Cortisone Injections vs Gel Injections (Hyaluronic Acid)

Understanding Your Knee Injection Options

When knee osteoarthritis pain limits your daily activities, injections offer relief without surgery. The two most common types are cortisone injections (corticosteroids) and gel injections (hyaluronic acid, also called viscosupplementation).

These treatments work in fundamentally different ways, and choosing the best knee injection depends on your specific situation, timeline, and long-term goals.

Cortisone is a powerful anti-inflammatory steroid that quickly reduces swelling and pain. Think of it as putting out a fire in your joint.

Gel injections (hyaluronic acid) restore your joint’s natural lubrication and cushioning. Think of it as replenishing high-quality oil to a squeaky, worn mechanism.

Let’s compare these knee injection types so you can make an informed decision.

Cortisone vs. Gel Injections: Head-to-Head Comparison

How Each Injection Works

Cortisone Injections: Fast-Acting Anti-Inflammatory

Cortisone is a synthetic corticosteroid that mimics cortisol, your body’s natural anti-inflammatory hormone. When injected directly into the knee:

Gel Injections: Joint Lubrication Restoration

Gel injections contain hyaluronic acid (HA), a naturally occurring substance in healthy joint fluid. When injected:

When Cortisone Makes Sense

Cortisone injections are often the right choice when you need fast, powerful relief. Consider cortisone if:

Cortisone Advantages

1. Rapid onset - Pain relief often within 24-72 hours
2. Powerful anti-inflammatory - Very effective at reducing swelling
3. Single injection - One visit, one shot per treatment
4. Lower upfront cost - Less expensive than gel injections
5. Strong short-term evidence - Well-studied for immediate relief
6. Good for diagnosis - Helps confirm that intra-articular injection works for you

Cortisone Limitations

When Gel Injections Are Better

Gel injections (hyaluronic acid) are often preferable for ongoing osteoarthritis management. Consider gel injections if:

Gel Injection Advantages

1. Longer duration - One treatment series can provide 6-12 months of relief
2. Safe for repeated use - Can be repeated every 6 months without steroid concerns
3. Joint protection - No evidence of cartilage damage; some studies suggest protective effects
4. Cumulative benefit - Some patients find relief improves with subsequent treatment series
5. Addresses root issue - Restores what’s depleted rather than just masking symptoms

Gel Injection Limitations

Can You Get Both?

Yes. Many patients benefit from using both injection types strategically:

Important timing note: Consult your provider about appropriate intervals between different injection types. Generally, you should wait 2-4 weeks between a cortisone injection and starting a gel injection series.

The Cartilage Question: Why It Matters

This is where the cortisone vs gel injection comparison gets serious for long-term joint health.

Research on Repeated Cortisone

Multiple studies have raised concerns about frequent cortisone use:

• A landmark 2019 study in JAMA found that patients receiving cortisone injections had greater cartilage volume loss over 2 years compared to those receiving saline placebo
• Research suggests the powerful anti-inflammatory effect may come at the cost of weakening cartilage structure
• Many orthopedic surgeons now limit cortisone to 3-4 lifetime injections per joint based on this evidence

Research on Gel Injections and Cartilage

In contrast, gel injections show a different profile:

• No evidence of cartilage damage in clinical studies
• Some research suggests protective effects through improved joint lubrication
• Can be repeated every 6 months without the concerns associated with steroids
• May help preserve cartilage by reducing friction and wear

Cost and Insurance Coverage

Both cortisone and gel injections are covered by Medicare and most private insurance plans.

Medicare Coverage Comparison

Private Insurance Considerations

Most commercial plans cover both treatments, but:

• Gel injections may require step therapy (trying other treatments first)
• Prior authorization is more common for gel injections
• Some insurers have specific brand preferences for gel products

Out-of-Pocket Costs (Without Insurance)

• Cortisone injection: $100-$300 per injection
• Gel injection series: $300-$1,500 per series

Making Your Decision: Quick Reference

Questions to Ask Yourself

1. How quickly do I need relief?

   • Need it now: Cortisone
   • Can wait a month: Gel injections may be better long-term

2. How many cortisone injections have I had?

   • Few or none: Either option reasonable
   • Several: Consider transitioning to gel injections

3. What’s my OA stage?

   • Mild to moderate: Both options work
   • Severe (bone-on-bone): Neither may work well; consider surgical consultation

4. What’s my long-term plan?

   • Managing for years: Gel injections offer safer repeated use
   • Bridge to surgery: Either option reasonable

The Importance of Accurate Injection Placement

Regardless of which injection type you choose, accurate placement matters:

• Blind injections (without imaging) miss the joint space up to 30% of the time
• Fluoroscopic (X-ray) guidance achieves 96-100% accuracy
• Accurate placement directly correlates with better outcomes

Always ask your provider: “Do you use imaging guidance for knee injections?”

Red Flags: When to Be Cautious

Be careful of providers who:

• Recommend cortisone more than 3-4 times per year per joint
• Don’t discuss potential long-term effects of repeated steroid use
• Don’t offer gel injections as an alternative to frequent cortisone
• Don’t use imaging guidance for injections
• Push expensive “regenerative” treatments without discussing proven options first

Frequently Asked Questions

Which injection is better for knee pain?

Neither is universally “better” - they serve different purposes. Cortisone is better for acute flare-ups requiring fast relief. Gel injections are generally better for ongoing osteoarthritis management because they last longer and can be safely repeated.

How long does a cortisone shot last compared to gel?

Cortisone typically provides relief for 6-12 weeks. Gel injections can provide relief for 6-12 months, though individual results vary.

Can I switch from cortisone to gel injections?

Yes, and many doctors recommend this transition. If you’ve been getting regular cortisone injections, gel injections offer a way to continue managing your knee pain with potentially safer long-term effects.

Why would my doctor limit cortisone injections?

Research shows that repeated cortisone injections may accelerate cartilage loss. Most guidelines recommend no more than 3-4 cortisone injections per joint per year to minimize this risk.

Are gel injections covered by Medicare?

Yes, gel injections (viscosupplementation) are covered by Medicare Part B when medically necessary. You’ll typically need documentation that you’ve tried other conservative treatments first.

How many gel injections do I need?

It depends on the specific product. Some gel injection brands (like Synvisc-One, Monovisc, Durolane, and Gel-One) require only a single injection. Others (like Hyalgan, Supartz, and Euflexxa) require 3-5 weekly injections.

Which has more side effects?

Both have relatively mild side effects. Common effects for both include temporary pain, swelling, or redness at the injection site. Cortisone can affect blood sugar in diabetics. Gel injections rarely cause a “pseudoseptic” inflammatory reaction.

Can I get both types in the same knee?

Yes, but not at the same time. Many patients use gel injections as their primary ongoing treatment and reserve cortisone for occasional acute flares. Discuss timing with your provider.

The Bottom Line

Both cortisone and gel injections can provide meaningful relief from knee osteoarthritis pain. The “best knee injection” depends entirely on your specific situation:

Choose cortisone when you need fast relief for an acute flare-up or want to test whether injections will help your knee.

Choose gel injections when you’re looking for longer-lasting relief and a treatment that can be safely repeated for ongoing OA management.

For most patients managing chronic knee OA long-term, gel injections offer a compelling combination of extended relief, safety for repeated use, and neutral-to-protective effects on cartilage.

Cortisone remains valuable for acute situations but may not be ideal as a first-line treatment for repeated, long-term use given the growing evidence about cartilage concerns.

Related Resources

• Hyaluronic Acid Injections: Complete Guide
• Cortisone Injections: What to Expect
• Knee Osteoarthritis: Causes, Symptoms, and Treatment
• Medicare Coverage for Knee Injections
• PRP vs. HA Injections
• How to Choose a Joint Pain Clinic