Hyaluronic Acid Injections vs Cortisone Injections

The Fundamental Difference

When your knee hurts from osteoarthritis, you have options beyond surgery and daily pills. The two most common injection treatments—hyaluronic acid (HA) and cortisone—work in completely different ways.

Hyaluronic acid restores the joint’s natural lubrication and cushioning. Think of it as adding high-quality oil to a squeaky hinge.

Cortisone (corticosteroid) reduces inflammation and swelling. It’s like putting out a fire—effective but doesn’t fix what caused the fire.

Understanding these differences helps you make an informed choice about which treatment fits your situation.

Side-by-Side Comparison

When to Choose Hyaluronic Acid

HA injections may be your better choice if:

• You want longer-lasting relief (months, not weeks)
• You’re managing chronic OA rather than acute flare-ups
• You’ve had multiple cortisone injections and they’re working less well
• You’re concerned about cartilage health over the long term
• You want to delay or avoid knee replacement
• You can wait 4-6 weeks for full benefit

HA Injection Advantages

1. Duration: One treatment series can provide relief for 6-12 months
2. Safety: Can be repeated every 6 months without the concerns associated with repeated steroid use
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

HA Injection Limitations

1. Slower onset: Takes 4-6 weeks to feel full benefit
2. Not for acute flares: Not ideal when you need immediate relief
3. Multiple visits: Some HA products require 3-5 weekly injections
4. May not work for everyone: Less effective in severe (Stage 4) OA

When to Choose Cortisone

Cortisone injections may be your better choice if:

• You need fast relief for an acute flare-up
• You have significant swelling that needs immediate reduction
• You’re preparing for an event (wedding, vacation, surgery)
• You haven’t tried cortisone before and want to see how you respond
• Cost is a primary concern (cortisone is less expensive)

Cortisone Advantages

1. Speed: Pain relief often within 24-72 hours
2. Powerful anti-inflammatory: Effectively reduces swelling
3. Single injection: One visit, one shot
4. Lower cost: Generally less expensive than HA
5. Strong evidence: Well-studied for short-term relief

Cortisone Limitations

1. Short duration: Relief typically lasts only 6-12 weeks
2. Frequency limits: Most guidelines recommend no more than 3-4 per joint per year
3. Cartilage concerns: Research suggests repeated use may accelerate cartilage loss
4. Diminishing returns: Often becomes less effective over time
5. Blood sugar impact: Can raise blood sugar in diabetics

The Cartilage Question

This is where the comparison gets serious.

What Research Shows

Multiple studies have raised concerns about repeated cortisone injections:

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

HA and Cartilage

In contrast, HA injections:

• Show no evidence of cartilage damage in studies
• May provide protective effects through improved lubrication
• Can be repeated every 6 months without the concerns associated with steroids

Important note: This doesn’t mean cortisone is “bad”—it means understanding the tradeoffs is essential for long-term joint health management.

Coverage and Cost Comparison

Medicare Coverage

Both treatments are covered by Medicare Part B, but with different requirements:

Private Insurance

Most commercial plans cover both treatments, though:

• HA may require step therapy (trying cortisone first)
• Prior authorization is more common for HA
• Copays vary by plan

Out-of-Pocket Costs

Without insurance:

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

Making Your Decision

Questions to Ask Yourself

1. How quickly do I need relief?

   • Immediate → Cortisone
   • Can wait 4-6 weeks → HA may be better long-term option

2. How many cortisone injections have I had?

   • Few or none → Either option reasonable
   • Multiple → Consider switching to HA

3. What’s my OA stage?

   • Mild to moderate → Both options viable
   • Severe/bone-on-bone → Neither may work well; surgical consultation may be needed

4. What’s my long-term plan?

   • Managing for years → HA offers safer repeated use
   • Bridge to surgery → Either option reasonable

A Common Approach

Many providers recommend this progression:

1. First: Try cortisone to see if injections help at all
2. If effective: Consider switching to HA for longer-lasting, repeatable relief
3. Ongoing: Use HA as primary treatment with cortisone reserved for occasional flare-ups

Can You Use Both?

Yes, some patients use both strategically:

• HA injections every 6 months for baseline management
• Occasional cortisone for acute flare-ups between HA treatments

However, timing matters—consult your provider about appropriate intervals between different injection types.

The Imaging Factor

Regardless of which injection you choose, accurate placement matters:

• Blind injections 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 injections?”

Red Flags to Watch For

Be cautious of providers who:

• Recommend cortisone more than 3-4 times per year
• Don’t discuss the potential long-term effects of repeated steroids
• Don’t offer HA as an alternative
• Don’t use imaging guidance
• Push expensive “regenerative” treatments without discussing proven options first

Summary: Which Should You Choose?

The Bottom Line

Both hyaluronic acid and cortisone injections can provide meaningful relief from knee osteoarthritis pain. The “right” choice depends on your specific situation, timeline, and long-term goals.

For most patients managing chronic knee OA, hyaluronic acid injections offer a compelling combination of longer-lasting relief, safety for repeated use, and neutral-to-protective effects on cartilage.

Cortisone remains valuable for acute situations requiring fast relief, but the growing evidence about cartilage concerns suggests it may not be ideal as a first-line, repeated treatment.

Related Resources

• Hyaluronic Acid Injections: Complete Guide
• Knee Osteoarthritis: Causes, Symptoms, and Treatment
• Medicare Coverage for Knee Injections
• BCBS Illinois Coverage Update — Important for BCBS members
• How to Choose a Joint Pain Clinic