Chronic shoulder rotator cuff tendinitis: Review of treatment options - corticosteroid or PRP?
Updated: May 26, 2020
During this article we want to look at shoulder pain, injury and inflammation - specifically tendinitis of the rotator cuff. Rotator cuff inflammation or shoulder impingement is of ongoing concern. This is why best practices are constantly being reviewed and updated for the best clinical outcomes for pain reduction and functional improvement. Below we have a recent 2019 double blinded randomised control trial on platelet rich plasma (PRP) treatment and corticosteroid.
Platelet rich plasma (PRP) is an evolving treatment modality that has been gaining high amounts of popularity in primary care, injury rehabilitation and sports medicine. PRP treatment is a safe and effective concentrated platelet solution from the patient, which is now becoming increasingly used in clinical practice. Platelet rich plasma acts by the modulation of bioactive factors in the injured tissue, increasing the regeneration potential, and facilitating repair. PRP treatment increases the production of type I collagen and the proliferation of New tissue cells, very important growth factors, while also stimulating the synthesis of new tissue matrix.
Corticosteroid injections are commonly used to reduce tendon inflammation. Shoulder application is considered a cheap and effective therapeutic option, but the longevity and side effects of corticosteroids are of concern in clinical practice. In respect to longevity, Corticosteroid injections for inflammation are generally short lived. In respect to side-effects, tissue degradation and damage, along with tendon ruptures following local injections of corticosteroids have also been found in the repetition of the treatment or even after single application. In addition, other noninfectious complications may occur, including nerve wasting, skin hypopigmentation, calcification around the joint capsule, increased sugar levels and inhibitory effects of the pituitary gland a couple of weeks after ministration.
The aim of this detailed study was to analyse the therapeutic efficacy of shoulder infiltration of PRP in patients with rotator cuff impingement syndrome compared with subacromial corticosteroid injection. This randomised, controlled, double-blind study demonstrates the effects of treatment with a single treatment of corticosteroids and PRP in the therapeutic process of rotator cuff tendinopathy (chronic shoulder tendinitis).
The patients who received PRP showed improvements in functional scores during the first month of follow-up, which already shows a significant improvement in pain and function in the short term. On the other hand, the patients in the corticosteroid group also presented a improvement in the short-term. These scores remained significant even after 3 and 6 months of follow-up. In the short term follow-up, both groups presented similar results. The clinical improvement observed in the group that received PRP in this study was also observed by other previous studies. A longitudinal study by Scarpone et al., on the effectiveness of platelet-rich plasma injection for rotator cuff tendinitis in 2013 identified a significant gradual improvement at 8 and 52 weeks of treatment. The therapeutic response was significant at 1 and 3 months of treatment.
The results of the trial show that a measurable improvement in the shoulder function was identified following PRP treatment and corticosteroid administration in the 1st month and then up to 3 months. However, in the corticosteroid group there was a general worsening of function in relation to admission. Platelet-rich plasma treatment has been shown to have improvement in several parameters of shoulder function - including pain and range of motion up to 3 months after injection, showing similar results when compared with this study.
A comprehensive 2017 systematic review meta-analysis has studied the efficacy of PRP on tendon and ligament healing using 37 articles. In this study, PRP groups showed significantly less pain in the long-term follow-up when compared with the control groups. This finding may correlate to the current study, when considering the long-term worsening found in shoulder function in the corticosteroid group, while the PRP effects have shown more durability.
A 2016 randomised, controlled study compared PRP and corticosteroid injection in 40 patients with partial rotator cuff tears. Both groups showed significant improvements. When comparing the groups, the PRP group showed significantly better results long-term at the 12 weeks evaluation, with Similarities at 3-6 months. This, showing again a deterioration in the corticosteroid group further down the line. This supports the study hypothesis that corticosteroids may not have value in the long-term treatment of chronic rotator cuff tendinitis. Despite the positive results with the subacromial use of corticosteroids, evidence in the literature does not value the use of this drug in rotator cuff diseases. interestingly, patients who underwent corticosteroid injections had to seek further health services more frequently due to persistence or relapse of symptoms, requiring new rounds of injections.
PRP is a safe and affective biological treatment and very well suited in clinical practice. Patients undergoing PRP treatment very rarely report any side effects during the whole follow-up period beyond the expected local pain up to 24 hours of the application, which is expected from the needle injection in the period after the end of the local anesthetic effect. Current studies seem to indicate that multiple PRP applications may have value in increasing the clinical response to this treatment. The application of 3 treatments of PRP has been shown to be significant in the treatment of early stages of osteoarthritis and chronic tendinitis and this pattern can also be repeated for rotator cuff issues. In addition, PRP has been studied to be used in conjunction with corticosteroid, as PRP does not affect the effects of steroid on tendon cells and its anti-inflammatory effect, showing that these treatments may have a synergic clinical response regarding pain and tissue regeneration.
The efficacy of PRP as a therapeutic modality is more clear, and its characteristics make it a promising therapy in the treatment of rotator cuff tendinopathy. Corticosteroids, although well studied, remain rising concern in its chronic use in clinical practice.
This 2019 double-blind randomised control study concludes that Subacromial shoulder injections of autologous PRP and corticosteroids have a positive and similar clinical response in the treatment of chronic rotator cuff tendinitis. When analysing progression in range of motion and strength, the patients only found significant results in the short term (1–3 months), and, in the corticosteroid group, functional worsening was observed at 6 months. These findings again, suggest that PRP is a safe and effective treatment and may be a very useful tool in the therapeutic arsenal against rotator cuff diseases, especially by avoiding possible adverse effects associated with the use of corticosteroids.
Effect of platelet-rich plasma on the degenerative rotator cuff tendinopathy according to the compositions (2019) The PRP group showed significant differences in all clinical outcomes compared with the exercise group, while the PRP group below the cut off value showed no significant differences in linear regression analysis.
Comparison of ultrasound-guided platelet rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions (2019) In patients with rotated cuff issues, corticosteroid injection is shown to provide short-term pain relief and function, while PRP injection works for long-term success and wellbeing.
PRP versus steroids in a deadlock for efficacy: long-term stability versus short-term intensity-results from a randomised trial (2019) Albeit corticosteroid injections show good short-term results at 6 weeks, patients receiving PRP injections fare better at 3 and 12 months.
Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study (2019) At 12-wk follow-up, a single dose of PRP injection was found to be more effective than an corticosteroid injection, in terms of improving pain, disability, and shoulder range of movement in patients with frozen shoulder (adhesive capsulitis) of the shoulder.
Allogenic Pure Platelet-Rich Plasma Therapy for Rotator Cuff Disease: A Bench and Bed Study (2018) This study showed that allogenic pure PRP had pleiotropic effects on new tendon cells depending on inflammation and that it did not cause adverse events but rather decreased pain and improved shoulder function to a degree comparable with steroid injection in patients with rotator cuff disease.
Treatment of the Shoulder Impingement Syndrome with PRP Injection (2018) Based on the results of our study, the hypothesis can be accepted that the concentrate of platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on the daily activities of patients as well as on the objective evaluation via the selected scoring systems.
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