PRP or cortisone for shoulder pain. A Quick review
Ross Hauser, MD, Danielle Steilen-Matias, PA-C
There are many people who have very good short-term outcomes with corticosteroid injections. We will demonstrate this in the research below. This article will discuss beyond the short-term gains of cortisone injections.
Typically a person will contact us with questions about their shoulder surgery recommendations following multiple cortisone injections and no noticeable improvement in their situation. For most, no noticeable improvement actually means accelerated deterioration of their shoulder situation.
The story these people tell is probably very familiar to some of your stories. We have the “master athlete” enjoying retirement or close to retirement age who likes to play pickleball, and golf, and stay active. Unfortunately, they now find that they have difficulty going overhead during a tennis serve, serves are now side-armed. The golf swing has been altered, and baseball or softball throws are now side-armed or even underhanded. Swimming with their shoulder pain is very difficult and can only be accomplished with an alternate method of swimming stroke.
We also have a person with a physically demanding job who has to stay on the job and needs anything that can help them. These are the people who have not developed into later stages of osteoarthritis yet, meaning that they have not been recommended for shoulder replacement, but they may have been recommended for arthroscopic surgery because their rotor cuff is frayed and torn up.
What both these types of people may have in common is a history of cortisone injections into the shoulder spaced four to six months apart. Both of these types of people may have found that the first cortisone injection helped, sometimes it helped a little, sometimes it helped a lot, but the injection helped enough to justify to them and his/her doctor that when shoulder pain returned a second cortisone injection a few months later was warranted. What both these people types may also have in common is the second cortisone injection’s effects wore off after a week or two. Following this, both of these people may find themselves continuing their daily routine of ice, anti-inflammatories, and a cream or ointment, to help stay active. The recommendation for shoulder replacement has been made. Can they avoid the surgery with PRP?
When someone contacts our office with this type of problem we discuss with them their range of motion. If there is a lot of bone spurs, they typically have a significant reduction in their range of motion because of bony overgrowth, not just because of pain, PRP or any conservative care will not restore that range of motion. Surgery will be necessary. If the shoulder’s range of motion is limited because of soft tissue damage and there is little evidence of bony overgrowth or bone spurs. Then PRP injections may help.
We are going to limit this article’s subject to PRP and cortisone injections. On our website, we have some comprehensive articles on shoulder surgery. They are:
- Alternatives to Shoulder impingement syndrome decompression surgery
- The evidence for shoulder replacement alternatives
- Partial rotator cuff tear surgery options
- Non-surgical treatments for Frozen Shoulder
Also see our article: Treating bone spurs in the shoulder is difficult. Even with surgery.
Cortisone because my problem is inflammation
The recommendation that you get cortisone injection is based on the diagnosis that you have inflammation. The inflammation is significant enough that is causing pain on movement and the extra fluid in your shoulder is impeding your ability to have a full or close to the full range of arm motion.
Here are some familiar tales:
I’ve been dealing with shoulder pain for over five years. I recently had a dye-injected MRI and it showed inflammation. I’ve had a cortisone shot which did not help me at all. I’ve also gone to physical therapy for six weeks which also did not help. I have trouble sleeping some nights because the pain will keep me awake. My range of motion is affected by this but it’s a constant aching pain that gets worse with repetitive motion.
In a situation like this, where the person has a good range of motion PRP would be considered beneficial. Generally speaking that the cortisone was not effective is indicative that inflammation was not the primary problem.
I injured my shoulder at the gym. An orthopedic physician told me that I had bursitis and had a cortisone shot. It lasted only about a month. I’ve been going to a massage therapist but am still having issues twisting my arm and sometimes raising it.
In a situation like this, inflammation-causing bursitis and limited range of motion returned after a month because the issue is not bursitis or inflammation but soft tissue damage in the shoulder. PRP would be considered beneficial for someone like this.
I am having pain in my shoulder at the AC joint due to the narrowing of this joint space – my orthopedic surgeon is suggesting surgery to shave the bone and eliminate the “rub” between the bones. Would PRP be a treatment option for the shoulder AC joint? My surgeon also suggested a cortisone shot to reduce the inflammation.
In this situation, shoulder instability may cause rub and inflammation. PRP can be helpful. This is a more complicated case and we describe AC joint problems in our article Chronic shoulder dislocation, subluxation, and shoulder instability.
I have been diagnosed with a frozen shoulder. Had a cortisone shot, and I am doing PT sessions, but have the feeling it won’t work and I will end up in surgery. Four years ago, I had a frozen shoulder on the other side and ended up in surgery, even though I had done the cortisone shot and the physical therapy. Will PRP work?
There are some people with Adhesive Capsulitis of the shoulder, or more commonly a “frozen shoulder,” who get a great benefit from cortisone injections, ART or Active Release Therapy, chiropractic manipulations, and sometimes no treatment at all, the problem “thaws,” out. PRP can also be beneficial in this situation even after failed cortisone. Please see our article: Frozen Shoulder – Adhesive Capsulitis: Injections, Physical Therapy and Surgery.
The rush to offer corticosteroid on the first visit – despite current medical guidelines
A May 2022 paper in the journal Family Practice (1) examined how general practitioners made treatment recommendations to patients who walked into the office with new shoulder pain. The authors of this paper write: “Guidelines for shoulder pain in general practice recommend treatment with corticosteroid injections if initial pain management fails. However, little is known about the actual use and safety of corticosteroid injections in treatment by general practitioners.” What is being suggested is, are general practitioners offering steroid shots when they may not be appropriate to offer?
To assess this line of thinking, the medical records of 200,000 patients were examined.
- In total, 26% of the patients with a new episode of shoulder pain received corticosteroid injections. The patient’s age and history of shoulder pain were significantly associated with the administration of a corticosteroid injection. Half of the patients received the corticosteroid injection in the first consultation.
- The authors wrote: “In contrast to the guidelines, corticosteroid injections were frequently administered in the first consultation. Older patients and patients with a history of shoulder pain were more likely to receive corticosteroid injections for shoulder pain.”
Comment: If you are older, and have a history of shoulder pain, cortisone injections will be more likely.
Is PRP a better anti-inflammatory than cortisone?
Platelet Rich Plasma Therapy (PRP). Sometimes PRP is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots.
- Platelet Rich Plasma Therapy (PRP) takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into the shoulder.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
A January 2023 paper led by researchers from St George’s University of London and published in the Journal of Orthopaedic (2) research investigated the functional outcomes and patient’s perception of pain following a PRP treatment compared to those injected with corticosteroid for managing rotator cuff disease.
What the researchers were looking for was:
- Did either group of patients get to a minimal clinically important difference threshold for patient benefit? (Was there enough evidence and outcome scores to say “Yes this worked.”)
- Did one injection work better than the other?
The researchers found both PRP treatment and corticosteroid reached a minimal clinically important difference before and after treatment although PRP in one outcome did not yet achieve a difference in the short-term but did in the middle and long-term results. This was further shown in that “a statistically significant difference in the short-term in favor of corticosteroid injection and a statistically significant difference in favor of PRP injection in the intermediate and medium term, there is no clinical difference between them since both reached MCID. Thus, neither can be considered clinically superior.”
The researchers however do note that several recent studies comparing corticosteroid and PRP injections for the treatment of rotator cuff diseases showed controversial (mixed) results. In review, the researchers did not find long-term patient benefit in using corticosteroids. Furthermore, PRP was shown to stimulate the repair of damaged tissue by releasing growth factors
PRP is an emerging alternative treatment for many different conditions. During the inflammatory stage of the tendon healing process, platelets will migrate toward the injured area and release growth factors in addition to having anti-inflammatory properties. “PRP also accelerates the healing process via its contribution to the differentiation and proliferation of tendon stem cells into tenocytes (PRP facilitates native stem cells to reconfigure themselves into the cells that build and repair tendon). Still further the researchers suggest the overall improvement in functional and pain scores seen in this (study) are mainly due to the symptom-modifying effects of PRP which are likely to be associated with the anti-inflammatory component rather than the tissue regeneration component.”
Comparing PRP, Cortisone, and Prolotherapy
Prolotherapy is an in-office injection treatment of simple dextrose or sugar. The science and research on Prolotherapy can be found on our Prolotherapy research page. At our center, we do not offer PRP as a stand-alone treatment. In the research below, you will see that PRP does not help everyone. Typically PRP fails when there is not enough treatment or it is not combined with other treatments that may make PRP work better. At our center, PRP is combined with Prolotherapy.
What is Prolotherapy? Is it like cortisone?
- The difference between Prolotherapy and Cortisone is extensive.
- Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injection and these injections are no longer effective for them.
- Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Again, while some people do benefit from cortisone in the short term – the evidence however points to cortisone causing more problems than it helps.
Prolotherapy is a regenerative injection treatment used to treat joint and spine pain by repairing damaged and weakened ligaments and tendons.
- Prolotherapy is considered a viable alternative to surgery and as an option to pain medications, cortisone, and other steroidal injections.
- The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
Because your shoulder pain may not be a primary problem of inflammation
Research comparing PRP, Cortisone, and Prolotherapy
Cortisone is an anti-inflammatory medication. Platelet Rich Plasma and Prolotherapy are Pro-inflammatory treatments. What does this mean? Cortisone acts to reduce swelling and thereby reduce pain. It does not fix what is causing the swelling. PRP and Prolotherapy injections attempt to fix soft tissue damage and thereby remedy the cause of inflammation. The differences in treatments are seen in the fact that initially, cortisone works better than PRP. According to numerous papers, long-term, PRP works better than cortisone.
Research comparing PRP and Cortisone
Doctors at the All India Institute of Medical Sciences published a paper in the journal Clinics in Shoulder and Elbow (3) evaluating the effectiveness of autologous platelet-rich plasma (PRP) injections in the treatment of common shoulder diseases. To do this the researchers examined previously published randomized controlled trials of PRP versus a control.
- From 8-12 weeks to more than 1 year, PRP injections were associated with better pain relief and functional outcomes than control interventions.
- PRP injections were also associated with greater quality of life.
- Compared with placebo and corticosteroid injections, PRP injections provided better pain relief and functional improvement.
Conclusions: “PRP injections could provide better pain relief and functional outcomes than other treatments for persons presenting with common shoulder diseases. PRP injections have a greater capacity to improve shoulder-related quality of life than other interventions.”
The image below presents a case history. Some explanatory notes are added to help explain this case better:
Case study. Glenoid labral tear, impingement, and osteoarthritis of the right shoulder.
In this case history, the patient suffered from unbearable shoulder pain for about a year. This pain could be traced back to shoulder problems that had developed over a 25-year history related to a clavicle fracture she sustained in a bike injury.
Her pain was constant and sharp referring to pain in her neck, chest, and thoracic area and limiting her motion. She was only able to perform 50% of her daily activities and the pain was hindering her ability to play tennis.
Her MRI showed bursitis, loose bodies, a labral tear, and osteoarthritis. Surgery and physical therapy were recommended by another provider. This patient was more familiar with regenerative medicine techniques and chose the non-surgical option instead – EIGHT treatments were originally estimated to be necessary but after 3 PRP Prolotherapy treatments the patient-reported vast improvement of over 90% return to playing doubles tennis twice weekly in addition to golfing and enjoying a very active lifestyle.
- While her MRI showed 17 abnormalities, surgery was not necessary, the body has incredible regenerative capabilities when a comprehensive enough treatment is performed in especially when the patient adheres to a healthy lifestyle that aids in faster healing. After three PRP Prolotherapy treatments, enough ligament repair to stabilize the shoulder and eliminate her local and referred pain.
- Results may not be typical. This is one case history where a patient had successful treatment. These treatments do not work for everyone.
Comments: This is something we see very frequently in people who contact us after they have had a single PRP injection. Cortisone is a one-shot treatment, PRP should not be given the same way.
People get confused with PRP treatment because they think it is “just like cortisone, only safer.” PRP is NOT just like cortisone. Cortisone has an immediate pain-reducing effect for many people, but not all because it reduces pain brought on by chronic inflammation. Nothing is being healed. PRP brings healing through inflammation. When tissue is repaired, the inflammation goes away.
My doctor wants to give me cortisone and PRP in my shoulder
In some people that we see at our center or contact us, they will tell us about their other doctor’s desire to use cortisone and PRP together at the same treatment. For some people, this has worked. These are typically not the people we see at our center. We see the people who may have tried cortisone and/or PRP at other clinics and have come to us because the effects were off or were not what they expected.
Injecting both cortisone and PRP is something we will not do. In over 30 years of treating thousands of patients, and having published numerous research papers, we do not see the benefit of this combined treatment as a standard of care.
In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations – there is no cortisone in these injections.
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- In this shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- This patient, in particular, comes to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
The side-effects of cortisone can include low testosterone levels
In a May 2023 paper, (x) doctors examined veterans who had intraarticular corticosteroid injections for shoulder pain. What the researchers were looking to determine was if there was a short-term effect of the corticosteroid injections on serum testosterone (T), luteinizing hormone (the hormone that stimulates testosterone production in men, and FSH (follicle stimulating hormone) levels. In this study group of thirty male veterans, triamcinolone acetonide given into the shoulder reduced serum testosterone levels significantly, but testosterone levels rebounded back to near baseline levels at four weeks.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
1 van Doorn PF, Schiphof D, Rozendaal RM, Ottenheijm RP, van der Lei J, Bindels PJ, de Schepper EI. The use and safety of corticosteroid injections for shoulder pain in general practice: a retrospective cohort study. Family Practice. 2022 Jun;39(3):367-72. [Google Scholar]
2 Adra M, El Ghazal N, Nakanishi H, Smayra K, Hong SS, Miangul S, Matar RH, Than CA, Tennent D. Platelet‐rich plasma versus corticosteroid injections in the management of patients with rotator cuff disease: A systematic review and meta‐analysis. Journal of Orthopaedic Research®. 2022 Oct 31. [Google Scholar]
3 Barman A, Mishra A, Maiti R, Sahoo J, Thakur KB, Sasidharan SK. Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases: a meta-analysis of randomized controlled trials. Clinics in shoulder and elbow. [Google Scholar]
4 Tahmasbi Sohi M, Cali M, Forster JE, Kiseljak‐Vassiliades K, Wierman ME. Short term effects of intraarticular triamcinolone acetonide injection on serum testosterone, luteinizing hormone, and follicle stimulating hormone levels in male veterans: A prospective pilot study. PM&R. 2023 May 25. [Google Scholar]