Is prednisone (corticosteroid) effective for treating shoulder pain?

Prednisone for Shoulder Pain

Oral prednisone is effective for specific shoulder conditions—particularly polymyalgia rheumatica (10-20 mg daily) and adhesive capsulitis (30 mg daily for 3 weeks)—but for most other causes of shoulder pain, corticosteroid injections are preferred over oral steroids. 1, 2

When Oral Prednisone IS Indicated

Polymyalgia Rheumatica (PMR)

• Start with 10-20 mg prednisone daily for acute bilateral shoulder and/or hip pain with morning stiffness 1
• PMR presents with predominantly bilateral shoulder pain, elevated inflammatory markers (ESR/CRP), and should have giant cell arteritis ruled out 1
• Taper to 10 mg/day within 4-8 weeks, then reduce by 1 mg every 4 weeks until discontinuation 1
• This is a strong recommendation from European League Against Rheumatism/American College of Rheumatology guidelines 1

Adhesive Capsulitis (Frozen Shoulder)

• 30 mg oral prednisolone daily for 3 weeks provides significant short-term benefit 2
• Expect marked improvement in pain (mean reduction of 4.1 points vs 1.4 for placebo), disability, and range of motion within 3 weeks 2
• Critical caveat: Benefits are not maintained beyond 6 weeks, so this is primarily for acute symptom relief 2

Complex Regional Pain Syndrome (CRPS/Shoulder-Hand Syndrome)

• Start with 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1
• Diagnose based on pain/tenderness of metacarpophalangeal joints, edema over dorsum of fingers, and limited range of motion 1

When Corticosteroid INJECTIONS Are Preferred

Rotator Cuff Disease

• Subacromial corticosteroid injection is more effective than oral steroids for rotator cuff tendonitis 3, 4
• Number needed to treat is 3.3 patients for one improvement 4
• Higher doses (≥50 mg prednisone equivalent) show better efficacy (relative risk 5.9) 4
• Injections are superior to NSAIDs with NNT of 2.5 4

Hemiplegic Shoulder Pain (Post-Stroke)

• Subacromial corticosteroid injections when pain is related to rotator cuff or bursa inflammation 1
• Botulinum toxin injections to subscapularis/pectoralis muscles for spasticity-related pain 1
• Oral prednisone is not recommended as first-line for post-stroke shoulder pain 1

What NOT to Do

• Do not use initial prednisone doses >30 mg/day for PMR (strong recommendation against) 1
• Do not use doses ≤7.5 mg/day as initial treatment for PMR (conditional recommendation against) 1
• Avoid overhead pulley exercises for shoulder pain—they encourage uncontrolled abduction and may worsen outcomes 1
• Do not use oral prednisone as first-line for non-specific shoulder pain when the diagnosis is unclear 1, 3

Practical Algorithm for Shoulder Pain

1. Identify the specific diagnosis first 1:

   • Bilateral shoulder pain + morning stiffness + age >60 + elevated ESR/CRP = Consider PMR → Oral prednisone 10-20 mg 1
   • Unilateral frozen shoulder with severe restriction = Consider oral prednisolone 30 mg × 3 weeks 2
   • Rotator cuff disease/subacromial pathology = Subacromial injection preferred 3, 4
   • Post-stroke shoulder pain = Injection or botulinum toxin, not oral steroids 1

2. For PMR specifically: Rule out giant cell arteritis (check for headache, jaw claudication, visual symptoms) before starting treatment 1, 5

3. Monitor response closely: If using oral prednisone for PMR, follow-up every 4-8 weeks in first year 1

Important Caveats

• Oral prednisone for adhesive capsulitis provides only short-term benefit (3-6 weeks), so plan for additional interventions 2
• The evidence for oral prednisone in non-specific shoulder pain is weak compared to targeted injections 3
• Consider patient comorbidities (diabetes, osteoporosis, glaucoma) when choosing between oral steroids and injections—injections have lower systemic exposure 1
• Neither dose nor preparation type (methylprednisolone vs triamcinolone) significantly affects outcomes for shoulder injections 6