What is more effective for osteoarthritis treatment, Platelet-Rich Plasma (PRP) or Hyaluronic Acid (HA)?

PRP vs Hyaluronic Acid for Osteoarthritis: Which is Better?

Neither PRP nor hyaluronic acid should be routinely used for knee osteoarthritis, but if you must choose between them, PRP has slightly more favorable evidence despite both receiving negative recommendations from major guidelines. 1

Guideline Recommendations: Both Receive Negative Ratings

Hyaluronic Acid

• Moderately recommended AGAINST for routine use in knee OA by the American Academy of Orthopaedic Surgeons (AAOS) 2022 guidelines 1
• Conditionally recommended AGAINST for knee OA and strongly recommended AGAINST for hip OA by the American College of Rheumatology (ACR) 2019 guidelines 1
• When limited to low risk-of-bias trials, the effect size of HA compared to saline approaches zero 1
• Benefits appear restricted to studies with higher risk of bias 1

Platelet-Rich Plasma

• Strongly recommended AGAINST for knee and hip OA by ACR 2019 guidelines due to lack of standardization and heterogeneity in preparations 1, 2
• Limited recommendation (may reduce pain and improve function) by AAOS 2022 guidelines, acknowledging some evidence but with inconsistent results, particularly in severe OA 1, 2
• The AAOS position is notably less negative than their stance on HA 1

Key Differences in Evidence Quality

The critical distinction: While both receive negative recommendations, the AAOS gives PRP a "limited" recommendation (may be beneficial) versus a "moderate" recommendation AGAINST HA for routine use 1. This reflects:

• PRP has some high-quality evidence showing pain reduction and functional improvement, though inconsistent 1, 2
• HA's apparent benefits disappear when only analyzing low risk-of-bias studies 1
• PRP works better in mild-to-moderate OA but shows worse responses in severe disease 1, 2

Research Evidence Comparison

PRP Advantages Over HA:

• Significantly greater pain reduction at 1,3,6, and 12 months compared to HA alone 3
• Better WOMAC physical activity scores at 12 months 3
• Longer duration of symptomatic relief with significantly fewer required re-injections over 36 months 4
• Reduction in bone marrow edema on MRI at 12 months when combined with HA 5

HA Advantages:

• Earlier pain relief at 1 and 6 months in one recent trial, though differences didn't reach clinical significance 5
• More standardized preparations compared to PRP's heterogeneity 1, 2

Clinical Decision Algorithm

First-Line Treatments (Use These First):

• Physical therapy and structured exercise programs 1, 2, 6
• Weight management for overweight patients 1, 2, 6
• Oral NSAIDs or topical NSAIDs 1, 2, 6

Second-Line Treatment:

• Intra-articular corticosteroid injections with benefits lasting approximately 3 months 1, 2, 6

If Considering PRP or HA Despite Guidelines:

• For mild-to-moderate knee OA (Kellgren-Lawrence grade 2-3): PRP shows more consistent evidence of benefit 3, 4
• Avoid both in severe knee OA: PRP shows worse treatment response in advanced disease 1, 2
• Never use either for hip OA: Both strongly recommended against 1
• Consider combination therapy (PRP + HA): Shows better outcomes than HA alone up to 1 year and better than PRP alone up to 3 months 3, 7, 8

Critical Caveats

Major concerns with PRP: Significant variability in platelet concentration, leukocyte presence, activation methods, volume, and number of injections makes it difficult to identify what is actually being injected 1, 2, 6

Major concerns with HA: The ACR notes that providers may view HA more favorably than offering no intervention when other treatments fail, but the conditional recommendation against is consistent with shared decision-making only after exhausting alternatives 1

Medicare coverage: Neither PRP nor HA for knee OA receives Medicare coverage based on these guideline recommendations 6

Bottom Line for Clinical Practice

If forced to choose between the two: PRP has marginally better evidence for pain relief, functional improvement, and longer-lasting effects in mild-to-moderate knee OA 3, 4. However, both should be avoided in favor of corticosteroid injections as the preferred intra-articular option, which has considerably more evidence (19 high-quality studies) supporting its use 1.