, increased heart rate, and increased white blood cell count, but does not involve a bacterial infection or actual sepsis.

Both allergic reactions and pseudosepsis are very uncommon.

Hyaluronic acid is naturally found in our joints, skin, eyes and connective tissue. It has high bio-compatibility. Therefore, when injected into the problem area, the body easily recognises and accepts it.

Extremely Rare SEVERE side effects (≤0.1% of patients):

• Infection: Like with any other injection, a needle must penetrate the skin to deliver the active ingredients. And this always carries a tiny risk of an infection. If you notice severe swelling, pain, intense warmth arising from the joint and/or fever, contact your doctor immediately.

Infections are extremely uncommon. They are more dependent on the doctor’s clinical expertise and sanitary practices than anything else.

Therefore Hyaluronic Acid injections are considered generally very safe, but they shouldn’t be used in pregnant and lactating women because they haven’t been evaluated under such conditions.

How to Prevent Side Effects?

To prevent or minimise the risk of side effects from any other hyaluronic acid injection, consider the following:

• Ultrasound Guidance: Ensure your doctor is using ultrasound to guide the injection. As this study demonstrated (18) patients receiving ultrasound-guided knee hyaluronic acid injections were significantly less likely to undergo subsequent knee complications than patients receiving landmark-guided (physical touch, no imaging) hyaluronic acid injections.
• Combined Therapy: Theoretically, combining Hyaluronic Acid with a Corticosteroid (such as Cortisone) may reduce the risk of an acute inflammatory reaction or pseudosepsis. Corticosteroids block pro-inflammatory mediators, suppress the production of cytokines, and prevent factor NF-κB from activating, all of which decrease inflammatory gene expression (19). Therefore, in theory, corticosteroids can reduce the risk of acute inflammation or pseudosepsis. And even augment the positive effects of HA. However, corticosteroids themselves can have side effects. This includes potentially impacting blood sugar levels and the tissues around the injection site. So you and your doctor should carefully consider the pros and cons of combined HA + Corticosteroid therapy.
• Treatment Quality: Ensure the Hyaluronic Acid brand your doctor uses is of high quality and sourced from reputable manufacturers. Be aware of the product’s origin and composition. HA derived from bacterial fermentation seems to cause fewer side effects than HA derived from avian sources. Also, certain additives or preservatives (excipients) might increase the risk of an adverse reaction, hence check the full ingredients list of the injection you’ll be getting.

Always ask the clinic or doctor who’ll be administering any type of HA injection about the inactive ingredients. What are they? Do they pose a risk of an allergic reaction or other adverse complications?

The Verdict – Which Brand Should You Pick?

To pick the best Hyaluronic Acid (HA) Injections for your specific case, we’ll use all the empirical and anecdotal data presented in this article.

And we’ll employ a pragmatic / inductive research methodology to reach a logical answer that you can discuss with your healthcare provider.

Let’s start with the most important variables you should consider:

• Standalone or mixed: Whether the injection brand contains only Hyaluronic Acid, or it’s mixed with another API (active pharmaceutical ingredient) such as Corticosteroids.
• Cross-linked status: Cross-linking is a chemical process that binds the HA molecules together. This creates a more stable and durable structure. In very simple terms, think of it as grabbing a lot of sticks and creating a lattice. But on a molecular level, it’s a network of intertwined HA molecules. This makes them more resistant to breakdown. So cross-linked HA products last longer and theoretically should provide longer relief. But interestingly, only the soluble portion of these cross-linked products has been shown to interact with the CD44 receptor. We have a video explanation of this above, (click here) in case you missed it. For this reason, cross-linked HA injections are dissimilar to the linear chain structure of normal, healthy endogenous HA (25).
• Molecular weight: Molecular weight refers to the size of the HA molecules. Higher molecular weight HA (>3,000 kDa) generally remains in the joint longer than lower molecular weight products (<1,000 kDa). The molecular weight is related to the cross-linking. Typically, cross-linked HA has a higher molecular weight and vice versa. Think of it as larger molecules being more difficult to break down, hence remaining in the joint for longer. However, some low-to-moderate weight HA products, which aren’t cross-linked (100 – 2,000 kDa) can still provide significant relief. That’s because they more closely mimic the natural HA found in healthy synovial fluid. Healthy joint synovial fluid HA has a linear chain structure (meaning it’s not cross-linked). And a molecular weight of 500 – 6,000 kDa. In some cases even under 500 kDA (26).
• Biological Origin: From where has the HA been derived. The main origins are Avian (usually derived from chicken combs), Bacterial fermentation (usually derived from Streptococcus zooepidemicus), and a newer promising but yet to be fully tested version – called Bioengineered HA. The Bacterial fermentation origin is currently the gold standard, as this method produces highly pure HA that is structurally identical to human HA. And it has longitudinal safety data. Whereas, Avian-based HA injection products have a small probability of causing allergic reactions due to immunogenicity and inflammation. Specifically for those patients with poultry allergies. Plus, some religious or ethical considerations may make this source less acceptable to certain people (27), (28), (29).

Based on these 4 main points, we recommend starting with a standalone Hyaluronic Acid injection.

Meaning, the only active ingredient in the injection is Hyaluronic Acid. There are no additional ones, such as corticosteroids.

If you’ve never had HA injections before, it’s best to try them in isolation.

In order to assess whether they’re efficacious for you, or not, you want the least amount of confounding variables.

If you start with something like Cingal, which has a potent corticosteroid, and you get significant relief, you won’t know what exactly caused the relief.

Was it the hyaluronic acid or the corticosteroid, or both?

So discuss this with your healthcare practitioner. Tell them you are considering starting with a non-avian, bacterial-fermentation-derived, low-to-moderate molecular weight Hyaluronic Acid injection first. This is the most bio-compatible form of HA and will have the best probability of working correctly without causing adverse side effects.

Yes, you might need to get a repeat injection a bit sooner because the lower molecular weight HA injections don’t last as long.

But almost all patients for whom HA injections work well, need repeat injections at some point.

Therefore regardless of the molecular weight, eventually you’ll still need repeat injections. So you might as well start with the least side-effect-causing ones. And, if you want a more long-lasting HA injection, you can try the higher-molecular-weight ones.

Of course, no matter the injection type, you should always strive to find a reputable clinic and an experienced injection specialist who uses ultrasound to guide the injection.