Medicine regenerative versus steroids: time to reconsider treatment of chronic inflammatory pain

BACKGROUND: Chronic musculoskeletal and spinal pain is a major clinical challenge. Corticosteroid (CS) injections provide rapid analgesia, but it is typically short-lived and may have adverse tissue-related effects. The most commonly used regenerative treatment is platelet-rich plasma (PRP), which modulates inflammation and extracellular matrix turnover and partly affects nociceptive signalling. PRP also has potential for longer-term disease-modifying benefits. This review compares PRP with CS in key musculoskeletal joints and spinal pain indications with focus on effectiveness, durability, and safety. METHODS: We conducted a review with a systematic search of PubMed/MEDLINE, Embase, Scopus, Cochrane Library, Web of Science, and Google Scholar (January 2000 - March 2025). English-language randomized controlled trials (RCTs) and prospective studies evaluating PRP versus CS (± local anesthetic) in osteoarthritis, tendinopathies, and spinal pain (discogenic, facet/zygapophyseal, sacroiliac joint, radicular) were included. The primary outcomes were pain intensity, function, and durability. Safety information was extracted when reported. Given the heterogeneity in the PRP formulations (leukocyte-poor/leukocyte-rich, platelet dose, activation), target tissues, and follow-up, the findings were synthesized qualitatively according to anatomical region and integrated with mechanistic evidence. RESULTS: Across indications, CS showed an early advantage at 2-8 weeks, whereas PRP demonstrated superior pain and functional outcomes at ≥3-6 months. In plantar fasciitis and osteoarthritis of the knee, PRP outperformed CS at 3-12 months. In gluteal tendinopathy, benefits of PRP emerged by 12 weeks. For cervical/lumbar facet and sacroiliac joint pain, PRP yielded more durable relief up to 6 months. In epidural approaches, PRP was non-inferior in the short term and in some studies superior by 24 weeks, and intradiscal PRP showed encouraging longer-term signals. Both strategies were generally safe, although local/systemic adverse events were more frequent with CS. Outcome variability was partly attributable to heterogeneity of PRP products. CONCLUSIONS: For inflammatory-degenerative musculoskeletal and spinal conditions, PRP seems to offer more persistent benefits than CS, while CS is valuable for rapid short-term analgesia. Treatment selection should be guided by phenotype. Standardization of PRP protocols (composition, dose, activation) and high-quality multicentre RCTs are still needed. Conceptualizing PRP as primarily an immuno-inflammatory modulator drug in pain therapy rather than strictly "regenerative" may better explain its longer-term effects.