PRP Shoulder Injections versus cortisone

Ross Hauser, MD, Danielle Steilen-Matias, PA-C

Typically a person will contact us with the question about shoulder surgery after cortisone treatments have failed them. The story these people tell is probably very familiar to some of your stories. We have the “masters athlete,” enjoying retirement or close to retirement age that likes to play pickleball, golf, stay active. Now they find that they have difficulty going overhead during a tennis serve, serves are now side-armed. They play baseball or softball as long as they stay sided-armed, but they do not shoot a basketball because they can’t keep their arm overhead.

We 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 to shoulder replacement, but they may have been recommended to arthroscopic surgery because their rotor cuff is frayed and torn up.

What both these people may have in common is a history of cortisone injection into the shoulder spaced 4-6 months apart. Both of these people may have found that the first one helped, sometimes a little sometimes a lot, but enough to justify a second injection a few months later. What both these people 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 boney 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:

Also see our article: Treating bone spurs in the shoulder is difficult. Even with surgery.

Comparing PRP, Prolotherapy, and cortisone

A brief understanding of the treatments: A video below demonstrates PRP and Prolotherapy treatment into the shoulder.

Platelet Rich Plasma Therapy (PRP). Sometimes PRP is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots.

PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
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. Platelets play a central role in blood clotting and wound/injury healing.
The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.

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.

Is Prolotherapy 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.

Research comparing PRP, Cortisone, and Prolotherapy

A 2020 randomized control study published in the Journal of Back and Musculoskeletal Rehabilitation, (1) compared ultrasound-guided platelet-rich plasma, prolotherapy, and corticosteroid injections in rotator cuff tears.

In this study:

One hundred and twenty-nine patients were divided into 4 groups:
- as platelet-rich plasma injection group,
- as cortisone injection group,
- as prolotherapy injection group
- and a lidocaine group.
The subacromial injection was applied to all groups. Pain and function scores were assessed at three weeks, twelve weeks, twenty-four weeks post-injection.

Results:

In the cortisone injection group in the 3rd week, pain and function scores were significantly better than in the PRP, Prolotherapy, and Lidocaine group.
However, by the 24th week, the PRP group had significantly better pain and function scores than the cortisone group.

Conclusion: In patients with rotator cuff tears, corticosteroid injection provides short-term relief for pain, function, and quality of life, while PRP injection works for long-term well-being. For all types of applied injections, Prolotherapy and Lidocaine as well, improvement in pain, function, and quality of life were observed.

Research comparing PRP and Cortisone

A February 2021 (2) study from doctors at the University of Calgary and the University of Manitoba in Canada published in the medical journal Arthroscopy compared platelet-rich plasma (PRP) with standard corticosteroid injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears.

Patients received either an ultrasound-guided PRP or corticosteroid injection.
Patients completed patient-reported outcome assessments at baseline and at 6 weeks, 3 months, and 12 months after injection.
Standard pain and functional scoring were used in post-treatment interviews to assess patient satisfaction.
Total 99 patients followed (47 in the PRP group and 52 in the corticosteroid injection group) until 12 months after injection.

Researchers note an oddity:

Despite randomization, patients in the PRP group had worse baseline pain and function scores than the cortisone group. This was unintentional and an oddity in the randomization process. The point is that the people in the PRP group started with more shoulder issues than the cortisone group.

At 3 months after injection, the PRP group had superior improvement in scores.

There were no differences in patient-reported outcomes of the two groups at 6 weeks or 12 months. There was no difference in the rate of failure or conversion to surgery between groups.

Patients with partial rotator cuff tears or shoulder tendinopathy experienced a clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided corticosteroid injection and PRP injections. Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months). There was no sustained benefit of PRP over corticosteroid injection at longer-term follow-up (12 months).

Cortisone injections into the shoulder prior to arthroscopic rotator cuff repair puts patients at greater risk for post-surgical complications

Researchers from Tufts Medical Center, Rush University Medical Center, and the Hospital For Special Surgery published a December 2019 study in the medical journal Arthroscopy (2) in which they highlighted that cortisone injections into the shoulder prior to arthroscopic rotator cuff repair, puts patients at greater risk for post-surgical complications and eventually, the need for a secondary or revision shoulder surgery.

From this research:

“Several recent clinical trials have demonstrated that corticosteroid injections are correlated with increased risk of revision surgery after arthroscopic rotator cuff repair.”

“Caution should be taken when deciding to inject a patient (with cortisone), and this treatment should be withheld if an arthroscopic rotator cuff repair is to be performed within the following six months.”

Earlier in 2019, researchers from the Mayo Clinic, Hospital for Special Surgery, and the University of Virginia, examined the association between the use of subacromial corticosteroid injections within a year before rotator cuff repair and subsequent need for revision rotator cuff surgery. Also published in the medical journal Arthroscopy (3), this research team published these findings:

“A single shoulder injection within a year prior to arthroscopic rotator cuff repair was not associated with an increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery”

One cortisone injection versus one PRP injection.

We are going to explain more about PRP or platelet-rich plasma injections below. For the purpose of our discussion on cortisone, we are going to make a comparison. In the research above we found that one cortisone injection did not present as much a risk for degenerating the rotator cuff as two cortisone injections would. So this next study examined how good one cortisone injection would be in helping the patient as compared to one Platelet Rich Plasma or PRP injection would.

Researchers from the University of Calgary’s section of orthopedic surgery published findings in the October 2020 issue of the medical journal Arthroscopy (5) in which they compared the benefits or non-benefits of cortisone against PRP. Here they wrote: “Patients with partial-thickness rotator cuff tears or tendinopathy experienced a clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided cortisone and PRP injections. Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months). There was no sustained benefit of PRP over cortisone at longer-term follow-up (12 months).”

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, not all, because it is reducing pain brought on by chronic inflammation. Nothing is being healed. PRP brings upon healing through inflammation. When tissue is repaired, the inflammation goes away.

In the above study, one injection of PRP into the shoulder worked for up to three months and surpassed the effectiveness of the cortisone injection. But at 12 months, both were not effective. PRP should be given. At our center, patients are generally seen every 4-6 weeks until the treatment goals are achieved. Some patients may require up to six treatments, like those demonstrated in the video below, over a six-month period. That is a treatment strategy that should never be considered with cortisone where injections are typically limited to 2 – 3 a year.

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 effects were off or were not what they expected.

Injecting both cortisone and PRP is something we will not do. In over 28 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. Please see our article on cortisone injections.

The reason your doctor may suggest a PRP cortisone combo

On the surface, this may sound beneficial to some patients. Especially those waiting for surgery. Your doctor may suggest this because there is some supportive research to suggest this dual treatment may work.

A 2013 study in the Journal of Orthopedic Research (3) examined the use of Triamcinolone acetonide (a synthetic corticosteroid) injection in the treatment of enthesopathy, enthesopathy is tearing or weakness in the enthesis, the soft-tissue connection that attached tendons and ligaments to the bone and the damage this injection may further cause. Also in this study was an examination of the ability of Platelet-rich Plasma to fix this damage.

What are we seeing in this image? The enthesis of the tendons and ligaments of the shoulder

In the image below we see the supraspinatus tendon, the long head of the biceps tendon, and the subscapularis tendon. The red is the muscle, the white at the ends of the muscle where the arrows point in the below illustration is the tendons. Where the white tendon sticks to the bone, that is the enthesis. In the same image, we see the white soft tissue suspended between the bones. That is a ligament. If the enthesis is damaged, the tendon and the muscle will pull away from the bone. If the ligament enthesis is damaged the shoulder bones will pull away from each other. In both cases, we have shoulder instability that will lead to worsening problems in the joint.

Study learning points:

The purpose of this study is to investigate whether Triamcinolone acetonide has a deleterious (bad) effect on human rotator cuff-derived cells and if PRP can protect these cells from the effects of Triamcinolone acetonide.

What you are next going to read is that this study was not conducted in people, but in a lab dish.

The researchers took human rotator cuff-derived cells. They were cultured in a dish to make more of them.
Then triamcinolone acetonide and platelet-rich plasma cells were added to the dish.
In the human rotator cuff-derived cells where the corticosteroid was added, some of the cells started dying or going through apoptosis (cell death). Measurement of cell viability showed an increase in dead cells and a decrease in living cells.
In the human rotator cuff-derived cells where the corticosteroid and PRP were added to the dish, PRP prevented cell apoptosis and cell viability increased.
In conclusion, the deleterious effect of triamcinolone acetonide was prevented by PRP, which can be used as a protective agent for patients receiving local triamcinolone acetonide injections.

In December 2016, these same researchers wrote in the journal Bone and Joint Research. (4)

“Triamcinolone acetonide is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, Triamcinolone acetonide can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of Triamcinolone acetonide and PRP (have not been studied.) The objective of this study was to determine how the combination of Triamcinolone acetonide and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß.

A simple explanation of interleukin (IL)-1ß – the inflammatory marker.

To help understand the findings that these researchers came to, we need to understand a little about interleukin (IL)-1ß. The interleukin-1 (IL-1) family is a group of small proteins called cytokines that are released by cells and affect the behavior of other cells through cell messages or in scientific terms, cell signaling. The family is put into action by infection, injury, or allergy. Once in the circulating blood, the interleukin-1 family becomes the communication and action hub of the immune system as they help initiate the inflammatory response. In joint damage, the family signals the start of systematic changes including tissue remodeling of ligaments, tendons, and cartilage, where it contributes to both destructive (catabolic) and (anabolic) repair processes.

This is what interleukin-1 does:

Stimulation of fibroblast cell growth (cartilage production)
Increased collage and procollagenase synthesis (cartilage production)
Chemotaxis of T and B lymphocytes (gets immune cells moving so they can better receive the message that the immune system is mobilizing).

Again in this research, the study was conducted in vitro, in a lab dish.

As in the earlier study, exposure to triamcinolone acetonide significantly decreased cell viability and changed the cell morphology (the size, shape, and abilities of the cell to do what it is supposed to do).
Again, these effects were prevented by the simultaneous administration of PRP. PRP significantly decreased the expression levels of degenerative marker genes.

Conclusions: The combination of Triamcinolone acetonide plus PRP exerts anti-inflammatory and anti-degenerative effects on rotator cuff-derived cells stimulated by IL-1ß. This combination has the potential to relieve the symptoms of rotator cuff injury.

A January 2021 study published in the journal Connective Tissue Research confirmed similar findings: (5)

Here is what they wrote: “Corticosteroid injections are used to treat shoulder pain. Platelet-rich plasma (PRP) is known to have anti-inflammatory and anabolic effects, as well as cytoprotective effects against corticosteroids. Thus, this study was to investigate the effects of co-treatment of corticosteroid and PRP on anti-inflammatory and matrix homeostasis of synoviocytes in IL-1ß-induced inflammatory conditions.”

Again this was a lab dish study. Everything was examined under a microscope, not in a shoulder.

“Corticosteroid regulated the inflammation and synovial homeostasis (the synovial fluid of the shoulder was diluted of excessive inflammation). When PRP and the corticosteroid were used together, it exhibited synergistic effects on synoviocytes (cells that produce anti-inflammatory cells) by regulating the parts that were not controlled by corticosteroid alone while not interfering with the effects of the corticosteroid in an inflammatory condition.”

In other words, the PRP did what it had to do to protect the shoulder from the cortisone.

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.

Summary and contact us. Can we help you?

Finally, let’s look at an editorial written in February 2021 in the medical journal Arthroscopy (6) written by Andrew J. Sheean of the Department Of Orthopaedic Surgery San Antonio Military Medical Center.

“. . . recent research favors platelet-rich plasma over corticosteroid injections in the nonoperative treatment of rotator cuff pathology. In light of evidence showing a deleterious effect of corticosteroids on subsequent surgical interventions, surgeons should continue to be wary of subacromial corticosteroid injections if alternatives such as platelet-rich plasma exist. A corticosteroid injection may have been the “go-to” nonoperative intervention in the past, but platelet-rich plasma may be a more effective (treatment option). Of course, the conspicuous cost differential between these 2 different injections remains a very real consideration. However, this should be weighed against the increased risk (and cost) of a revision repair in the event that a surgical repair is performed subsequent to a corticosteroid injection.”

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

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References:

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This article was updated April 8, 2021