First ankle OA guideline advises against PRP, hyaluronic acid monotherapy

Clinical takeaway: For adults with symptomatic ankle osteoarthritis, AAOS recommends against routine use of intra-articular platelet-rich plasma (PRP) and against hyaluronic acid (HA) alone, while supporting consideration of physical therapy, weight reduction, NSAIDs/acetaminophen, and short-term corticosteroid injections as part of individualized, multimodal management.

The American Academy of Orthopaedic Surgeons (AAOS) has released its first-ever Clinical Practice Guideline for the management of ankle osteoarthritis (OA), addressing a condition that often affects younger, working-age adults because of its predominantly post-traumatic origin. Despite reviewing more than 7,000 abstracts, the panel found sufficient evidence to issue only two formal recommendations, underscoring major gaps in the ankle OA literature.

The guideline’s strongest message is what clinicians should avoid. AAOS strongly recommends against using intra-articular HA alone for symptomatic ankle OA, citing high-quality evidence showing no meaningful benefit versus saline injections. However, the panel notes that combining HA with a corticosteroid may provide short-term improvements in pain and function compared with corticosteroid alone.

AAOS also moderately recommends against routine use of intra-articular PRP, based on evidence showing no sustained benefit over saline placebo through 12 months. “I administered PRP injections for ankle OA for about 10 years, and I remain supportive of biologic treatment options, but unfortunately, there is no high-quality evidence demonstrating that PRP provides better pain control than injecting saline into the ankle,” said guideline co-chair Christopher Gross, MD.

Among consensus-based recommendations, the workgroup states that intra-articular corticosteroid injections may be considered for short-term symptom relief. Prescription opioids should not be used for ankle OA management, whereas NSAIDs and/or acetaminophen may be used for initial symptomatic relief when not contraindicated. The panel also found no reliable evidence supporting stem-cell injections for ankle OA.

The guideline further suggests that patients seeking to avoid surgery may benefit from skilled physical therapy, home exercise programs, weight reduction, and durable medical equipment such as braces or orthoses. For end-stage disease that has failed nonoperative treatment, both ankle arthrodesis and total ankle arthroplasty are considered reasonable options, with treatment selection guided by patient goals and clinical factors.

“Unlike the hip and knee OA population, which traditionally affects an older population, ankle OA is a distinct clinical entity,” Dr. Gross noted, emphasizing the need for ankle-specific treatment guidance.

The authors stressed that shared decision-making remains essential because evidence is limited for many commonly used interventions and significant research gaps remain across both nonoperative and surgical treatment strategies.

Source: American Academy of Orthopaedic Surgeons. (2026 July 7) Management of Ankle Osteoarthritis: Evidence-Based Clinical Practice Guideline