Injections for Ankle Arthritis: A Guide for Patients

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Expert Patient Guide · Mr Matt Welck · Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore

Injections for Ankle Arthritis: A Guide for Patients

What the research actually shows — and what it means for you. A plain-language guide to steroid, hyaluronic acid, PRP, Botox and stem-cell injections, written by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore.

01

What Is Ankle Arthritis, and Why Are Injections Different Here?

If you have arthritis in your ankle, you may have been offered an injection into the joint, or seen one advertised. This guide explains in plain language what each type of injection is, what the research shows, and how to weigh up your choices.

Ankle arthritis is not the same as arthritis of the hip or knee. It is usually the long-term result of an injury — a broken ankle or repeated bad sprains — and it often affects younger, more active people. Almost all of the good research on joint injections has been done on knees, so we cannot assume those results apply to the ankle.

02

Why an Injection Can Help Even When the Medicine Does Not

This is the most important thing to understand before reading anything about injections. In the best studies, people are given either the real treatment or a harmless injection of salt water, and nobody knows which they received. Time and again, both groups improve by about the same amount, and the improvement can last for months.

The injection effect: The improvement is real — people genuinely feel better. But it appears to come from the injection itself rather than from the medicine inside it. That is why so many clinics can honestly say their patients improve, while the carefully controlled trials show no advantage over salt water.

03

Types of Injections for Ankle Arthritis

Steroid Injections

A steroid is a strong anti-inflammatory medicine, injected straight into the joint, usually with a local anaesthetic and often guided by an ultrasound or X-ray so it goes in the right place. It is cheap, widely available and has been used for decades.

There has never been a proper trial comparing a steroid injection with a dummy injection in the ankle, so we rely on experience and on records of how patients have done. Those records are encouraging: in one review of 166 patients, pain scores fell by more than half, about half said their pain went away completely and more than eight in ten were satisfied. A repeat injection usually helps again, though often a little less.

In short: the most dependable option for calming a painful flare-up or getting you through a few months — for example while you wait for surgery. The relief usually lasts weeks to a few months and it does not slow the arthritis down. There is some concern about weakening cartilage and nearby tendons if injections are repeated often.

Gel Injections (Hyaluronic Acid)

Hyaluronic acid is a thick, slippery substance found naturally in joint fluid. The idea is that topping it up cushions and lubricates a worn joint. It is the only injection that has been tested in several ankle trials, which makes it the best studied — but that is not the same as proven.

The key trial compared gel injections with salt water in 64 people: both groups improved by the same amount. A large review of all the ankle trials, and the most recent summary of the evidence, both found no real difference between gel and dummy injections. One analysis calculated that roughly nine tenths of the apparent benefit was the injection effect described above. Another trial found a course of gel injections worked about as well as a supervised exercise programme.

In short: safe, with only short-lived soreness at the injection site. A reasonable thing to try if simple painkillers have not worked and you want to put off surgery, ideally as a course of injections given under scan guidance — but you should know that no trial has shown it beats a dummy injection in the ankle. For that reason the NHS does not usually fund it.

Platelet-Rich Plasma (PRP)

A small amount of your own blood is taken and spun in a machine to concentrate the platelets — the part of blood rich in healing proteins. That concentrate is then injected into the joint. PRP is heavily marketed, often privately and at considerable cost.

The ankle is one of the few joints where this has been tested properly. In a high-quality trial of 100 people, published in a leading medical journal, two scan-guided PRP injections were compared with salt water. Both groups improved by the same amount over six months, and the researchers concluded the results do not support using PRP for ankle arthritis. Smaller studies that look positive did not include a dummy injection group, and their own authors point out that the improvement matches the injection effect.

In short: PRP is safe, but the best evidence we have in the ankle shows it works no better than salt water. If you are considering paying for it privately, you deserve to know that.

Botox Injections

Botox is best known for relaxing muscles, but injected into a joint it may work differently, by dampening down pain signals. Only one small ankle study exists, and it simply found Botox performed about the same as gel injections — and since gel injections have not been shown to beat a dummy, that tells us very little.

In short: experimental in the ankle. Knee and shoulder studies suggest it is safe and may ease pain for a while, and it might suit people whose pain behaves like nerve pain, but the right dose and technique are still unknown. Not a routine option.

Stem Cell and Other Cell Treatments

These treatments use cells taken from your own bone marrow or fat, sometimes grown in a laboratory, with the aim of repairing cartilage rather than just easing pain. They are the most expensive option and the most heavily promoted.

In the ankle, the studies that exist are small, look back at past patients rather than testing the treatment properly, and — importantly — the cells were always added to an operation that also realigned the ankle and stimulated the bone surface. Those patients did better than patients who had the surgery alone, and cartilage looked healthier when surgeons looked inside again. But we cannot tell how much of that came from the cells, and there is no evidence at all for a cell injection on its own.

In short: genuinely promising, and worth studying, but still experimental in the ankle. It is expensive, regulated inconsistently, and should not be sold to you as a proven cure for worn cartilage.

Combining Treatments

Mixing a steroid with a gel injection is a sensible idea — fast relief from the steroid, longer cushioning from the gel — and in knee studies that combination performed well early on. It has never been tested in the ankle.

The clearest ankle finding is that injections seem to work best alongside an operation that corrects the shape and alignment of the joint, rather than used on their own. Pairing an injection with exercise and physiotherapy is safe and reasonable, although exercise alone often does just as well.

In short: logical and low risk, but there is not enough ankle evidence to recommend any particular combination.

Other Injections You May Hear About

Ozone, sugar-water (prolotherapy) and various blood-derived products are all offered for joint pain. For the ankle joint itself, there are no good trials of any of them. The few ankle-area studies looked at different problems altogether, such as heel pain or an unstable ankle.

In short: mostly safe and some are cheap, but recommending them for ankle arthritis would be guesswork. Reasonable to study; not yet reasonable to rely on.

04

What This All Means for You

Two things come up again and again. First, injections into the ankle produce a large and lasting improvement whatever is in the syringe — which is why so many treatments look good until they are properly tested. Second, the ankle has been badly under-researched compared with the knee, so much of what is offered is borrowed from a different joint that behaves differently.

Putting it simply: a steroid injection gives the most reliable short-term relief and is a sensible first choice, especially before surgery. Gel injections are safe and the best studied, but have not been shown to beat a dummy injection. PRP has been properly tested in the ankle and did not work better than salt water. Botox and stem cell treatments are interesting but still experimental. Combinations are reasonable but untested. Other injections have no ankle evidence at all.

The treatments with the strongest foundation remain the least glamorous: simple painkillers, losing weight if that applies to you, supportive footwear or a brace, and physiotherapy. Injections are best thought of as a helpful extra rather than a cure. When these are no longer enough, surgery — to realign, stiffen or replace the joint — is what genuinely changes the picture.

05

Questions Worth Asking Before You Agree to an Injection

  • What is the realistic best case, and how long is it likely to last?
  • Has this injection been compared with a dummy injection in ankles specifically, and what did that show?
  • What does it cost, and what happens if it does not work?
  • Would physiotherapy, a brace or a conversation about surgery serve me better at this stage?

06

References

These are the medical studies this article is based on, listed in case you or your GP would like to read them. They are written for doctors, so the language is technical.

  1. Vincent CN, Cowie J, Mooteeram J, Sugathan H. Efficacy of Cortisone Injection in Foot and Ankle Osteoarthritis. Cureus. 2024;16(11):e74814. doi.org/10.7759/cureus.74814
  2. Anil U, Markus DH, Hurley ET, et al. The efficacy of intra-articular injections in the treatment of knee osteoarthritis: a network meta-analysis of randomized controlled trials. Knee. 2021;32:173–182. doi.org/10.1016/j.knee.2021.08.008
  3. Witteveen AGH, Hofstad CJ, Kerkhoffs GMMJ. Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle. Cochrane Database Syst Rev. 2015;(10):CD010643. doi.org/10.1002/14651858.CD010643.pub2
  4. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician. 2003;68(7):1356–1362. pubmed.ncbi.nlm.nih.gov/14567490
  5. DeGroot H, Uzunishvili S, Weir R, Al-omari A, Gomes B. Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 2012;94(1):2–8. doi.org/10.2106/JBJS.J.01763
  6. Tham A, Mercer NP, Butler JJ, et al. Limited Evidence to Support the Use of Intra-Articular Hyaluronic Acid for the Treatment of Ankle Osteoarthritis: A Systematic Review and Meta-Analysis of RCTs. Foot Ankle Spec. 2026 (Epub 2026 Jan). doi.org/10.1177/19386400251403922
  7. Chang KV, Hsiao MY, Chen WS, Wang TG, Chien KL. Effectiveness of intra-articular hyaluronic acid for ankle osteoarthritis treatment: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013;94(5):951–960. doi.org/10.1016/j.apmr.2012.10.030
  8. Karatosun V, Unver B, Ozden A, Ozay Z, Gunal I. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. Clin Exp Rheumatol. 2008;26(2):288–294. pubmed.ncbi.nlm.nih.gov/18565251
  9. Witteveen AGH, Kok A, Sierevelt IN, Kerkhoffs GMMJ, van Dijk CN. The optimal injection technique for the osteoarthritic ankle: a randomized, cross-over trial. Foot Ankle Surg. 2013;19(4):283–288. doi.org/10.1016/j.fas.2013.07.003
  10. Khenioui H, Houvenagel E, Catanzariti JF, et al. Usefulness of intra-articular botulinum toxin injections. A systematic review. Joint Bone Spine. 2016;83(2):149–154. doi.org/10.1016/j.jbspin.2015.10.001
  11. Sconza C, Leonardi G, Carfì C, et al. Intra-Articular Injection of Botulinum Toxin for the Treatment of Knee Osteoarthritis: A Systematic Review of RCTs. Int J Mol Sci. 2023;24(2):1486. doi.org/10.3390/ijms24021486
  12. Kim YS, Lee M, Koh YG. Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis. J Exp Orthop. 2016;3(1):12. doi.org/10.1186/s40634-016-0048-2
  13. Kim YS, Koh YG. Injection of Mesenchymal Stem Cells as a Supplementary Strategy of Marrow Stimulation Improves Cartilage Regeneration After Lateral Sliding Calcaneal Osteotomy for Varus Ankle Osteoarthritis. Arthroscopy. 2016;32(5):878–889. doi.org/10.1016/j.arthro.2016.01.020
  14. Altomare D, Di Matteo B, Kon E. Conservative Treatment for Ankle Cartilage: Cellular and Acellular Therapies: A Systematic Review. Foot Ankle Clin. 2024;29(2):253–263. doi.org/10.1016/j.fcl.2023.07.003
  15. Paget LDA, Reurink G, de Vos RJ, et al. Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis (PRIMA): A Randomized Clinical Trial. JAMA. 2021;326(16):1595–1605. doi.org/10.1001/jama.2021.16602
  16. Laohajaroensombat S, Prusmetikul S, Rattanasiri S, Thakkinstian A, Woratanarat P. Platelet-rich plasma injection for the treatment of ankle osteoarthritis: a systematic review and meta-analysis. J Orthop Surg Res. 2023;18(1):373. doi.org/10.1186/s13018-023-03828-z
  17. Xiong Y, Gong C, Peng X, et al. Efficacy and safety of platelet-rich plasma injections for the treatment of osteoarthritis: a systematic review and meta-analysis of RCTs. Front Med. 2023;10:1204144. doi.org/10.3389/fmed.2023.1204144
  18. Henning PR, Grear BJ. Platelet-rich plasma in the foot and ankle. Curr Rev Musculoskelet Med. 2018;11(4):616–623. doi.org/10.1007/s12178-018-9522-z
  19. Monticone M, Frizziero A, Rovere G, et al. Hyaluronic acid intra-articular injection and exercise therapy: effects on pain and disability in lower limb joint osteoarthritis (SIMFER systematic review). Eur J Phys Rehabil Med. 2016;52(3):389–399. pubmed.ncbi.nlm.nih.gov/26365146
  20. Toy S, Tuncer K, Topal M, Aydın A. Corticosteroid, Platelet-Rich Plasma, and Ozone Injections for Sinus Tarsi Syndrome. J Am Podiatr Med Assoc. 2023;113(1). doi.org/10.7547/20-221
  21. Bahrami MH, Raeissadat SA, Barchinejad M, Elyaspour D, Rahimi-Dehgolan S. Local ozone (O2–O3) versus corticosteroid injection efficacy in plantar fasciitis treatment: a double-blinded RCT. J Pain Res. 2019;12:2251–2259. doi.org/10.2147/JPR.S202045
  22. Sit RWS, Wu RWK, Ling SKK, et al. A protocol for a randomized clinical trial assessing the efficacy of hypertonic dextrose injection (prolotherapy) in chronic ankle instability. Trials. 2022;23(1):1063. doi.org/10.1186/s13063-022-07037-7
  23. Daniels TR, Pinsker E. A firmer base for clinical judgment about hyaluronic acid injection (commentary on DeGroot et al.). J Bone Joint Surg Am. 2012;94(1):e4. doi.org/10.2106/JBJS.K.01335

07

Book a Consultation

If you have been offered an injection for ankle arthritis, or want an opinion on the options available to you, Mr Matthew Welck sees NHS and private patients across London and North London for the full range of ankle arthritis treatment, from injections through to joint-preserving and replacement surgery.

This page is for information only. It does not replace personalised medical advice. Always consult a qualified specialist for diagnosis and treatment.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 15 September 2026

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