Is a prednisone (corticosteroid) taper the best practice for treating left shoulder pain?

Is a Prednisone Taper Best Practice for Left Shoulder Pain?

No, a prednisone taper is not best practice for most cases of left shoulder pain. The evidence supports targeted corticosteroid injections (subacromial or intra-articular) as the preferred corticosteroid approach for shoulder pain, with oral prednisone reserved only for specific conditions like adhesive capsulitis (frozen shoulder), and even then with limited benefit.

Treatment Approach Based on Diagnosis

For Rotator Cuff Disease/Tendonitis

Subacromial corticosteroid injection is the evidence-based corticosteroid approach, not oral prednisone.

• Subacromial steroid injections demonstrate significant benefit over placebo with a number needed to treat of 3.3 patients for one improvement 1
• Higher doses (≥50 mg prednisone equivalent) show superior efficacy with a relative risk of 5.9 for improvement 1
• Subacromial injections are more effective than NSAIDs alone, with a number needed to treat of 2.5 1
• Subacromial corticosteroid injections can be used when pain is thought related to subacromial region injury or inflammation 2

For Adhesive Capsulitis (Frozen Shoulder)

Oral prednisone shows only short-term benefit and is not recommended as primary therapy.

• A 3-week course of 30 mg oral prednisolone daily provides significant benefit at 3 weeks but benefits are not maintained beyond 6 weeks 3
• At 12 weeks, outcomes actually tended to favor the placebo group 3
• Intra-articular corticosteroid injection is preferred over oral steroids, showing short-term benefit over physiotherapy (success rate RR=1.66) 2
• An early course of oral corticosteroids (30-50 mg daily for 3-5 days, then tapering over 1-2 weeks) may be used specifically for Complex Regional Pain Syndrome (CRPS/shoulder-hand syndrome) complicating shoulder pain 2

For Post-Surgical Shoulder Pain

A methylprednisolone taper shows promise but is specific to the post-arthroplasty setting.

• A 6-day methylprednisolone taper after total shoulder arthroplasty reduced opioid consumption from 132.1 to 41.1 oral morphine equivalents 4
• This reduced acute pain and improved early recovery but is specific to surgical patients, not general shoulder pain 4

First-Line Management Algorithm

Start with conservative measures before any corticosteroids:

1. Initial therapy (Grades 1-2 pain): Acetaminophen and/or NSAIDs (naproxen 500 mg BID or meloxicam 7.5-15 mg daily) for 4-6 weeks 2
2. If NSAIDs ineffective: Consider prednisone 10-20 mg daily for 2-4 weeks only for inflammatory arthritis 2
3. For persistent symptoms: Escalate to targeted corticosteroid injection rather than continuing oral steroids 2

Critical Caveats About Oral Prednisone

Oral corticosteroids carry significant risks that must be weighed:

• Prednisone suppresses the HPA axis, with potential for adrenocortical insufficiency lasting up to 12 months after discontinuation 5
• Abrupt withdrawal must be avoided; tapering should be gradual 5
• Side effects include increased infection risk, bone loss, hypertension, fluid retention, and hyperglycemia 5
• The lowest effective dose for the shortest duration should always be used 5

When Oral Prednisone Might Be Considered

Very limited scenarios where oral prednisone has a role:

• Adhesive capsulitis with severe symptoms where injection is not immediately available (30 mg daily for 3 weeks maximum) 3
• CRPS/shoulder-hand syndrome (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) 2
• Inflammatory arthritis affecting the shoulder when NSAIDs fail (10-20 mg daily, not a taper) 2

Bottom Line

The evidence strongly favors targeted corticosteroid injections over oral prednisone tapers for shoulder pain. Subacromial injection for rotator cuff disease and intra-articular injection for adhesive capsulitis provide superior, more sustained benefit with fewer systemic side effects 6, 1. Oral prednisone should be reserved for specific inflammatory conditions or when injections are contraindicated, and even then, benefits are modest and short-lived 3.