The evolving efficacy landscape of intra-articular injections for rotator cuff injuries over time: a network meta-analysis of randomized controlled studies

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. 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. 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. 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. 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 I Systematic Review and MetaAnalysis.