Skip to main content

Comparison of three common shoulder injections for rotator cuff tears: a systematic review and network meta-analysis



To compare the clinical effectiveness of three common shoulder injections mentioned in the guidelines [corticosteroid, sodium hyaluronate (SH) and platelet-rich plasma (PRP)] on rotator cuff tears.

Material and methods

The PubMed, Embase and Cochrane Library databases were systematically searched up to June 1, 2022, for randomized controlled trials (RCTs) and prospective studies on the three injection therapies for rotator cuff tears. The main results were pain relief and functional improvement at 1–5 months and over 6 months, pooled using a network meta-analysis and ranked by SUCRA score. The risk of bias of the included studies was assessed using the Cochrane Collaboration tool.


Twelve RCTs and 4 prospective studies comprising a total of 1115 patients were included in the review. Three prospective studies were judged to be at high risk of selection bias and performance bias, and one was considered as having a high risk of detection bias. SH injection ranked first in the short term in pain relief (MD: − 2.80; 95%CI − 3.91, − 1.68) and functional improvement (MD:19.17; 95%CI 12.29, 26.05), while PRP injection obtained better results in the long term in both pain relief (MD: − 4.50; 95%CI − 4.97, − 4.03) and functional improvement (MD:11.11; 95%CI 0.53,21.68).


PRP injection has the potential to successfully treat rotator cuff tears as an alternative to corticosteroids in the long term, in terms of either therapeutic efficiency or adverse effects, followed by SH injection. More research is needed to make high-quality recommendations on treatment options for injection treatments of rotator cuff tears.


Rotator cuff tears are a common musculoskeletal disorder and a major cause of shoulder pain, with injury and degeneration being the two main causes [1]. The prevalence of rotator cuff tears increases with age, from 9.7% in patients aged 20 years and younger to 62% in patients aged 80 years and older [2]. A recent study found that patients with rotator cuff tears returned to previous work at approximately 8 months after surgery, and more than 35% of them could not return to their previous level of work [3].

Treatments for rotator cuff tears range from noninvasive physical therapy to more invasive procedures such as shoulder injections and surgery. There is no clear consensus on the best way to treat patients with rotator cuff tears so far. Although surgical repair is the standard treatment for rotator cuff tears, the poor self-repair capability of the tendon leading to a high retear rate and the financial and time pressures on patients make conservative therapies equally important [4]. Conservative treatment consists of several interventions, including physiotherapy like scheduled stretching and strengthening exercises, systemic medications such as pain medication and anti-inflammatory drugs, intraarticular injections and hyperthermia [5, 6]. Clinical practice guidelines for rotator cuff injuries have mentioned three injection therapies [corticosteroid, platelet-rich plasma (PRP) and hyaluronic acid (HA)] were mentioned for the nonsurgical management of patients; however, the guideline strength of recommendation for PRP and HA injections was limited, and corticosteroids were moderate, although a large number of studies and meta-analyses on injection therapies have been performed [7,8,9,10,11]. Intraarticular steroid injections reduce aseptic inflammation of the synovium, shoulder capsule and surrounding tissues. The PRP injection collects the patient’s own plasma and injects it into the joint capsule to help revascularize the torn part area and promote tissue recovering. Hyaluronic acid could not only lubricate the shoulder joint but also suppress the inflammatory response. The previous systematic reviews show different views on the effectiveness of these three injections. Some studies suggest that PRP injections may have a positive effect on clinical outcomes such as pain relief and long-term retear rates [9, 10]. However, another meta-analysis found no statistically significant differences between PRP and other conservative treatments [8]. Meanwhile, a study on PRP injection considered it as not cost-effective on rotator cuff tears despite the reduced retear rate [4]. Similarly, there is controversy over the short- and long-term effects of corticosteroids and hyaluronic acid [12, 13]. The varied classification of patients and treatments may lead to the bias.

Most of the current studies focus on comparisons between single drug injections, and direct comparisons between multiple drug injection categories are lacking. A better understanding of the comparative efficacy of these therapies is expected to help physicians refine treatment strategies for rotator cuff tears. A network meta-analysis can make up for the deficiency of traditional meta-analysis and compare of multiple treatments simultaneously by integrating both direct and indirect evidence [14]. Therefore, the aim of the present analysis is to evaluate the clinical effects of these three injection therapies on patients with rotator cuff tears and give a ranking according to their short-term and long-term effects for practical application.


The detailed protocol for this study was designed according to the Cochrane intervention review and has been registered on the PROSPERO website (CRD42022336258).

Search strategy

This review was conducted according to the standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [15]. We used a combination of keywords, Medical Subject Headings and entry terms to conduct an extensive literature search on PubMed, Embase and the Cochrane Library in June 1, 2022. Web of Science and Scopus were not within the scope of our literature search. The search strategy is available in Additional file 1. The gray literature, including books and conference proceedings, was searched via the Opengrey database ( and Google Academic; meanwhile, we manually checked the latest review or similar meta-analysis related our study to obtain the documents that may be missed during the retrieval process. The search had no language restrictions, and the search period was from June 1, 2003, to June 1, 2022 (last 20 years).

Eligibility criteria

We constructed eligibility criteria using the population, intervention, control/comparison and outcome models (PICO). (1) Participants: We included adults (> 18 years of age) of either sex diagnosed with any type of degenerative, traumatic, partial or full-thickness rotator cuff tears confirmed by clinical symptoms, medical history, physical examination and imaging evaluation (ultrasound, magnetic resonance imaging (MRI) or arthrography). The definition of rotator cuff tears was derived from the guidelines and previous reviews on rotator cuff injuries [7, 16]. Trials that only include patients with shoulder pain, calcific tendinitis or subacromial impingement syndrome were excluded from our studies unless they also included patients with any type of rotator cuff tears. (2) Intervention and Comparison: Trials treated with at least 2 arms of nonoperative injection therapies, including corticosteroid, PRP, SH and placebo, were eligible. (3) Outcomes: The primary measures of treatment effect were pain reduction and improvement in shoulder function, including the Visual Analog Scale (VAS), Constant–Murley scores (Constant), Western Ontario Rotator Cuff Index (WORC) and American Shoulder and Elbow Surgeons Standardized Form (ASES). (4) Randomized controlled trials (RCT) and prospective studies were included in our review, and literature reviews, expert consensus, nonclinical studies or case reports were all excluded.

Data collection and quality assessment

Two authors independently screened the full text and extracted all the data, including the baseline demographic characteristics, symptoms, injection dosage, injection site, outcome measures, adverse effects and the time points of follow-up assessments. Disagreements between the results were resolved through a third independent author. The outcomes calculated in the meta-analysis were the VAS pain score and the constant score. Outcomes were extracted separately for the short and long term, with an assessment at a time point of less than 6 months being defined as a short-term effect and more than 6 months being defined as a long-term effect. Two reviewers independently performed a quality assessment of the trials. The Cochrane Collaboration tool was used to evaluate the risk of bias as high, low or unclear, which covers the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting and other bias. The quality of evidence from the network meta-analysis for each network contrast was estimated in terms of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, which could be rated from high, moderate, low to very low.

Statistical and inconsistency analysis

The network meta-analysis was performed using the “network” package in Stata (version 15.0). Comparisons between different therapies are presented using network plots, where the size of the nodes represents the total sample size of multiple treatments and the width of the lines represents the number of studies between 2 treatments. We used the mean difference (MD) and 95% credible interval (CI) to compare the outcome change between 2 different injection therapies, using the frequentist approach to random-effects network meta-analysis. The Wald test and node-splitting analysis were adopted to evaluate the overall and local inconsistencies within the network, respectively, and the consistency model was used to calculate the pooled effect size if the p value of the inconsistency analysis was more than 0.05. The surface under the cumulative ranking curve (SUCRA) was used to calculate the probabilities of each treatment being the best among all therapies. Publication bias was assessed using funnel plots.


Search results

A total of 985 articles were retrieved from the initial search of the major databases, and 654 articles remained after duplicate articles were excluded. We discarded 615 articles by screening the titles and abstracts, and 16 studies were finally included in this review after evaluation of the full-text articles, including 12 RCTs [17,18,19,20,21,22,23,24,25,26,27,28] and 4 prospective studies [29,30,31,32] with a total of 1115 patients (Fig. 1). Two studies [18, 26] included 4 types of interventions, and 2 studies [21, 30] adopted 3 types of interventions. Only one study included patients receiving conservative therapies with full-thickness rotator cuff tears [21], while the others included participants with partial rotator cuff tears. The average age of the patients in the trials ranged from 39.0 to 79.4 years. Among them, 16 studies reported short-term outcomes (1–5 months), and 11 studies reported long-term outcomes (over 6 months). Regarding the location of injection, 14 studies performed subacromial injections, and 2 performed intraarticular injections. The characteristics of the included studies are available in Table 1.

Fig. 1
figure 1

Flow diagram of the study selection process

Table 1 Characteristics of included studies

Quality assessment

The risk of bias summary and graph are presented in Fig. 2. Three prospective studies were judged to be at high risk of selection bias and performance bias because they generated the treatment allocation schedule according to the patients’ wishes, resulting in a lack of blinding of the patients and personnel [29,30,31]. We rated the study by Gialanella et al. as having a high risk of detection bias because the outcomes were measured by the same physician who performed the injection therapies [21]. All the studies were assessed as having a low risk of incomplete outcome data for the minor and balanced loss to follow-up between groups.

Fig. 2
figure 2

Risk of bias assessment for all included studies

Network geometry

The comparison network plot for pain relief and functional improvement in the short/long term is presented in Fig. 3. All three interventions were directly compared with controls. The short-term results for VAS and constant score showed closed loops, while direct comparisons between corticosteroid and SH for the long-term outcomes were lacking.

Fig. 3
figure 3

Network map of the studies included in the network meta-analysis: A pain relief in short-term follow-up, B pain relief in long-term follow-up, C functional improvement in short-term follow-up, D functional improvement in long-term follow-up. CS, Corticosteroid; PRP, platelet-rich plasma; SH, sodium hyaluronate

Inconsistency analysis

The results of the inconsistency analysis are available in Table 2. The node-splitting analysis detected inconsistency only in the short-term VAS score of the comparison between PRP and control groups (p = 0.009), and the Wald test reported no significant global inconsistency in these loops (p > 0.05). Thus, we used the consistency type to perform the network meta-analysis.

Table 2 Results of the global and local inconsistency

Effectiveness of the inventions

The results of the network meta-analysis are shown in Fig. 4. A total of 11 trials with 775 patients were included in the analysis for short-term pain relief [18,19,20,21,22, 24,25,26, 29,30,31]. The extent of pain relief was evaluated by the change in the VAS score, which ranged from 0 to 10, with lower MD values indicating better effectiveness. The pooled network MD values indicated that all three interventions (CS, PRP, SH) showed significant superiority over the control group in terms of pain relief, with SH therapy leading to a greater reduction in the VAS score (MD: − 2.80; 95% CI − 3.91, − 1.68) (moderate certainty evidence). There is no significant difference in the comparisons between these three interventions. The analysis for long-term pain relief contained 5 studies with 395 patients [18, 21, 22, 24, 26]. The long-term efficacy of these three therapies compared with the control groups was better than that in the short term, and PRP injection had the greatest reduction in VAS score (MD: − 4.50; 95% CI − 4.97, − 4.03). PRP was also reported to have better improvement in pain relief than CS (MD: − 1.18; 95% CI − 1.61, − 0.75) and SH (MD: − 0.79; 95% CI − 1.31, − 0.28) in the long term (moderate certainty evidence).

Fig. 4
figure 4

Forest plot of the network meta-analysis: comparison of the three treatments in pain relief and functional improvement in the short/long term: A pain relief in short-term follow-up, B pain relief in long-term follow-up, C functional improvement in short-term follow-up, D functional improvement in long-term follow-up. CS, Corticosteroid; PRP, platelet-rich plasma; SH, sodium hyaluronate

Ten trials with 648 patients provided short-term data on functional improvement of the shoulder [18, 19, 21, 22, 25, 28,29,30,31,32], and a constant score ranging of 0–100 was used to assess this outcome, with higher MD values indicating better efficacy. All three treatments showed superiority over control groups in short-term functional improvement, with SH obtaining greater improvement in the constant score (MD: 19.17; 95% CI 12.29, 26.05) (moderate certainty evidence). A total of 8 studies with 589 patients reported a constant score at long-term follow-up [18, 21, 22, 25, 27, 28, 31, 32], and the pooled result revealed that only PRP therapy had a statistically significant benefit over the control group (MD: 11.11; 95% CI 0.53, 21.68) (moderate certainty evidence).

The SUCRA analysis provided a ranking of these three injection therapies according to their efficacy in improving the VAS and constant score (Fig. 5). According to the ranking results shown in Table 3, SH therapy ranked first at short-term follow-up and might be the best injection treatment in terms of pain relief (SUCRA score: 89.9) and functional improvement (SUCRA score: 86.4). Nevertheless, PRP injection seemed to be the best injection treatment in both pain relief (SUCRA score: 100.0) and functional improvement (SUCRA score: 89.2) in the long term. The funnel plots are presented in Additional file 2, which showed a possible low risk of publication bias in functional improvement.

Fig. 5
figure 5

Rank probability for the three treatments in pain relief and functional improvement in the short/long term: A pain relief in short-term follow-up, B pain relief in long-term follow-up, C functional improvement in short-term follow-up, D functional improvement in long-term follow-up. CS, Corticosteroid; PRP, platelet-rich plasma; SH, sodium hyaluronate

Table 3 Results of the SUCRA score

Effectiveness of the combined therapies

Two trials investigated the additive effects of the combined therapies of the three injections [17, 18]. Byun et al. made a comparison between subacromial bursa injection of hyaluronate with steroid and corticosteroid alone in patients with partial or full-thickness rotator cuff tears [17]. Both groups were found to have statistically significant improvements in VAS and shoulder disability questionnaire (SDQ) scores; however, the active range of motion (AROM) and shoulder function assessment scale (SFA) showed significant improvement only in the combination therapy group. Cai et al. evaluated the combined use of SH and PRP in the treatment of small to medium rotator cuff tears [18]. The SH + PRP group was reported to have significant improvement in the constant VAS and ASES scores compared with SH or PRP injection alone at the 12-month follow-up, along with a significant reduction in tear size from the MRI scan.


Our updated systematic review and network meta-analysis is a further exploration of the therapeutic effects of three shoulder injections for rotator cuff tears. Fifteen of the 16 studies included in our review focused on patients with partial thickness rotator cuff tears, for whom nonoperative treatment is a viable first-line option with a low risk of fatty infiltration, tear progression and muscle atrophy [33]. Physiotherapy, medicine injections and activity modification are common options for nonoperative rotator cuff repair; however, if the underlying tears are not addressed, over 40% of partial thickness defects would progress to full-thickness tears within three years [34]. There have been many trials and meta-analyses comparing treatments for rotator cuff tears, but very few have focused on the integration of injection treatments. Maillot et al. performed a network meta-analysis of multiple treatments for massive rotator cuff tears and found that PRP injections did not appear to provide any additional benefit [8]. This finding differs from the results of some previous meta-analyses which favored PRP injection for rotator cuff repair [9, 10]. This discrepancy might be due to the fact that Maillot et al. did not exclude studies evaluating the efficacy of PRP injection in arthroscopic repair. Lin et al. compared the effectiveness of injection therapies mainly in rotator cuff tendinopathy, including chronic tendinosis, partial cuff tears, subacromial impingement syndrome, etc. [11], and corticosteroids were found to be beneficial in the short term, whereas PRP and prolotherapy yielded better long-term outcomes. Despite their similarity to ours at long-term conclusions, the different diagnostic labels used in their inclusion criteria could lead to heterogeneity.

The present study showed better short-term improvements in pain relief and shoulder function with SH injection for patients with rotator cuff tears. Hyaluronate is a major component of the synovial fluid on the surface of articular cartilage and can act as a lubricant and shock absorber in the movements of the joint [35]. In regard to the efficacy of SH in rotator cuff tears, as mentioned in the guideline from the American Academy of Orthopedic Surgeons, there is limited evidence to support the use of SH injections in nonsurgical treatment. Osti et al. reported the function of SH in improving VAS and functional scores without serious adverse reactions in a systematic review of 11 prospective trials [36]. Frizziero et al. demonstrated the prompt clinical improvement of intraarticular HA injection on patients with rotator cuff tendinopathies and was not lost to extracorporeal shock therapy [37]. Due to the tear, the subacromial bursa can communicate with the tendon in the tear on the side of the bursa, and SH can penetrate into the tear site and surrounding tissue. SH has beneficial effects on both the repair site and the synovial sheath, participating in the repair process through epithelial and endothelial cells, reducing peripheral inflammatory responses and promoting contact healing [38, 39]. Gallorini et al. found that hyaluronic acid could improve cell escape from H2O2-induced oxidative stress and decrease cytotoxicity by reducing Nrf2 expression in human tenocytes, thereby counteracting inflammation [40]. The increased viability and proliferation of extracellular matrix cells induced by SH have also been demonstrated in some studies [41, 42].

In the present study, PRP injection showed great efficacy in both pain relief and functional improvement at long-term follow-up. PRP is obtained by centrifugation of whole blood collected from patients, resulting in a platelet-rich fraction with a higher platelet concentration than whole blood [43]. PRP was injected into the injury site to stimulate healing at the tendon–bone interface with a high concentration of platelets and growth factors, including platelet‐derived growth factor (PDGF), transforming growth factor-β (TGF‐β), fibroblast growth factor (FGF), insulin‐like growth factor (IGF‐I, IGF‐II) and vascular endothelial growth factor (VEGF) [44]. Several studies have demonstrated the potential benefit of promoting tendon matrix repair in tendon-related disorders [45]. With regard to rotator cuff disease, there are few meta-analyses that include nonsurgical cases only. Xiang et al. reported a significant effect of PRP as a conservative therapy with a constant score in both the short and long term, which is consistent with our findings, but no long-term effect on pain relief was observed. Their subgroup analysis also found that PRP with double centrifugation was associated with better recovery for the presumably higher platelet concentration compared with a single centrifugation [46, 47]. Lui et al. found that nonoperative PRP injection reduced pain from 3 to 12 months after injection but no significant improvement compared with physical therapy [48]. Other studies have focused on the effect of PRP in patients receiving ARCR. Wang et al. demonstrated that PRP injection could significantly improve the short-term outcomes after arthroscopic repair of full-thickness rotator cuff tears and reduce the retear rate with single-row fixation [49], and a meta-analysis of 13 trials by Ahmad et al. reported a similar result [50]. The analysis by Warth et al., however, found no significant differences in overall gain in outcome scores or retear rates between groups with and without PRP supplementation after rotator cuff repair [51]. This may be related to the differences in PRP preparation, such as the platelet count and leukocyte concentrations. In vitro studies have proved that leukocyte-reduced PRP promotes normal collagen matrix synthesis and reduces cytokines associated with matrix degradation and inflammation to a greater extent than high-leukocyte concentrated PRP [52]. Further studies are needed to determine the potential mechanisms and efficiency of combined therapies.

There are a few limitations that cannot be ignored in this review. Firstly, further classification of patients can be made with less than 6 months of follow-up (e.g., 1–3 months and 3–5 months) to increase the credibility of the results. Second, the treatment protocols and doses varied; for example, patients in some studies received more than one injection, while others included additional treatments such as physical exercise. Third, future studies should use a more accurate classification of patients, as the efficiency of injection therapies might vary in patients with partial, massive, incomplete rotator cuff tears, not to mention tendinopathy or subacromial bursitis. Fourth, failure to search certain databases like Web of Science or Scopus may result in the omission of articles. Fifth, the certainty of evidence in our study was mainly downgraded for study limitations, as what we have drawn in the risk of bias assessment, blinding the participants and staff was difficult sometimes for some comparisons, and unblinded outcome assessments may also be biased in effect estimates. Finally, the conceptual and statistical heterogeneity, such as different outcome measures and clinical scores used, and the inconsistency might introduce errors into our meta-analysis.


The present network meta-analysis demonstrated that among the three injection treatments in patients with rotator cuff tears, SH injection plays a role in short-term [1,2,3,4,5] functional improvement and pain relief, while PRP injection may achieve better results in long-term follow-up (over 6 months). Corticosteroids, although one of the most common therapies, may not be as good as the above two therapies in terms of therapeutic effect and safety. However, how to get these therapies out of their maximum function is not clear, i.e., the site and numbers of injections, the dosages and whether they should be combined with other treatments. More research is needed to make high-quality recommendations on treatment options for injection treatments of rotator cuff tears.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the original source articles or from the corresponding author on reasonable request.


  1. Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589–604.

    Article  PubMed  Google Scholar 

  2. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913–21.

    Article  PubMed  Google Scholar 

  3. Haunschild ED, Gilat R, Lavoie-Gagne O, Fu MC, Tauro T, Forsythe B, et al. Return to work after primary rotator cuff repair: a systematic review and meta-analysis. Am J Sports Med. 2021;49(8):2238–47.

    Article  PubMed  Google Scholar 

  4. Vavken P, Sadoghi P, Palmer M, Rosso C, Mueller AM, Szoelloesy G, et al. Platelet-rich plasma reduces retear rates after arthroscopic repair of small- and medium-sized rotator cuff tears but is not cost-effective. Am J Sports Med. 2015;43(12):3071–6.

    Article  PubMed  Google Scholar 

  5. Longo UG, Franceschi F, Berton A, Maffulli N, Droena V. Conservative treatment and rotator cuff tear progression. Med Sport Sci. 2012;57:90–9.

    Article  PubMed  Google Scholar 

  6. Giombini A, Di Cesare A, Safran MR, Ciatti R, Maffulli N. Short-term effectiveness of hyperthermia for supraspinatus tendinopathy in athletes: a short-term randomized controlled study. Am J Sports Med. 2006;34(8):1247–53.

    Article  PubMed  Google Scholar 

  7. Weber S, Chahal J. Management of rotator cuff injuries. JAAOS J Am Acad Orthop Surg. 2020;28(5):e193–201.

    Article  PubMed  Google Scholar 

  8. Maillot C, Martellotto A, Demezon H, Harly E, Le Huec JC. Multiple treatment comparisons for large and massive rotator cuff tears: a network meta-analysis. Clin J Sport Med. 2021;31(6):501–8.

    Article  PubMed  Google Scholar 

  9. Chen X, Jones IA, Togashi R, Park C, Vangsness CT Jr. Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: a systematic review and meta-analysis with bias assessment. Am J Sports Med. 2020;48(8):2028–41.

    Article  PubMed  Google Scholar 

  10. Chen X, Jones IA, Park C, Vangsness CT Jr. The efficacy of platelet-rich plasma on tendon and ligament healing: a systematic review and meta-analysis with bias assessment. Am J Sports Med. 2018;46(8):2020–32.

    Article  PubMed  Google Scholar 

  11. Lin MT, Chiang CF, Wu CH, Huang YT, Tu YK, Wang TG. Comparative effectiveness of injection therapies in rotator cuff tendinopathy: a systematic review, pairwise and network meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2019;100(2):336-49 e15.

    Article  PubMed  Google Scholar 

  12. Wang C, Zhang Z, Ma Y, Liu X, Zhu Q. Platelet-rich plasma injection vs corticosteroid injection for conservative treatment of rotator cuff lesions: a systematic review and meta-analysis. Medicine. 2021;100(7): e24680.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Khan M, Shanmugaraj A, Prada C, Patel A, Babins E, Bhandari M. The role of hyaluronic acid for soft tissue indications: a systematic review and meta-analysis. Sports health. 2023;15(1):86–96.

    Article  PubMed  Google Scholar 

  14. Rouse B, Chaimani A, Li T. Network meta-analysis: an introduction for clinicians. Intern Emerg Med. 2017;12(1):103–11.

    Article  PubMed  Google Scholar 

  15. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350: g7647.

    Article  PubMed  Google Scholar 

  16. Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;2016(6): cd012224.

    PubMed  PubMed Central  Google Scholar 

  17. Byun SD, Park DH, Choi WD, Lee ZI. Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders. Ann Rehabil Med. 2011;35(5):664–72.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Cai YU, Sun Z, Liao B, Song Z, Xiao T, Zhu P. Sodium hyaluronate and platelet-rich plasma for partial-thickness rotator cuff tears. Med Sci Sports Exerc. 2019;51(2):227–33.

    Article  CAS  PubMed  Google Scholar 

  19. Chou WY, Ko JY, Wang FS, Huang CC, Wong T, Wang CJ, et al. Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo-controlled study. J Shoulder Elbow Surg. 2010;19(4):557–63.

    Article  PubMed  Google Scholar 

  20. Dadgostar H, Fahimipour F, Pahlevan Sabagh A, Arasteh P, Razi M. Corticosteroids or platelet-rich plasma injections for rotator cuff tendinopathy: a randomized clinical trial study. J Orthop Surg Res. 2021;16(1):333.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Gialanella B, Prometti P. Effects of corticosteroids injection in rotator cuff tears. Pain Med. 2011;12(10):1559–65.

    Article  PubMed  Google Scholar 

  22. Jo CH, Lee SY, Yoon KS, Oh S, Shin S. Allogeneic platelet-rich plasma versus corticosteroid injection for the treatment of rotator cuff disease: a randomized controlled trial. J Bone Joint Surg Am. 2020;102(24):2129–37.

    Article  PubMed  Google Scholar 

  23. Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioğlu K. Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up. Am J Sports Med. 2013;41(11):2609–16.

    Article  PubMed  Google Scholar 

  24. Kwong CA, Woodmass JM, Gusnowski EM, Bois AJ, Leblanc J, More KD, et al. Platelet-rich plasma in patients with partial-thickness rotator cuff tears or tendinopathy leads to significantly improved short-term pain relief and function compared with corticosteroid injection: a double-blind randomized controlled trial. Arthroscopy. 2021;37(2):510–7.

    Article  PubMed  Google Scholar 

  25. Moghtaderi A, Sajadiyeh S, Khosrawi S, Dehghan F, Bateni V. Effect of subacromial sodium hyaluronate injection on rotator cuff disease: a double-blind placebo-controlled clinical trial. Adv Biomed Res. 2013;2:89.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sari A, Eroglu A. Comparison of ultrasound-guided platelet-rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions. J Back Musculoskelet Rehabil. 2020;33(3):387–96.

    Article  PubMed  Google Scholar 

  27. Schwitzguebel AJ, Kolo FC, Tirefort J, Kourhani A, Nowak A, Gremeaux V, et al. Efficacy of platelet-rich plasma for the treatment of interstitial supraspinatus tears: a double-blinded, randomized controlled trial. Am J Sports Med. 2019;47(8):1885–92.

    Article  PubMed  Google Scholar 

  28. Shams A, El-Sayed M, Gamal O, Ewes W. Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears. Eur J Orthop Surg Traumatol. 2016;26(8):837–42.

    Article  PubMed  Google Scholar 

  29. Huang SH, Hsu PC, Wang KA, Chou CL, Wang JC. Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears. J Chin Med Assoc. 2022.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Setaro N, Gigante A. Conservative treatment of partial rotator cuff tears, comparison between infiltrative treatment with corticosteroids, medium molecular weight hyaluronic acid and high molecular weight hyaluronic acid: a prospective study. J Biol Regul Homeost Agents. 2021;35(3):1073–80.

    CAS  PubMed  Google Scholar 

  31. Tagliafico A, Serafini G, Sconfienza LM, Lacelli F, Perrone N, Succio G, et al. Ultrasound-guided viscosupplementation of subacromial space in elderly patients with cuff tear arthropathy using a high weight hyaluronic acid: prospective open-label non-randomized trial. Eur Radiol. 2011;21(1):182–7.

    Article  PubMed  Google Scholar 

  32. von Wehren L, Blanke F, Todorov A, Heisterbach P, Sailer J, Majewski M. The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3787–92.

    Article  Google Scholar 

  33. Thangarajah T, Lo IK. Optimal management of partial thickness rotator cuff tears: clinical considerations and practical management. Orthop Res Rev. 2022;14:59–70.

    PubMed  PubMed Central  Google Scholar 

  34. Keener JD, Galatz LM, Teefey SA, Middleton WD, Steger-May K, Stobbs-Cucchi G, et al. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am. 2015;97(2):89–98.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kirwan J. Is there a place for intra-articular hyaluronate in osteoarthritis of the knee? Knee. 2001;8(2):93–101.

    Article  CAS  PubMed  Google Scholar 

  36. Osti L, Buda M, Buono AD, Osti R, Massari L. Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid. Muscles Ligaments Tendons J. 2015;5(4):270–5.

    Article  PubMed  Google Scholar 

  37. Frizziero A, Vittadini F, Barazzuol M, Gasparre G, Finotti P, Meneghini A, et al. Extracorporeal shockwaves therapy versus hyaluronic acid injection for the treatment of painful non-calcific rotator cuff tendinopathies: preliminary results. J Sports Med Phys Fit. 2017;57(9):1162–8.

    CAS  Google Scholar 

  38. Amiel D, Ishizue K, Billings E Jr, Wiig M, Vande Berg J, Akeson WH, et al. Hyaluronan in flexor tendon repair. J Hand Surg Am. 1989;14(5):837–43.

    Article  CAS  PubMed  Google Scholar 

  39. Oliva F, Marsilio E, Asparago G, Frizziero A, Berardi AC, Maffulli N. The impact of hyaluronic acid on tendon physiology and its clinical application in tendinopathies. Cells. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Gallorini M, Berardi AC, Gissi C, Cataldi A, Osti L. Nrf2-mediated cytoprotective effect of four different hyaluronic acids by molecular weight in human tenocytes. J Drug Target. 2020;28(2):212–24.

    Article  CAS  PubMed  Google Scholar 

  41. Dean BJ, Franklin SL, Carr AJ. A systematic review of the histological and molecular changes in rotator cuff disease. Bone Joint Res. 2012;1(7):158–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Osti L, Berardocco M, di Giacomo V, Di Bernardo G, Oliva F, Berardi AC. Hyaluronic acid increases tendon derived cell viability and collagen type I expression in vitro: comparative study of four different hyaluronic acid preparations by molecular weight. BMC Musculoskelet Disord. 2015;16:284.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009;37(11):2259–72.

    Article  PubMed  Google Scholar 

  44. Sheean AJ, Anz AW, Bradley JP. Platelet-rich plasma: fundamentals and clinical applications. Arthroscopy. 2021;37(9):2732–4.

    Article  PubMed  Google Scholar 

  45. Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc. 2018;26(7):1984–99.

    Article  PubMed  Google Scholar 

  46. Xiang XN, Deng J, Liu Y, Yu X, Cheng B, He HC. Conservative treatment of partial-thickness rotator cuff tears and tendinopathy with platelet-rich plasma: a systematic review and meta-analysis. Clin Rehabil. 2021;35(12):1661–73.

    Article  PubMed  Google Scholar 

  47. Nagata MJ, Messora MR, Furlaneto FA, Fucini SE, Bosco AF, Garcia VG, et al. Effectiveness of two methods for preparation of autologous platelet-rich plasma: an experimental study in rabbits. Eur J Dent. 2010;4(4):395–402.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Lui M, Shih W, Yim N, Brandstater M, Ashfaq M, Tran D. Systematic review and meta-analysis of nonoperative platelet-rich plasma shoulder injections for rotator cuff pathology. Pm r. 2021;13(10):1157–68.

    Article  PubMed  Google Scholar 

  49. Wang C, Xu M, Guo W, Wang Y, Zhao S, Zhong L. Clinical efficacy and safety of platelet-rich plasma in arthroscopic full-thickness rotator cuff repair: a meta-analysis. PLoS ONE. 2019;14(7): e0220392.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Ahmad Z, Ang S, Rushton N, Harvey A, Akhtar K, Dawson-Bowling S, et al. Platelet-rich plasma augmentation of arthroscopic rotator cuff repair lowers retear rates and improves short-term postoperative functional outcome scores: a systematic review of meta-analyses. Arthrosc Sports Med Rehabil. 2022;4(2):e823–33.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Warth RJ, Dornan GJ, James EW, Horan MP, Millett PJ. Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: a meta-analysis and meta-regression. Arthroscopy. 2015;31(2):306–20.

    Article  PubMed  Google Scholar 

  52. Cross JA, Cole BJ, Spatny KP, Sundman E, Romeo AA, Nicholson GP, et al. Leukocyte-reduced platelet-rich plasma normalizes matrix metabolism in torn human rotator cuff tendons. Am J Sports Med. 2015;43(12):2898–906.

    Article  PubMed  Google Scholar 

Download references


Not applicable.


This study was funded by Jiangyin People's Hospital Affiliated to Nantong University.

Author information

Authors and Affiliations



JXZ had the original idea for the study and proposed the study design. JXZ, ZH and WQ conducted the literature search, screened and selected the studies initially identified. JXZ and CY read and evaluated the quality of the studies included. JXZ and CY conducted the meta-analysis. JXZ wrote the initial manuscript. All authors contributed to interpreting the study findings and to the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tian Jiang.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1

. Search strategy

Additional file 2

. Funnel plot of the network meta-analysis

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jiang, X., Zhang, H., Wu, Q. et al. Comparison of three common shoulder injections for rotator cuff tears: a systematic review and network meta-analysis. J Orthop Surg Res 18, 272 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Rotator cuff tear
  • Network meta-analysis
  • Platelet-rich plasma
  • Hyaluronic acid
  • Corticosteroid