Rotator Cuff Tendinitis: PRP vs. Cortisone
What is the rotator cuff?
The rotator cuff is a group of four muscles and tendons in the shoulder whose function is help move the arm in multiple directions, such as overhead, to the side, and behind the back. The rotator cuff connects the shoulder blade (scapula) to the upper arm bone (humerus).
As the shoulder is a “ball-and-socket” joint, the rotator cuff also helps keep the humeral head (ball) within the glenoid of the scapula (socket).
Figure 1 – Schematic photo showing the rotator cuff. Image courtesy of 3D Muscle Lab (1).
What is rotator cuff tendinitis?
The term rotator cuff tendinitis is somewhat of a misnomer, as the term “tendinitis” implies the presence of inflammation. In fact, once symptoms have been present for at least two weeks, there is little inflammation present. Instead, the rotator cuff tendon fibers become disorganized, thickened and may even develop small partial tears. This wear pattern is more accurately termed “rotator cuff tendinopathy.”
Key Distinction: Partial-Thickness Tears Versus Complete Tears (Figures 2 and 3)
Partial-thickness tears of the rotator cuff are common and typically do not require surgery to improve pain and function as the tendon is still intact.
Complete tears of the rotator cuff tend to not respond well long-term to physical therapy and/or injections and typically warrant a surgical consultation.
Figure 2 – Schematic image showing different rotator cuff tendon tear types. Image courtesy of Zaremski et al., PM&R Knowledge Now (2).
Figure 3 – Ultrasound images showing supraspinatus tendinopathy with bursal-sided partial-thickness tear. The yellow arrow shows the tear (dark area) in the tendon. Image courtesy of Serpi et al., Journal of Ultrasonography, 2021 (3).
What are the symptoms of rotator cuff tendinopathy?
Patient typically describe the following symptoms associated with rotator cuff tendinopathy:
Pain at the front or side of the shoulder
Pain worse with reaching overhead, reaching behind the back, and/or with sleeping on the affected shoulder at night
Feeling of decreased strength or limited range of motion
What are the causes of rotator cuff tendinopathy?
Repetitive overhead activities
Repetitive lifting of the arm to the side or in front of the body
While acute traumatic injuries are relatively uncommon compared to overuse injuries, traumatic injuries can precipitate disorganization and partial (or complete) tearing of tendon fibers.
What are treatment options for rotator cuff tendinopathy?
First-line management typically consists of formal physical therapy. The purpose of physical therapy is to:
Strengthen the muscles which surround and support the rotator cuff
Place optimized load through the rotator cuff muscles and tendons
Restore muscle balance around the shoulder
Improve posture and biomechanics
What if physical therapy does not help?
Despite best efforts via physical therapy, patients may still have symptoms traceable to rotator cuff tendinopathy. However, partial tears and tendinosis (disorganization of tendon fibers) are typically responsive to injections options without needing surgery. In this scenario, there are minimally invasive treatment options available, such as corticosteroid (cortisone) injections and platelet-rich plasma (PRP) injections.
Figure 4 – Ultrasound-guided injection technique to the subacromial-subdeltoid bursa. Image courtesy of Molini et al., Journal of Ultrasound, 2012 (4).
Corticosteroid (Cortisone) Injections
Corticosteroid injections are anti-inflammatory treatments that have been used for decades for various tendon conditions.
Most studies show there is short term benefit of a few weeks to months, but the recurrence rate of symptoms is high (Rasmussen et al., Scand J Rheumatol, 1985; Rompe et al., Am J Sports Med, 2009; Shbeeb et al., J Rheumatol, 1996; Williams et al., Anesth Analg, 2009) (5-8).
Recent studies show cortisone injections may be harmful to tendons. Specifically, a recent systematic review of 16 basic science studies showed cortisone may decrease tenocyte (tendon cell) viability and function while also weakening the structure of the tendon (Puzzitiello et al., Arthrosc Sport Med Rehabil, 2020) (9).
Platelet-Rich Plasma (PRP)
Given the potential for failure of physical therapy and cortisone injections, interest has emerged in the use of other treatment options such as platelet-rich plasma (PRP).
A recent prospective double-blind controlled trial evaluated pain and function outcomes for 100 patients ages 18-50 with clinical and MRI-confirmed rotator cuff tendinopathy (Rossi et al, J Shoulder Elbow Surg. 2024) (10). Outcomes were measured to one year after injection. 50 patients received a cortisone injection while 50 patients received a PRP injection.
All patients had tried formal physical therapy and did not satisfactorily improve prior to study enrollment.
The following pain and function outcomes were measured at 1, 3, 6, and 12 months after injection:
Visual Analog Scale (VAS) score for pain
American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score
Single Assessment Numeric Evaluation (SANE) score
Pittsburgh Sleep Quality Index (PSQI)
Treatment failure was defined as persistent pain at 3 months post-injection which required a subsequent injection.
The results showed the following:
All 100 patients completed all study follow-ups
The following outcomes were determined at 12 months post-injection
PRP group showed significantly greater reduction in VAS pain score compared to the corticosteroid group
PRP group showed significantly improved sleep quality compared to the corticosteroid group
PRP group showed significantly greater shoulder function (SANE and ASES)
Failure rate was significantly higher in the corticosteroid group (30%) than in the PRP group (12%).
One limitation of the study was exclusion of patients over age 50, which is a common age group presenting with rotator cuff tendinopathy.
Key study summary: One PRP injection in patients with rotator cuff tendinopathy showed significantly superior pain, function, and sleep outcomes compared with one corticosteroid injection at 1-year follow-up.
Key Takeaways
Rotator cuff tendinopathy is a common cause of shoulder pain that can significantly affect pain, function, sleep, and overall quality of life
Typical first-line treatment is physical therapy
A single corticosteroid injection may be reasonable to make physical therapy more tolerable and fruitful. However, corticosteroid may weaken the tendon, particularly with multiple injections.
PRP is a minimally invasive evidence-based intervention which may provide a sustainable solution for rotator cuff tendinopathy when physical therapy does not work.
Recent evidence suggests PRP provides superior pain, function, and sleep outcomes compared to corticosteroid injection one year after injection.
Appointment
Dr. Verma provides treatment for orthopaedic and sports medicine conditions of the shoulder, elbow, hand/wrist, hip, knee, and foot/ankle. If you are a patient interested in exploring treatment for your condition, please schedule a consultation with Dr. Verma to discuss the available options.
References
Rotator Cuff Muscles And Shoulder Pain – Why Does It Happen? https://3dmusclelab.com/rotator-cuff-muscles-shoulder-pain/
Zaremski J, Rinaldi, Joseph. Rotator Cuff Shoulder Tendon and Muscle Injuries. Updated 3/10/2024. https://now.aapmr.org/shoulder-tendon-and-muscle-injuries/
Serpi F, Albano D, Rapisarda S, Chianca V, Sconfienza LM, Messina C. Shoulder ultrasound: current concepts and future perspectives. J Ultrason. Jun 7 2021;21(85):e154-e161. doi:10.15557/JoU.2021.0025
Molini L, Mariacher S, Bianchi S. US guided corticosteroid injection into the subacromial-subdeltoid bursa: Technique and approach. J Ultrasound. Feb 2012;15(1):61-8. doi:10.1016/j.jus.2011.12.003
Ege Rasmussen KJ, Fano N. Trochanteric bursitis. Treatment by corticosteroid injection. Scand J Rheumatol. 1985;14(4):417-20. doi:10.3109/03009748509102047
Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med. Oct 2009;37(10):1981-90. doi:10.1177/0363546509334374
Shbeeb MI, O'Duffy JD, Michet CJ, Jr., O'Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol. Dec 1996;23(12):2104-6.
Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. May 2009;108(5):1662-70. doi:10.1213/ane.0b013e31819d6562
Puzzitiello RN, Patel BH, Forlenza EM, et al. Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies. Arthrosc Sports Med Rehabil. Apr 2020;2(2):e161-e169. doi:10.1016/j.asmr.2020.01.002
Rossi LA, Brandariz R, Gorodischer T, et al. Subacromial injection of platelet-rich plasma provides greater improvement in pain and functional outcomes compared to corticosteroids at 1-year follow-up: a double-blinded randomized controlled trial. J Shoulder Elbow Surg. Dec 2024;33(12):2563-2571. doi:10.1016/j.jse.2024.06.012