Introduction
Knee care · Knee arthritis
Steroid vs hyaluronic acid knee injections: how they compare
Dr Sean LeoOrthopaedic Surgeon, Singapore
Clinic enquiries · Not an emergency service
Illustrative image
At a glance
At a glance
At a glance: how steroid and gel knee injections compare
A steroid (corticosteroid) injection and a hyaluronic acid (gel) injection both ease knee osteoarthritis symptoms. A steroid injection calms inflammation and typically relieves pain for weeks. A gel injection supplements the joint’s lubrication and may last longer in some people. Guidelines disagree about gel injections, so the choice is individual.
What’s covered on this webpage
Follow the route in order, or jump to the stop you need. Stops you have read are marked.
What is each injection, in plain words
What is each injection, in plain words
What is each injection, in plain words?
Both go into the joint. They do different jobs.
An injection into the joint itself is called an intra-articular injection. A steroid (corticosteroid) injection places an anti-inflammatory medicine in the joint. It calms the inflammation that is part of osteoarthritis (OA) pain. A hyaluronic acid injection, often called a gel injection or viscosupplementation, places hyaluronic acid in the joint [1]. Hyaluronic acid is a substance found naturally in joint fluid, and the injection is meant to supplement the joint’s lubrication [9]. This comparison concerns knee OA.
Steroid and gel injections side by side
Steroid and gel injections side by side
Steroid and gel injections side by side
| Steroid (corticosteroid) injection | Hyaluronic acid (gel) injection | |
|---|---|---|
| What it is | An anti-inflammatory medicine placed in the joint | Hyaluronic acid, found naturally in joint fluid [9], placed in the joint [1] |
| How it is meant to help | Calms inflammation | Supplements lubrication [9] |
| How long relief lasts | Short-term, typically weeks [4] | OARSI describes symptom improvement beyond 12 weeks [1] |
| What the guidelines say | Broadly agree: short-term relief [1] [4] [5] | Disagree: ACR/AF conditionally against [2], AAOS not for routine use [5], NICE do not offer [4], OARSI conditionally for [1] |
| Key caution | Cartilage question for repeated injections is unresolved [2] [6] | ACR/AF conditionally recommends against [2]. In its analysis of trials at low risk of bias, the effect compared with saline approached zero [2] |
How quickly does each work, and how long does relief last
How quickly does each work, and how long does relief last
How quickly does each work, and how long does relief last?
Steroid relief is short-term. For gel injections the picture is less certain.
A steroid injection gives short-term relief, typically lasting weeks [2] [3]. The OARSI guideline supports it for acute pain relief over 1 to 2 weeks and short-term relief over 4 to 6 weeks [1]. NICE says it provides short-term relief of 2 to 10 weeks [4].
A Cochrane review of steroid injections for knee OA found a moderate improvement in pain compared with control. The evidence was low quality. It found no evidence that an effect remains six months after the injection [3].
For gel injections, OARSI conditionally recommends them for longer-term treatment effect and describes symptom improvement beyond 12 weeks [1]. Other guidelines are less convinced (see the next section).
These are group-level ranges. How long either injection lasts for you is individual.
What do the guidelines say?
What do the guidelines say?
What do the guidelines say?
The guidelines broadly agree about steroid injections. They disagree about gel injections.
Four guidelines address both injections: the American College of Rheumatology and Arthritis Foundation (ACR/AF, 2019) [2], the American Academy of Orthopaedic Surgeons (AAOS, 2021) [5], the Osteoarthritis Research Society International (OARSI, 2019) [1] and the UK’s National Institute for Health and Care Excellence (NICE, 2022) [4]. Each grades its advice in its own way. “Strongly recommended” in one and “moderate strength” in another can both be true within their own frameworks. The disagreement about gel injections is real, and it is useful information.
| Guideline | Steroid injection | Gel injection |
|---|---|---|
| ACR/AF 2019 [2] | Strongly recommended | Conditionally recommended against. Steroid conditionally recommended over gel |
| AAOS 2021 [5] | Could provide short-term relief (moderate strength, downgraded) | Not recommended for routine use (moderate strength, downgraded) |
| OARSI 2019 [1] | Conditionally recommended for acute and short-term pain relief | Conditionally recommended for longer-term effect |
| NICE 2022 [4] | Consider when other medicines are ineffective or unsuitable, or to support exercise. Short-term relief only | Do not offer |
When the ACR/AF limited its analysis to trials at low risk of bias, the effect size of hyaluronic acid compared with saline approached zero [2]. That is the ACR/AF panel’s own analysis.
Safety, steroid injections: A trial gave triamcinolone 40 mg every 12 weeks for two years. It found more cartilage volume loss than with saline and no significant difference in pain [6]. The ACR/AF panel was uncertain of the clinical significance of this finding [2]. That schedule is not the typical clinical pattern. Questions about how often to inject belong with your treating clinician.
Two short-lived effects are worth knowing about. Occasionally a steroid injection causes a brief flare of pain in the joint within the first 24 hours, which usually settles by itself within a couple of days [7]. If you have diabetes, the injection can raise your blood sugar for a few days, so check it more often during that time [8].
Joint infection after an injection is not common [7]. However, if the joint becomes more painful and hot, especially if you feel unwell, get medical help straight away (see ‘When is urgent help needed?‘ below) [7].
Safety, gel injections: The ACR/AF conditionally recommends against hyaluronic acid injections [2]. In its analysis of trials at low risk of bias, the effect compared with saline approached zero [2].
What do injections not do?
What do injections not do?
What do injections not do?
They ease symptoms. They do not replace the core treatments.
Both injections are symptom tools, not joint repair. A steroid injection eases symptoms. In the one trial in this review that looked at it, repeated steroid injections were not shown to slow the narrowing of the joint seen on X-ray, compared with a comparison group [3]. The guidelines assess a gel injection for symptom relief [1]. Injections sit alongside the core treatments of education, exercise and weight management, not instead of them [1]. For other ways to ease arthritis pain, see how to manage arthritis pain.
How is the choice made?
How is the choice made?
How is the choice made?
The choice is made with you, at an assessment. It is not made from a table.
An injection decision is made with your own knee, history and goals in view. These questions can help.
- What symptom is the injection meant to ease, and for roughly how long?
- Have the core treatments been tried: education, exercise and, where it applies, weight management?
- What do the guidelines say about this injection, and where do they disagree?
- What are the risks and uncertainties for my knee?
The knee injections article explains each injection on its own.
When is urgent help needed?
When is urgent help needed?
When is urgent help needed?
The list below applies to any knee problem. A knee that becomes suddenly very painful, hot, red and swollen, especially with a fever, is on it whether or not you have had an injection.
Signs that need urgent help
Some symptoms should not wait for a routine appointment. Each item below says where to go.
After an injury
- The kneecap has slipped out of place and is still out, or the knee looks deformed. Go to an emergency department. If the kneecap went back into place by itself, arrange an early assessment.
- The leg looks twisted or bent, a bone is showing, there is a deep cut, or the foot or leg turns cold, pale, numb, blue or white. Go to an emergency department or call 995.
- You cannot lift your leg up with the knee kept straight, and you may feel a gap just above or just below the kneecap. Arrange an urgent same-day assessment.
At any time
- The knee is stuck and will not straighten, or it is very painful and you cannot move it or put weight on it. Arrange an urgent same-day assessment.
- The knee is suddenly very painful, hot, red and swollen, especially with a fever or feeling generally unwell. Go to an emergency department or call 995.
- One calf or thigh is newly painful and swollen. Arrange an urgent same-day assessment. If you also feel short of breath or have chest pain, call 995.
After knee surgery
- The operated knee becomes more painful, swollen or red, a wound is leaking, or you develop a fever. Contact your surgical team straight away. If you cannot reach them the same day, go to an emergency department. If you feel very unwell, go to an emergency department. If you are short of breath or have chest pain, call 995.
If you are admitted by the doctor at the urgent care centre of one of these private hospitals, the Parkway Pantai hospitals (Mount Elizabeth Orchard, Mount Elizabeth Novena, Gleneagles and Parkway East), Farrer Park Hospital and Thomson Medical Centre, you may ask for Dr Sean Leo to be your attending orthopaedic surgeon. If you are instead discharged and referred for orthopaedic follow-up, you may contact the clinic to arrange an appointment. Both are subject to the hospital’s admission processes and to Dr Leo’s availability.
Questions people often ask
Common questions
Frequently asked questions
Which is better, a steroid or a gel injection?
Neither is better for everyone. The guidelines agree that steroid injections give short-term relief and disagree about gel injections. The choice is made at an assessment, with your knee and goals in view.
How long do steroid injections last in the knee?
Relief is typically short-term, lasting weeks [4]. NICE describes 2 to 10 weeks [4]. How long it lasts for you is individual.
Are hyaluronic acid injections worth it?
The guidelines disagree. The ACR/AF conditionally recommends against them [2], AAOS says not for routine use [5], NICE says do not offer them [4] and OARSI conditionally recommends them [1]. Whether one is worth considering for your knee is an individual decision.
Do knee injections repair cartilage?
Not as far as the evidence shows. Injections are used to ease symptoms. In the one trial in this review that looked at it, repeated steroid injections were not shown to slow the narrowing of the joint seen on X-ray, compared with a comparison group [3]. The guidelines assess a gel injection for symptom relief [1].
Can I have a steroid injection and a gel injection together?
Any injection plan, including more than one type, is decided with you at an assessment. It rests on your knee, your history and your response so far.
With you through the seasonsMeet Dr Sean Leo
Meet Dr Sean Leo
A consultant orthopaedic surgeon whose clinical focus is the knee, sports injuries and the lower limb.
- Dr Sean Leo is a consultant orthopaedic surgeon. OrthoKinetics is his professional brand; clinical services are provided through OrthoSports Orthopaedic & Sports Surgery at Mount Elizabeth Novena Specialist Centre and Connexion, Farrer Park Hospital.
- His clinical interests include sports injuries, including those in adolescent athletes; ligament reconstruction; realignment surgery; cartilage repair and joint-preservation approaches; knee replacement; and technology-assisted hip and knee surgery.
- The consistent aim is to return people to meaningful function and activity while avoiding unnecessary downtime.
- Qualifications: MBBS, MRCS (Ed), MMed (Ortho), FRCSEd (Ortho).
More detail: Meet Dr Sean Leo
- Training and career: Dr Leo trained in medicine at the National University of Singapore and served in the Singapore Armed Forces Medical Corps from 2000 to 2012, where his work included the care of soldiers in physically demanding roles. He completed postgraduate orthopaedic training in 2009 and a one-year clinical fellowship at Royal North Shore Hospital in Sydney, Australia, before joining Changi General Hospital as an orthopaedic consultant in 2012, where he later held the positions of Senior Consultant and Director of the Hip and Knee Service. With seniority, his educational contribution has evolved towards mentorship and support for junior doctors.
Sources
References
References
- Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-1589. PMID 31278997; doi:10.1016/j.joca.2019.06.011.
- Kolasinski SL, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res. 2020;72(2):149-162. PMID 31908149; PMC11488261; doi:10.1002/acr.24131.
- Jüni P, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;(10):CD005328. PMID 26490760; PMC8884338; doi:10.1002/14651858.CD005328.pub3.
- National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management (NG226). 2022. https://www.nice.org.uk/guidance/ng226
- American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline, 3rd edition. 2021. https://www.aaos.org/oak3cpg. JAAOS summary: PMID 35383651.
- McAlindon TE, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967-1975. PMID 28510679; PMC5815012; doi:10.1001/jama.2017.5283.
- Versus Arthritis. Steroid injections (patient information booklet VA2250). 2019. https://www.mcht.nhs.uk/download_file/1647/272
- Musculoskeletal Association of Chartered Physiotherapists. Aftercare following steroid injection (patient leaflet, V1 November 2025). https://macpweb.org/_userfiles/pages/files/resources/aftercare-advice-following-cortcosteroid-injection-scb-md-nl-copy-to-launch-151125.pdf
- Altman RD, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskelet Disord. 2015;16:321. PMID 26503103; doi:10.1186/s12891-015-0775-z.
What should I do next?
What should I do next?
What should I do next?
An assessment is a sensible next step for anyone weighing a knee injection.
- To read about each injection on its own, see knee injections for osteoarthritis.
- If symptoms are more advanced or do not improve with non-surgical care, the surgical options are described on the total knee replacement and partial knee replacement pages.
An assessment brings together your story, an examination and any tests that help, so that you and your clinician can decide together what to do next. An appointment supports an informed decision. It is not a commitment to an injection or to surgery. Our knee hub has related pages.
- OrthoKinetics does not provide emergency or urgent care through this webpage or its WhatsApp contact.
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