The purpose of physical therapy (PT) is to restore the normal alignment and balance of the shoulder girdle, take stress off of the rotator cuff, optimize posture and decrease inflammation in the shoulder joint. This can be done with a combination of hands on massage and joint mobilization, stretching and range of motion exercises, along with strengthening and stability exercises. Evaluation by a trained professional can be helpful to create an individualized treatment plan for you.
The purpose of medications in treatment of shoulder disorders is aimed at decreasing inflammation. There are a variety of medications that may be recommended for you. We recommend you check with your primary care provider for any questions regarding safety of these medications as they apply to you.
- Non-Steroidal Anti-Inflammatory medications (NSAIDs)
- Over-the-counter: Ibuprofen, Aleve, Advil, Motrin
- Prescription: Meloxicam (Mobic), Ibuprofen, Naproxen, Celebrex
- Pain Reducers (non-narcotic)
- Over-the-counter: Tylenol, Acetaminophen
- Steroid Medication
- Methylprednisolone (Medrol), Prednisone
The purpose of an injection into the shoulder is to provide a concentrated dose of steroid directly into the shoulder joint. There are different areas that can be targeted to address different problems. We can use fluoroscopy (x-ray) or ultrasound guidance to ensure the injection is located in the proper area. While shoulder joint injections can be helpful, they are not always the preferred treatment option. Repeated injections into the shoulder have been shown to degenerate cartilage and the rotator cuff tendons over time. In addition, for those considering surgery, it has been shown to increase the risk of infection for up to 3-5 months after the injection.
- Glenohumeral Injection: This is the most common injection and can be used to alleviate pain and dysfunction related to arthritis, frozen shoulder, rotator cuff tendinitis or tears.
- Subacromial Injection: This injection is aimed on top of the rotator cuff. Ultrasound guidance is used to target a specific area of the rotator cuff, typically one that has a calcium deposit called calcific tendinitis.
- Acromioclavicular Injection: This injection is aimed at the AC joint and is used for those with AC joint arthritis and pain
Information on Different Types of Injection Materials
Many patients have questions about different types of injections that can be offered to help with their shoulder pain. The most commonly known types of injection are steroid (cortisone) and PRP (platelet-rich plasma). Both of these types of injection materials have benefits, and some are more appropriate for different patient populations in the non-operative setting. For some patients, it may also be beneficial to receive an injection in the operative setting, as well.
The purpose of any injection into the shoulder is to decrease pain by injecting a material directly into the shoulder joint. Whether we use cortisone, PRP or bone marrow aspirate, the goal is to bathe the structures of the shoulder in the substance in order to reduce inflammation that causes pain. Different types of injection materials do this by different mechanisms.
Cortisone is a steroid that is very effective in reducing inflammation. It can be useful to treat patients who have arthritis and are not interested in shoulder surgery. In the best case scenarios, the effects can last for several months. Steroid injections typically are not recommended for younger patients who have relatively intact rotator cuff tendons, or even partial thickness rotator cuff tendon tears. In these cases, steroid injections can structurally worsen (or damage) healthy rotator cuff tissues and cartilage.
Pros: Cortisone is effective at reducing inflammation that causes pain and can last several months.
Cons: Cortisone can damage healthy tissue or worsen existing damage in the soft tissues and cartilage of the shoulder such as the rotator cuff tendons, muscles, or cartilage covering the bone. This risk increases as the number of injections into the area increases. Additionally, with increased numbers of injections, the effect becomes less potent, and lasts a shorter period of time.
Major risks: In patients with diabetes, blood sugars can be elevated to dangerous levels after an injection. There can be skin disruption or discoloration.
Uses in our practice: We typically use cortisone injections as a way of avoiding surgery in patients with arthritis who have no desire or are unable to undergo shoulder surgery. Cortisone injections into different areas of the shoulder can be effective in treating frozen shoulder or bursitis caused by vaccination or other injections
Platelet-rich plasma (PRP) is derived from blood that is drawn from your body. It is spun down in a centrifuge to concentrate the sample, allowing for separation of blood contents. The final product contains cytokines with different types of growth factors (factor beta, basic fibroblast growth factor, and platelet derived growth factor). These can help to decrease inflammation and pain by helping to heal microtears in the rotator cuff tendons. PRP differs from pluripotent stem cells. Though it may help with healing of the tendon on a microscopic level, it does not regenerate new tendons on a macroscopic (larger) level.
This type of therapy cannot be used in the place of surgery in patients with large rotator cuff tendon tears, but is instead used most commonly in patients with very small rotator cuff tendon tears, or with rotator cuff tendinitis/tendinopathy.
Pros: PRP is effective at reducing inflammation that causes pain and can last several months. It may also help in microscopically healing small tears.
Cons: Out of pocket cost and not covered by insurance. Uses in our practice: In most cases, PRP injections can be used in the place of cortisone injections. Studies have shown that PRP and cortisone injections have similar results in pain reduction over the course of 24 weeks. PRP injections do not carry the same systemic medical risks or potential risk of damaging healthy structures of the shoulder when compared to cortisone injections. PRP injections are an effective option for patients with medical conditions that do not allow for use of steroids.
Uses in our practice: In most cases, PRP injections can be used in the place of cortisone injections. Studies have shown that PRP and cortisone injections have similar results in pain reduction over the course of 24 weeks. PRP injections do not carry the same systemic medical risks or potential risk of damaging healthy structures of the shoulder when compared to cortisone injections. PRP injections are an effective option for patients with medical conditions that do not allow for use of steroids.
In this type of therapy, bone marrow is drawn from a bone in your body and then injected in the area of need. This is most commonly done at the time of a surgery. Bone marrow contains similar types of cells and growth factors as PRP (stromal cells, progenitor cells, growth factors), but can be in higher proportions. Typically, the bone marrow is drawn from a bone in your body and then spun down with a centrifuge to concentrate the sample. However, this process can also be performed without the concentration process.
Pros: Bone marrow aspirate is effective at reducing inflammation and may help promote healing in surgically repaired areas.
Cons: Harvesting the bone marrow outside of a surgical procedure can be painful and costly.
Uses in our practice: In patients who are undergoing an arthroscopic surgery that requires rotator cuff repair, we often harvest bone marrow from the humeral head (arm bone) and inject it over the area of repair at the end of the procedure to help with inflammation, pain control and robust rotator cuff healing. Though the repair with sutures and anchors is necessary for structural integrity, we find that the bone marrow aspiration contributes to the healing process.
Carr JB, Rodeo SA. The role of biologic agents in the management of common shoulder pathologies: Current state and future directions. Journal of Shoulder and Elbow Surgery. 2019;28(11):2041-2052. doi:10.1016/j.jse.2019.07.025