Hyaluronic Acid Injections

Hyaluronic Acid (HA) Injections

A joint refers to any structure in the human body at which two different bones are fitted together. There is often space between the bones of the joint filled with fluid. Depending on the joint, there are other structures often inside the joint that provide specific function (such as the meniscus of the knee or the labrum of the shoulder). The joint can often be a source of pain and inflammation.

Hyaluronic acid (HA) is a substance that is naturally found in the human body. It is found within joints of the body, providing a natural lubrication for joint movement. In the knee joints, it may also function as a shock absorber, helping the bones to absorb some of the impact forces associated with walking. In the medical field, hyaluronic acid is often used by patients with knee osteoarthritis to improve pain and joint stiffness. The hyaluronic acid used for this purpose can be extracted from rooster combs or made by bacteria in a research laboratory.

Osteoarthritis is a joint disease that mostly affects the cartilage covering the ends of the bone in a joint. In osteoarthritis, joint cartilage breaks down and begins to wear away exposing the underneath bone. The joint fluid normally present in a healthy joint is also decreased or lost with osteoarthritis. As the cartilage breaks down, the underlying bones start making contact with other joint structures causing pain, swelling, and loss of motion. Over time, this may lead to the formation of bone spurs in the joint.

Osteoarthritis tends to occur in older people. As we age, the cartilage of the joints, especially the weight bearing joints such as the hips and knees, begin to break down. Younger people may get early onset osteoarthritis if they had an injury or trauma to their joint at an early age, or if they have joints that did not form properly at birth (genetics). Being overweight likely increases the risk of hip and knee arthritis, as the extra weight increases the forces applied across these joints.

A hyaluronic joint injection involves the injection of synthetic hyaluronic acid into a joint to help with pain relief associated with joint osteoarthritis. Hyaluronic acid can help to perform some function of the original joint fluid, including lubrication of the joint. As a result, this injection can provide pain relief for arthritis pain. .

Shoulder- Shoulder Arthritis - Rotator Cuff Tendonitis - Biceps Tendonitis - Shoulder Bursitis

Elbow- Elbow Arthritis - Lateral/Medial Epicondylitis (Tennis/Golfers Elbow) - Elbow Ligament Injuries

Hand & Wrist- Hand/Wrist Arthritis - Carpal Tunnel Syndrome - Wrist Tendonitis

Hip/Pelvis- Hip Arthritis - Trochanteric Bursitis - Hamstring Tendonitis/Bursitis - Piriformis Syndrome - Pubic Symphysis Pain

Knee- Knee Arthritis - Knee Ligament Injuries - Knee Tendonitis - Knee Bursitis

Foot & Ankle- Foot/Ankle Arthritis - Ankle Tendonitis - Plantar Fasciitisursa

Hyaluronic acid injections can theoretically be used for arthritis anywhere in the body. However, at this time, the only FDA approved use for these injections is for knee joint arthritis. This substance can be injected into other arthritic joints, however, your insurance will not cover the cost of the medication for this purpose.

Your physician will talk with you about your symptoms and perform a thorough physical examination to determine the source of your knee pain. Imaging, such as x-rays or MRI, may help to confirm this diagnosis, if needed. During your appointment in the office, your doctor will go over the reasons he feels that knee OA is the source of your pain.
There are numerous treatments that may be helpful for the treatment of OA. Doctors often combine treatments to fit a patient's needs, lifestyle, and health. Osteoarthritis treatment is designed to improve joint function and to control pain. Non-medicine treatments for osteoarthritis often involve things such as exercise, weight control, physical therapy, and chiropractic care. Medicine treatments include anti-inflammatory medications, pain medications, steroid injections, hyaluronic acid injections, and PRP injections. The most aggressive treatment of OA consists of surgery.

There are a few recommended criteria needed to be considered a good candidate for a hyaluronic acid joint injections. Usually, patients should have failed to improve with appropriate conservative measures. Conservative measures depend on the patient and the condition being treated. This may consist of anti-inflammatory medications, physical therapy, chiropractic care, massage, etc. Prior to being considered a candidate for an injection, most patients will need some form of imaging study (x-ray, MRI) to correlate with history and exam findings. The first injection usually performed for knee OA is a steroid injection. If the steroid injection does not provide long lasting relief of the knee pain, it is reasonable to attempt a series of hyaluronic acid injections for the knee joints.

Hyaluronic acid injections are often tried by people who can't take or do not benefit from painkillers like Advil or Motrin (ibuprofen), Aleve (naproxen sodium), or Tylenol (acetaminophen). It is also used by those who cannot have or are not ready to have a total knee replacement.

The procedure does involve placing a needle through the skin, so you may feel some mild discomfort. Local anesthetic or a topical cold spray is used to lessen the pain associated with skin puncture. You can take pain medication prior to the injection if you wish. The injection is usually performed under ultrasound guidance to help reduce pain. The physician will be as gentle as possible to make the injection as pain free as possible. Injection of the viscous solution into the joint can cause a sensation of deep pressure inside the joint. This sensation of increased pressure inside the knee may last for minutes, hours or days. This pressure sensation does decrease with time.

This varies with each patient. Some start to notice the benefits immediately after the first injection. Others may require several weeks after the injections are completed until they notice any benefit.

These injections can provide great pain relief for the right patient. The injection does not change any anatomy or help to heal any damaged cartilage or bone spurs that may be present inside the joint. However, it does help to replace the lost lubricating joint fluid inside the joint, allowing the osteoarthritic joint to have as much normal function as possible. This injection does tend to help more with mild to moderate joint arthritis more than severe joint arthritis. The more severe the arthritis, the less likely this injection may provide long lasting pain relief. If there is another source of knee pain, such has meniscus injury or ligament injury, then these injections usually does not help as much with that pain. The majority of patients receiving these injections do not have 100% of their pain go away. The goal of the injection is to reduce pain so that you can become more functional with your daily functions and exercise program. Often, after pain is reduced, starting a therapeutic exercise program or physical therapy can help to prolong the response of the injection.

Everyone responds differently to the injection. Prior to your injection, your physician will assess your individual condition and the chances of success of the injection. A good response to the injection will be at least 5-6 months of good pain relief. It is possible that the injection will provide relief lasting much longer than 6 months. However, it is also possible that the injection will not provide much relief at all. The only way to truly know how effective the injection will be is to wait and see.

Many formulations are designed to be injected in a series of 3 injections, scheduled about one week apart. There are a few formulations that offer the entire volume of fluid to be injected at one visit.

These injections can only be repeated once every 6 months. If you had significant relief of pain with a HA series, then the injections can be repeated in the future. You can talk to your doctor about the effectiveness of the medication and the needed for more injections. If you did not have any pain relief, your doctor will re-evaluate your condition to determine the next step in the treatment plan.

If the injection does not help your pain, then the doctor will re-evaluate you at your follow up appointment. No pain relief from these injections could mean that your pain is coming from a different source in the knee. It may also mean that your knee OA is not responsive to the treatment. If you have a severe arthritis or other condition, the injection may not provide any significant long lasting benefit.

The goal of our clinic is to prevent surgical intervention, if possible. Your physician will help you decide if surgical intervention is appropriate.

Your doctor will explain all the risks and benefits of the procedure with you and you will have an opportunity to ask as many questions as you would like to ask. Once you agree to proceed with injection, you will sign a consent form authorizing the injection, stating that you understand the risks and benefits of the injection. There are no restrictions in terms of eating or taking medication prior to the procedure. You may take your pain medication prior to this procedureMost joint injections are performed in our office under ultrasound guidance.

Generally speaking, this procedure is very safe. However, as with any procedure, there are risks, side effects, and the possibility of complications. Some of these common risks are listed below.

Pain:The injection site may be sore after the injection, due to the needle passing through painful tissue. Usually, any increase in pain is temporary. In most cases, very little discomfort is felt by the patient.

Bruising at the site of injection

Infection:Rare. The skin is cleaned thoroughly prior to the injection to minimize this risk. Everything is done under sterile technique.

Bleeding:Usually any bleeding stops spontaneously. You physician will use ultrasound guidance to avoid any blood vessels in the vicinity of the injection. For most of these injections, you are not required to stop blood thinning medication.

Insurance does typically cover hyaluronic joint injections for the knee joint only. Other locations are not covered. If you are interested in trying these injections for another body part such as the hip, you would be responsible for paying the cash price for this medication.

Post-Injection Instructions

  • Your activity level after your injection should be at the following levels:
    • Day of Injection: We recommend no new activities. You should take it easy the day of the procedure. You can still perform regular everyday activities on this day.
    • Day 2: Up to 50% of your usual activity level.
    • Day 3: Activity is unrestricted as tolerated.
  • You may take pain medications immediately after your injection, if needed.
  • You may use ice compresses over the injection site – 20 minutes on, then 20 minutes off. Repeat this cycle as required. If using a gel pack, make sure a towel or piece of cloth is placed between the cold pack and the skin. Do not apply the cold packs to the numb areas following injection.
  • You may shower immediately, but please avoid swimming or baths/Jacuzzis/hot tubs for the first 2 days after the procedure, to reduce the risk of infection.
  • Should you have fever, chills, drainage, excessive swelling or redness at the injection site, bladder or bowel dysfunction, or change in sensation or muscle strength, please contact our office immediately.
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