In a world where exercise, physical activity, and movement are increasingly “prescribed” to patients with knee osteoarthritis (OA), the message is simple: stay active without relying on long-term medication. However, a recent consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) suggests that intra-articular injections represent a well-established clinical option for OA treatment.
Intra-articular hyaluronic acid (IAHA) offers a targeted, evidence-based intervention that aligns with a patient-centered, multimodal approach to joint health. While generally exhibiting a strong safety profile, modern IAHA formulations continue to evolve and now include hybrids and combinations with active ingredients such as mannitol or polynucleotides to enhance efficacy. Ultimately, this approach prioritizes patient preferences for minimally invasive, non-steroidal treatments that support a return to an active lifestyle.
Orthobiological Relevance: Restoration of the Inflammatory Joint Environment
Hyaluronic acid (HA) is a naturally occurring linear polysaccharide found in healthy synovial fluid. In osteoarthritic joints, as commonly seen in older adults, former athletes, and individuals with joint injuries, HA concentrations decline. IAHA aims to compensate for this loss and thus support the joint’s natural lubrication and shock absorption. There is strong evidence from clinical trials, meta-analyses, and reviews supporting the use of IAHA for the treatment of knee osteoarthritis. As with all arthritic and rheumatic conditions, however, timing is crucial. IAHA is most effective for chronic treatment and should not be used during acute, active inflammatory flare-ups.
Effects Beyond Lubrication: Innovative New Formulations
Modern IAHA treatments continue to evolve to meet the specific demands of an active lifestyle by combining HA with additional ingredients. Combinations with mannitol or sorbitol can improve the stability of the HA formulation. Formulations containing chondroitin sulfate, tranexamic acid, and polynucleotides show great potential for efficacy that goes beyond the basic effects of HA acting alone. But are these formulations safe? The majority of published evidence confirms that IAHA has an extremely favorable safety profile, making it a reliable option for those who wish to avoid the systemic side effects of painkillers and repeated corticosteroid injections.
Meeting the needs of patients and the demands of athletes
We must always focus on meeting patients’ expectations. Athletes and fitness enthusiasts often seek “drug-free” or minimally invasive solutions that allow them to maintain their performance. IAHA perfectly aligns with this patient-centered preference by offering a non-steroidal alternative that overcomes the potential long-term tissue damage sometimes associated with repeated corticosteroid use. Symptom relief with lower risk compared to surgical procedures is another key benefit. Furthermore, IAHA works best when integrated into a more comprehensive strategy that includes exercise, improved microcirculation, and muscle function.
IAHA as a Multimodal Solution
For the sports medicine practitioner, IAHA is a valuable tool in the toolbox. It bridges the gap between basic self-care, healing, and invasive surgery, enabling patients to actively participate in their own recovery. By prioritizing patients’ preferences for low-risk, highly effective treatment options, we can better manage musculoskeletal pain and promote sustainable, long-term joint health. When treating knee osteoarthritis in older adults or athletes, we must always consider the patient’s desire for non-surgical treatment as well as the potential of hybrid IAHA formulations to support a return to high-performance activities.
Conclusion
- Hyaluronic acid is a naturally occurring component of synovial fluid, and there are robust studies supporting its use in the treatment of osteoarthritis (outside the context of disease flare-ups).
- The majority of the literature demonstrates an extremely favorable safety profile for hyaluronic acid in terms of side effects.
- Intra-articular hyaluronic acid (IAHA) can be injected in combination with other active ingredients, including mannitol, sorbitol, chondroitin sulfate, tranexamic acid, polynucleotides, and hybrid IAHA formulations, which demonstrate potential efficacy beyond that of their individual components.
Reference
Fuggle N, Rannou F, Maheu E, Migliore A, Al-Daghri N, Alokail M, Ammann P, Berenbaum F, Botto-van Bemden A, Brandi ML, Burlet N, Chapurlat R, Cooper C, Dennison E, Harvey NC, Im GI, Kurth A, Matijevic R, Messina D, Faure JM, Radermecker RP, Schmidmaier R, Silverman S, Wegrzyn J, Zakraoui L, Rizzoli R, Reginster JY, Bruyère O, Mobasheri A. Expert consensus on hyaluronic acid injections for knee osteoarthritis: a patient-centered approach. Aging Clin Exp Res. 2026 Apr 1;38(1):110. doi: 10.1007/s40520-026-03366-8.
Autoren
is Professor of Musculoskeletal Biology in the Research Unit of Health Sciences and Technology, within the Faculty of Medicine at the University of Oulu in Finland. He is a Past President of the Osteoarthritis Research Society International (OARSI).
» Professor am Lehrstuhl für Proteinforschung, Institut für Biochemie, Naturwissenschaftliche Fakultät, König-Saud-Universität, Riad, Königreich Saudi-Arabien
» Präsident der European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)
(Stand 2026)
