Hyaluronic Acid Injections for Shoulder Osteoarthritis: What the Evidence Shows

Key Takeaways

Emerging evidence supports HA injections for shoulder (glenohumeral) osteoarthritis
Systematic reviews show significant pain reduction and functional improvement
Safety profile is excellent with few adverse events reported
Duration of effect may exceed corticosteroids at 6+ month follow-up
Best candidates are patients with mild-to-moderate shoulder OA who haven’t responded to conservative care

Introduction

While hyaluronic acid (HA) injections are well-established for knee osteoarthritis, their role in shoulder osteoarthritis has been less clear—until recently. A growing body of research now demonstrates that viscosupplementation can provide meaningful relief for patients with glenohumeral joint osteoarthritis.

This article reviews the current clinical evidence for HA injections in shoulder OA, examining efficacy, safety, and how this treatment compares to alternatives.

Understanding Shoulder Osteoarthritis

The glenohumeral joint—the ball-and-socket connection between the upper arm (humerus) and shoulder blade (scapula)—can develop osteoarthritis from:

Age-related cartilage wear
Previous injuries or dislocations
Rotator cuff tears (accelerate degeneration)
Repetitive overhead activities
Inflammatory conditions

Why shoulder OA matters: Unlike hip or knee OA, shoulder arthritis directly impacts everyday activities like dressing, reaching, lifting, and even sleeping. Quality of life can deteriorate significantly as the condition progresses.

The Evidence Base for Shoulder HA Injections

Systematic Reviews and Meta-Analyses

2023 Systematic Review and Meta-Analysis

Journal of Orthopaedic Research

A comprehensive meta-analysis of randomized controlled trials for glenohumeral osteoarthritis found:^[1]

Outcome	Result
Pain (VAS)	Significant reduction vs baseline and placebo
Shoulder Function	Significant improvement on validated scales
Quality of Life (SF-36)	Improvements in physical function domains
Serious Adverse Events	None reported

Conclusion: “Intra-articular hyaluronic acid is effective and safe for patients with glenohumeral osteoarthritis.”

Dr. Millett Meta-Analysis

Shoulder Surgery Specialist Analysis

An analysis of available RCTs by a leading shoulder surgeon confirmed:^[2]

Statistically significant improvements in pain scores
Improved range of motion measurements
Enhanced shoulder-specific quality of life measures
Durable effects lasting several months

Individual Study Findings

Pain Reduction

Multiple studies demonstrate significant pain reduction following HA injections:

VAS pain scores decreased by 30-50% from baseline in most trials
Pain relief typically begins within 2-4 weeks of injection
Peak benefit observed at 8-12 weeks post-injection
Sustained improvement documented at 6-month follow-up in some studies^[3]

Functional Improvement

Validated Outcome Measures Showing Improvement:

Oxford Shoulder Score (OSS): Significant improvement vs baseline
Constant-Murley Score: Enhanced function and strength metrics
ASES Score: Better American Shoulder and Elbow Surgeons ratings
Range of Motion: Improved active elevation and rotation

Quality of Life Benefits

Beyond pain and function, studies show improvements in:

Sleep quality (reduced night pain)
Ability to perform daily activities
Return to recreational activities
Reduced need for oral pain medications

HA vs. Corticosteroid Injections for Shoulder OA

A critical question for patients and clinicians: How does HA compare to the more commonly used corticosteroid injections?

Comparative Evidence

Factor	Corticosteroid	Hyaluronic Acid
Onset of Relief	Rapid (days)	Gradual (2-4 weeks)
Duration	4-8 weeks typically	3-6+ months
6-Month Outcomes	Waning effect	Sustained improvement^[4]
Repeat Injections	Limited (cartilage/tendon risks)	Safer for serial use
Rotator Cuff Safety	May weaken tendons	No tendon damage

Key Findings from Comparative Studies

Important Consideration: Rotator Cuff Integrity

Many patients with shoulder OA also have rotator cuff disease. Corticosteroids may weaken tendon tissue, making them potentially problematic for patients with partial rotator cuff tears.

HA injections do not carry this risk, making them a potentially safer option for patients with concurrent rotator cuff pathology.

A study comparing corticosteroid to HA injections for shoulder OA found:^[4]

Both provided short-term pain relief
HA showed superior long-term outcomes at 6 months
HA demonstrated better functional improvement
Fewer adverse effects in the HA group

Safety Profile

What the Evidence Shows

The safety of HA injections for shoulder OA is well-documented:

No serious adverse events reported in systematic reviews

Mild local reactions (injection site pain, temporary swelling) are most common

No systemic side effects - HA is a natural component of synovial fluid

Suitable for patients who can’t tolerate NSAIDs or have contraindications to steroids

Reported Side Effects

Side Effect	Frequency	Management
Injection site pain	Common	Ice, resolves in 24-48h
Temporary swelling	Occasional	Ice, rest
Warmth/redness	Rare	Monitor, usually resolves
Allergic reaction	Very rare	Avoid avian-derived HA if egg allergy

Who is a Good Candidate?

Ideal Candidates for Shoulder HA Injections

Based on current evidence, the best candidates include patients with:

Mild to moderate glenohumeral OA (not bone-on-bone)
Failed conservative treatment (PT, NSAIDs, activity modification)
Contraindications to steroids or limited steroid injections remaining
Concurrent rotator cuff issues (HA doesn’t weaken tendons)
Desire to delay surgery and maintain function

Less Ideal Candidates

Severe end-stage OA (bone-on-bone)
Active infection
Allergy to HA or avian products (for avian-derived HA)
Unrealistic expectations (HA won’t restore cartilage)

Clinical Considerations

Injection Technique Matters

For shoulder injections, imaging guidance is particularly important because:

The glenohumeral joint space is smaller than the knee
Surrounding structures (rotator cuff, labrum, nerves) must be avoided
Accurate intra-articular placement improves outcomes

Ultrasound or fluoroscopic guidance ensures proper needle placement and optimal medication distribution.

HA Products Used for Shoulder

While specific FDA approval for shoulder use varies by product, commonly used HA preparations include:

Sodium hyaluronate preparations
Cross-linked hyaluronic acid
Single-injection and multi-injection protocols

What to Expect from Shoulder HA Injections

Timeline of Expected Response

Timeframe	What to Expect
Day 1-3	Possible mild soreness at injection site
Week 1-2	Gradual reduction in pain beginning
Week 4-8	Maximum benefit typically reached
Month 3-6	Sustained relief in responders
Month 6+	May need repeat injection if effective

Realistic Expectations

HA injections for shoulder OA may:

Reduce pain by 30-50% in many patients
Improve function and range of motion
Allow better participation in physical therapy
Delay the need for shoulder replacement surgery
Reduce reliance on oral pain medications

HA injections will not:

Cure osteoarthritis
Regenerate lost cartilage
Work for everyone (some patients are non-responders)

The Bottom Line

Summary of Evidence

Hyaluronic acid injections for shoulder osteoarthritis are supported by a growing evidence base:

Systematic reviews demonstrate significant pain reduction and functional improvement
Safety is excellent with no serious adverse events reported
Duration of effect may exceed corticosteroids, especially at 6+ months
Good option for patients who have failed conservative care or have steroid contraindications
May delay surgery while maintaining quality of life

While the evidence is still “emerging” compared to knee OA, the trajectory is positive, and HA represents a valuable treatment option for appropriate candidates.

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References

Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: systematic review and meta-analysis. Journal of Orthopaedic Research, 2023. Full Text
Dr. Millett et al. Hyaluronic acid outcomes in shoulder osteoarthritis: systematic review and meta-analysis. PDF
Intra-articular shoulder injection outcomes. Open Orthopaedics Journal. Full Text
Corticosteroid vs hyaluronic acid comparison for shoulder OA. ScienceDirect, 2017. Full Text
Viscosupplementation overview. NCBI StatPearls. NBK602915
Emerging evidence for shoulder HA. PMC, 2024. PMC11907566
Hyaluronic acid injection effectiveness. Regional Anesthesia & Pain Medicine, 2025. Full Text

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