Abstract
BACKGROUND: Rotator cuff injury (RCI), a leading cause of shoulder disability, necessitates effective non-surgical interventions. Despite widespread use of intra-articular injections (corticosteroids, hyaluronic acid [HA], prolotherapy, platelet-rich plasma [PRP]), comparative efficacy across short-, mid-, and long-term outcomes remains unclear due to heterogeneous evidence. PURPOSE: To systematically review the literature to compare corticosteroids, hyaluronic acid, prolotherapy, and platelet-rich plasma for rotator cuff injuries, using network meta-analysis stratified by short-, mid-, and long-term outcomes. METHODS: A comprehensive search was conducted across PubMed, Embase, Cochrane Library, Web of Science, Scopus, CNKI, VIPC, and Wanfang Data up to May 2025. Pain (VAS) and functional outcomes (e.g., Constant-Murley Score) were assessed at short- (≤ 1 month), mid- (1-3 months), and long-term (> 3 months) intervals. Frequentist models with random effects ranked interventions via SUCRA. RESULTS: Twenty-nine RCTs (1800 patients) were included. For pain relief, prolotherapy consistently ranked highest across all timeframes. PRP also exhibited favorable long-term analgesic efficacy. Corticosteroids showed short-term benefits but inferior long-term efficacy. For functional improvement, HA demonstrated the best short-term results, whereas prolotherapy was optimal for mid-term recovery. Long-term functional outcomes favored HA and prolotherapy. The detailed SUCRA values and rankings for all interventions and timepoints are presented in Table 2. CONCLUSIONS: Comparative efficacy analysis suggests temporal variations in treatment outcomes: prolotherapy and HA offer the most favorable early (≤ 3 months) symptom control for both pain and function. For sustained pain relief (> 3 months), prolotherapy and PRP rank highest, while HA and prolotherapy are associated with better long-term functional outcomes. Corticosteroids appear most effective for short-term analgesia, with diminishing efficacy over longer durations. This evidence supports a shift from using a single injection agent towards a tailored strategy that selects different injections based on the patient's symptoms and the specific treatment phase to achieve optimal outcomes. PROSPERO registration: PROSPERO registration number: CRD42025632416. LEVEL OF EVIDENCE: Level I Systematic Review and MetaAnalysis.