The Benefits of Hyaluronic Acid for Athletes: The Evidence Base

Hyaluronic acid in capsules is marketed as a means for “healthy joints” for those who run, lift weights or play team sports. But has it been studied specifically in athletes? The editorial team analyzed the available clinical work to separate the proven from the assumed and show which conclusions can be transferred to active people.

Why athletes are interested in hyaluronic acid

Athletes load their joints far more than people with a sedentary lifestyle. Repeated impact loads in running, jumping and strength exercises, as well as injuries to the menisci and ligaments, increase the risk of early development of osteoarthritis, especially of the knee joint.

Hyaluronic acid is a natural component of synovial fluid and cartilage, so the idea of “feeding” the joints from within is intuitively understandable. Marketing adds to this the image of “lubricating the joints,” although the mechanism of action of the oral form, as we wrote in our review, is most likely indirect.

Besides joints, active people are interested in the condition of tendons and ligaments, as well as the skin, which suffers from sun, chlorinated pool water and frequent washing. Hyaluronan could theoretically affect all of these tissues.

However, theoretical appeal is not the same as proven benefit. To assess the real effects, one must look at randomized placebo-controlled studies, their participants and endpoints.

Studies in knee pain

The most data concern people with osteoarthritis of the knee joints or chronic knee pain. A pilot randomized study by Kalman and colleagues (2008) used a rooster-comb extract with a high content of hyaluronic acid (80 mg per day, 8 weeks) in 20 participants with osteoarthritis. The authors reported improvement in individual measures of pain and quality of life, but the sample was very small.

The best known is the 12-month double-blind study by Tashiro and colleagues (2012), in which 60 patients with knee osteoarthritis received 200 mg of hyaluronic acid per day or placebo alongside exercises to strengthen the quadriceps. Overall, improvements were observed in both groups, and the advantage of hyaluronic acid was more pronounced in the subgroup of patients under 70 years old.

The review by Oe and colleagues (2016), which summarized Japanese and other studies, concluded that there was a moderate reduction in knee pain with oral intake. However, most of the included works are small, some are manufacturer-funded, and the methods of assessing pain are not uniform.

Importantly, the clinical guidelines of OARSI (2019) and the American College of Rheumatology (2020) do not include oral hyaluronic acid among the recommended methods of treating osteoarthritis — because of insufficient quality of evidence. This does not mean it does not work, only that the data are not yet convincing enough for a mass recommendation.

Data on skin and connective tissue

The second direction of research is the skin. Kawada and colleagues (2014) summarized several placebo-controlled works in which oral hyaluronic acid improved measures of skin hydration in people with dry skin. Oe and colleagues (2017), in a 12-week study with 120 mg per day, observed a reduction in wrinkle depth.

For athletes these data have indirect significance: they confirm that orally taken hyaluronan can cause measurable changes in distant tissues. This is consistent with preclinical data from Balogh and colleagues (2008) on the distribution of labeled hyaluronan in the connective tissues of animals.

As for tendons and ligaments, there are practically no oral clinical studies. There are works with injections of hyaluronic acid in tendinopathies, but they concern medical procedures rather than supplements, and the results of injections cannot be transferred to capsules.

Hyaluronic acid is often part of complexes with collagen, glucosamine and chondroitin. In such cases it is impossible to determine the contribution of each component, so the results of studies of complexes are not proof of the effectiveness of hyaluronan on its own.

What about studies specifically in athletes

The honest answer: the editorial team is not aware of high-quality randomized studies of oral hyaluronic acid specifically in healthy athletes without joint diseases. The bulk of the data was obtained in middle-aged and older people with osteoarthritis or dry skin.

This is a fundamental difference. In healthy young people the synthesis of their own hyaluronan is usually sufficient, the inflammatory background in the joints is minimal, and so there is less room for improvement. An effect noticeable in a patient with arthrosis may be imperceptible in a 25-year-old runner.

At the same time, athletes with already existing changes in the joints — sport veterans, athletes after meniscus injuries, people with early arthrosis — are closer to the populations in the studies. For them the data on knee pain are more relevant.

Hyaluronic acid is not on the WADA Prohibited List, so from an anti-doping standpoint it is not a problem. However, as with any supplement, athletes undergoing doping control should choose products with independent certification to minimize the risk of contamination.

How to read these data: limitations

The first limitation is sample size. Most studies included from a few dozen to a few hundred participants. For subjective measures such as pain this is too few to reliably separate the effect from placebo and random fluctuations.

The second is the heterogeneity of products. Hyaluronic acid of different molecular weight was used, obtained by fermentation or from rooster combs, alone or as part of complexes. The result of one product does not guarantee the same result for another.

The third is conflict of interest. Some of the studies were funded by raw-material manufacturers. This does not make them automatically unreliable, but it calls for independent replication, of which there is still little.

• Small samples and short durations.
• Different molecular weights and raw-material sources.
• Predominantly older people with osteoarthritis.
• Funding of some works by manufacturers.
• Absence of studies in healthy athletes.

Practical conclusion: for an active person with knee pain, oral hyaluronic acid can be a low-risk option, but not a substitute for diagnosis, physical therapy and correction of loading, which have a much stronger evidence base.

Editorial conclusions

Oral hyaluronic acid has moderate evidence of benefit for knee pain in people with osteoarthritis and for skin hydration.

There are practically no direct high-quality studies in healthy athletes, so promises to “protect an athlete’s joints” are so far unconfirmed.

For athletes with early changes in the joints the supplement can be a reasonable addition to rehabilitation, but not a replacement for it.

Read also: “Hyaluronic acid: what it is and how it works,” “How to take hyaluronic acid: dosage, timing, duration” and “Hyaluronic acid: available forms and which to choose.”

References

1. Kalman DS, Heimer M, Valdeon A, Schwartz H, Sheldon E. Effect of a natural extract of chicken combs with a high content of hyaluronic acid (Hyal-Joint) on pain relief and quality of life in subjects with knee osteoarthritis: a pilot randomized double-blind placebo-controlled trial. Nutr J. 2008;7:3.
2. Tashiro T, Seino S, Sato T, et al. Oral administration of polymer hyaluronic acid alleviates symptoms of knee osteoarthritis: a double-blind, placebo-controlled study over a 12-month period. ScientificWorldJournal. 2012;2012:167928.
3. Oe M, Tashiro T, Yoshida H, et al. Oral hyaluronan relieves knee pain: a review. Nutr J. 2016;15:11.
4. Oe M, Sakai S, Yoshida H, et al. Oral hyaluronan relieves wrinkles: a double-blinded, placebo-controlled study over a 12-week period. Clin Cosmet Investig Dermatol. 2017;10:267–273.
5. Kawada C, Yoshida T, Yoshida H, et al. Ingested hyaluronan moisturizes dry skin. Nutr J. 2014;13:70.
6. Balogh L, Polyak A, Mathe D, et al. Absorption, uptake and tissue affinity of high-molecular-weight hyaluronan after oral administration in rats and dogs. J Agric Food Chem. 2008;56(22):10582–10593.
7. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–1589.
8. World Anti-Doping Agency. The World Anti-Doping Code International Standard: Prohibited List. Montreal: WADA; 2024.