Long before orthobiologics like platelet-rich plasma (PRP) entered the arena, if you were somebody suffering from joint or muscle inflammation (i.e. osteoarthritis or tendinopathy), you likely heard of or were informed about cortisone injections.
What are cortisone injections?
Cortisone injections, otherwise known as steroid injections (the legal kind), are a commonly used tool by medical practitioners to treat all kinds of inflammation due to their potent anti-inflammatory properties. They also come with reimbursement codes by provincial payers, are easily administered in an office setting, and work quickly.
What's the downside?
Well for one thing, corticosteroids (active ingredient found in cortisone injections) are toxic substances to the human body. They actively suppress the natural healing process by interfering with the inflammatory response (a critical phase of healing) and even poison local stem cell populations responsible for tissue repair and regeneration (1). This trade-off results in short-term pain relief that does nothing to address the underlying condition - a true band-aid solution.
In order to overcome the problem of short-term pain relief, practitioners will re-inject with cortisone at regular intervals. This is risky business that needs to be closely managed as repeat steroid injections are damaging and can increase the risk of soft tissue rupture and accelerate cartilage degradation (2). Now this may not be a problem for somebody with a severely arthritic knee already on the waitlist for total knee replacement surgery, but for a young and otherwise healthy patient, it's simply not a good option anymore.
Orthobiologics like PRP are emerging as a promising alternative to corticosteroids for treating these issues. Rather than impede on the natural healing process, they contribute to it by delivering growth factors and active proteins to the injured site to accelerate tissue repair. But is it time to abandon corticosteroids all together? Let's explore the latest.
Soft Tissue Tendinopathies / Tendonitis
In a 2019 study on the effects of corticosteroids and platelet-rich plasma for the treatment of chronic plantar fasciitis (3), 20/20 patients were treated with either PRP or steroids. Both outcomes and imaging (ultrasound and MRI) were measured at three and six months following treatment.
What authors found was that while there were improvements in both groups, patients receiving PRP showed significant improvement in both patient reported outcomes and imaging over the steroid group. What's more, improvement in the PRP group was sustained for at least 33 months before study follow up ended.
For rotator cuff tendinopathy? A 2021 randomized clinical trial we just covered in the June Research Roundup and evaluated 58 patients that received either PRP or steroids (4). Both treatment arms saw similar results in most clinical aspects, however, pain and ROM was significantly improved in the PRP group over all follow-up periods. The authors concluded that these results combined with the risk of tendon rupture with repeat steroid injections suggests that PRP should be used as a standard of care among patients with RC tendinopathy.
If you're still not convinced that PRP injected into tendons offers more sustained benefit without the downside risk of further soft tissue damage, a 2019 review of randomized clinical trials for lateral epicondylitis concluded that while steroid injections offered favorable outcomes during short-term follow-up period (4 and 8-weeks post treatment), patients treated with PRP consistently saw improvement in pain and function in follow-ups longer than 24-weeks post treatment.
Joint Inflammation
When it comes to joint injections to treat inflammation, the risk of steroid injections is not localized to the surrounding soft tissue but rather the internal cartilage that exists to keep joint motion fluid and cushioned. In an inflamed joint, this cartilage is already under attack and while it is important to treat the symptoms of pain and immobility, proper care should be taken to not further compromise cartilage structural integrity.
Unfortunately, as I mentioned earlier repeat steroid injections to treat pain associated with chronic inflammatory conditions like knee osteoarthritis carry the risk of further damage to cartilage. While they are effective for short term pain management, they should not be looked at as a long term solution as these patients will more often than not end up in the surgical OR, which is something that orthobiologics can now prevent in many cases.
In a 2020 randomized control trial of 40 patients with Kellgren-lawrence grades ll-lll knee osteoarthritis, patients were equally randomized to receive either PRP or steroid injections (6). Once again, both groups saw short term improvement in pain and function in the affected knee, however, PRP demonstrated statistically significant improvement over steroids in a 1-year follow up.
Conclusion
With more evidence emerging everyday, orthobiologics like PRP appear to offer patients the same benefits in pain and functionality as cortisone injections, over longer periods, and without the negative side-effects associated with soft tissue rupture and cartilage damage. But does that mean that cortisone injections should be substituted in all situations for their orthobiologic counterparts? Not necessarily.
Cortisone injections may offer more rapid relief whereas it appears the effects from PRP develop and are sustained over longer periods. In unique cases where surgical intervention is required and the benefit of rapid pain relief outweigh the costs of further damage to the affected area, cortisone injections may be warranted. However, for the vast majority of patients PRP is a promising alternative that can help address the underlying condition in addition to providing long term improvements in pain and functionality. Now, it's time for insurance companies to play catch-up so that we can remove as many barriers as possible between patients and accessing the best medical care.
References:
Wyles CC, Houdek MT, Wyles SP, Wagner ER, Behfar A, Sierra RJ. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015 Mar;473(3):1155-64. doi: 10.1007/s11999-014-3925-y. Epub 2014 Sep 4. PMID: 25187334; PMCID: PMC4317436.
McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967–1975. doi:10.1001/jama.2017.5283
Jiménez-Pérez AE, Gonzalez-Arabio D, Diaz AS, Maderuelo JA, Ramos-Pascua JR. Clinical and imaging effects of corticosteroids and platelet-rich plasma for the treatment of chronic plantar fasciitis: A comparative non randomized prospective study. Foot and Ankle Surgery. 2019(25):354-360. ISSN 1268-7731, https://doi.org/10.1016/j.fas.2018.01.005.
Dadgostar H., Fahimipour F., Pahlevan Sabagh A. et al. Corticosteroids or platelet-rich plasma injections for rotator cuff tendinopathy: a randomized clinical trial study. J Orthop Surg Res 16, 333 (2021). https://doi.org/10.1186/s13018-021-02470-x
Li A, Wang H, Yu Z, Zhang G, Feng S, Liu L, Gao Y. Platelet-rich plasma vs corticosteroids for elbow epicondylitis: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Dec;98(51):e18358. doi: 10.1097/MD.0000000000018358. PMID: 31860992; PMCID: PMC6940118.
Elksniņš-Finogejevs A, Vidal L, Peredistijs A. Intra-articular platelet-rich plasma vs corticosteroids in the treatment of moderate knee osteoarthritis: a single-center prospective randomized controlled study with a 1-year follow up. J Orthop Surg Res. 2020;15(1):257. Published 2020 Jul 10. doi:10.1186/s13018-020-01753-z
This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and any related subjects. The views and opinions expressed in this post are those of the author and may not reflect the views and opinions of MDBiologix. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if any treatment is right for you.