Corticosteroid versus Hyaluronic acid injections – which is best for me?


If you have a painful joint or tendon that has not responded to conservative treatment like exercise, rest and anti inflammatory medication then you might be looking for other treatment options to help reduce pain. Injectable steroids and Hyaluronic acid have become popular in the treatment of painful joints, particularly those afflicted with arthritis. 

These treatments are also utilised in the management of tendon problems and bursitis. To decide what treatment is right for you, we first must understand what your injury is and what we are trying to achieve. 

Frozen Shoulder

Cortisone, Corticosteroid or Steroid injections

Corticosteroid injections also known as (cortisone or a steroid injection) is a powerful anti inflammatory medication we use to treat pain and inflammation caused by conditions like arthritis, a chronic joint sprain or tendinitis (more correctly termed tenosynovitis). Intra-articular (inside the joint) corticosteroid injections are frequently performed to treat the symptoms of arthritis in knees.

It is a synthetic version of what the body already produces to control the process of inflammation. As a result it can have a very powerful effect on a painful inflamed joint like in the treatment of a Frozen shoulder. The effect can’t last forever though, so at some point the body will process the medication and excrete it. Depending on what steroid is used dictates how long it might stay in the body tissues.

Bannuru et al. (2019) published recommendations  for the Osteoarthritis research society international (OASRI) based on systemic reviews of the literature stating that corticosteroid injections can provide significant short-term (4-6 weeks) decreases in pain in those suffering with knee arthritis.

With this is mind, you should treat a steroid injection as a short term treatment to either provide a pain free window in which to perform your rehabilitation in or to break the inflammatory cycle so you can function again and correct the cause of the injury. 

There are a couple of conditions however that a steroid injection can fix with 1 injection. A trigger finger or De Quervains tenosynovitis will usually resolve with a steroid injection but most other instances a steroid injection is an adjunct to regular treatment. 

What are the down sides of a steroid injection? 


There are a few side effects to be aware of whenever you take medication. The most common side effects from having a steroid are: 

  • Temporary elevation in blood sugar levels in diabetics. This is managed easily though by someone who has well controlled diabetes. 
  • A “steroid flare”- this is where you will experience more pain after having a steroid injection due to the body reacting to the medication. This can be concerning as you are having the procedure to reduce pain! This is temporary but could last from between 24hours up to a week. Most cases are managed with ice and over the counter painkillers and settle after a couple of days. 
  • Joint damage. There is evidence to suggest that despite the relative safety of corticosteroid injections regarding systemic side effects, repeated steroid injections into the same joint can deteriorate the joint surfaces leading to earlier arthritic changes (Kompel et al in 2019 , Wernecke et al. 2015, Nakazawa et al 2002). As a result the recommended number of steroid injections into a specific joint is no more than 3 per year. 
  • Tendon rupture. Steroids injected around tendons can temporarily cause weakening to the tendon structure. So it is important not to load a tendon too soon after an injection as it may cause the tendon to fail and rupture. When someone feels less pain, they are likely to get back to activity quite quickly and this may pose a risk of loading too early. As a result, we advise a period of at least 2 weeks rest after an injection around a tendon to prevent this complication.


Stages of Knee OA

Hyaluronic acid injections


Hyaluronic acid is a substance already present in our bodies. It is used in joints to help with joint lubrication. It is often referred to as a “viscosupplement” or artificial joint fluid. As a joint becomes arthritic, the quality of the joint fluid diminishes.

Osteoarthritis of joints causes degeneration of the joint surfaces, but there are also changes in the surrounding muscle, joint capsule and joint fluid (Obrien et al. 2019).  It is the changes in the joint fluid that is the primary focus of treatment using Hyaluronic acid. 

Hyaluronic acid is the main viscoelastic constituent of the joint fluid with lubricating and cushioning properties (Raeissadat et al. 2020). Putting Hyaluronic acid back into the joint can help reduce pain through filtering inflammatory molecules and helping lubricate the joint.

Hyaluronic acid is also used to lubricate sites of friction like around a tendon. A tendon suffering from friction may present as “tenosynovitis” which is a painful swelling around a tendon. You can experience a crunching sensation as the tendon slides through the inflamed tendon sheath. This can be common around the achilles tendon and will often benefit from an injection of Hyaluronic acid to help the tendon glide freely again.

The benefits of a Hyaluronic acid injection is that it is not a drug. Therefore there are no interactions with other medications, and no reported long term detrimental effects to the joints. Pain relief can also last between 6- 9 months following an injection. This makes it a very suitable treatment for mild to moderate arthritis (Görmeli et al 2015). There is also no limit to the number of Hyaluronic acid injections you can have, so it is a good choice for chronic conditions like arthritis.

Bellamy et al (2006) found that Hyaluronic acid injections appear to be an effective treatment for arthritis of the knee with beneficial effects on pain and function. They suggest that intra-articular injections of Hyaluronic acid may be more durable than a steroid injection, albeit with a slower response.

Durolan Hyaluronic Acid injection

What are the down sides of a Hyaluronic acid injection?


It is not a powerful anti inflammatory drug. Therefore if you are in a lot of pain, a Hyaluronic acid injection might not be right for you. However, you can have it as an adjunct to a steroid injection either at the same time or after the pain settles with a steroid injection. So if you have a lot of pain and inflammation, a steroid injection is more likely to give you better relief. In severe arthritis, Hyaluronic acid may not help as there is too much joint deterioration.

Another possible side effect is post injection flare. Like a steroid injection, some patients may experience a flare of pain after the injection. This is because we are injecting more fluid into a confined space and the substance and pressure can aggravate things temporarily. This is managed with painkillers and if required anti inflammatory medications. Most flares only last a day or 2 but some joints may feel uncomfortable for a week or so until the benefits are noticed. 

An injection of Hyaluronic acid can take up to 3 weeks to take effect. Those that do experience relief will notice a peak benefit around 5-13 weeks post injection Bellamy et al (2006).

The benefits of Hyaluronic acid injections are unpredictable. A lot of patients will experience relief but not everyone will respond the same meaning that some people may only experience little or no relief. 

In Summary


Both steroid and Hyaluronic acid injections can give you relief for varying amounts of time. Mild to moderate arthritis may be a good candidate for Hyaluronic acid injections and more painful conditions may be better suited to a steroid injection. The key is understanding what the diagnosis is. Our clinical specialists will assess the condition with diagnostic ultrasound to understand what the pathology is. Once we know what structure is likely to be causing the pain, we can advise on the treatment options for you.

If you would like more information or would like to book an appointment, please contact us on 0207 636 5774 or email


Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997.

Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD005321. doi: 10.1002/14651858.CD005321.pub2. PMID: 16625635.

Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006;(2):CD005328. Epub 2006/04/21. CD005328.pub2. PubMed PMID: 16625636.

Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017 Mar;25(3):958-965. doi: 10.1007/s00167-015-3705-6. Epub 2015 Aug 2. PMID: 26233594.

Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology. 2019 Dec;293(3):656-663. doi: 10.1148/radiol.2019190341. Epub 2019 Oct 15. PMID: 31617798.

O’Brien, D. W., Chapple, C. M., Baldwin, J. N., & Larmer, P. J. (2019). Time to bust common osteoarthritis myths. New Zealand Journal of Physiotherapy, 47(1), 18-24.

Nakazawa F, Matsuno H, Yudoh K, et al. Corticosteroid treatment induces chondrocyte apoptosis in an experimental arthritis model and in chondrocyte cultures. Clinical and Experimental Rheumatology. 2002 Nov-Dec;20(6):773-781.

Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015 Apr 27;3(5):2325967115581163. doi: 10.1177/2325967115581163. PMID: 26674652; PMCID: PMC4622344.


About us

Oxford Circus Physiotherapy is home to a team of expert Physiotherapists who aim to make people better faster. Based in the heart of London’s West End, offering Diagnostic Ultrasound, Steroid injections, Post Op Rehab and Womens Health Services.

Expert Clinicians

The clinician that assess you is also the clinician who provides the treatment. Our clinicians have Post Graduate Diplomas in MSK Ultrasound and further qualifications in injections including steroids, cortisone, PRP and Hyaluronic acid. 

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