What is the recommended management for mild tendinosis of the supraspinatus with no discrete tear and subacromial subdeltoid bursitis in a healthy 36-year-old female?

Management of Mild Supraspinatus Tendinosis with Subacromial Subdeltoid Bursitis

First-line management for mild supraspinatus tendinosis with subacromial subdeltoid bursitis should include NSAIDs, relative rest with activity modification, and a structured physical therapy program focusing on eccentric strengthening exercises for the rotator cuff. 1

Pharmacological Management

• NSAIDs: Should be used as first-line medication for pain and inflammation

  • Naproxen 500mg initially, followed by 500mg every 12 hours or 250mg every 6-8 hours as needed
  • Initial total daily dose should not exceed 1250mg, with subsequent daily doses not exceeding 1000mg 2
  • Duration: As needed for pain control

• Acetaminophen: Can be used as an alternative if NSAIDs are contraindicated or poorly tolerated

  • Dosage: Up to 4g/day 1

• Corticosteroid Injection: Consider if symptoms persist despite 4-6 weeks of conservative management

  • Limited to 2-3 injections with 4-6 weeks between injections 1
  • Ultrasound guidance improves accuracy of placement into the subacromial bursa 3
  • Caution: Avoid multiple repeated injections due to potential tendon weakening

Non-Pharmacological Management

Physical Therapy (Critical Component)

• Initiate immediately alongside medication management 1
• Focus on:
  • Eccentric strengthening exercises for rotator cuff muscles
  • Scapular stabilization exercises
  • Range of motion exercises
  • Deep transverse friction massage to reduce pain
  • Supervised exercise program is superior to home-based programs 4

Activity Modification

• Relative rest during acute phase
• Avoid overhead movements that stress the supraspinatus tendon
• Gradually return to activities as symptoms improve
• Modify work or recreational activities that exacerbate symptoms 1

Other Conservative Measures

• Ice application for 15-20 minutes several times daily during acute phase
• Heat therapy may be beneficial in later stages to improve blood flow
• Consider Extracorporeal Shock Wave Therapy (ESWT) if symptoms persist despite 3 months of conservative treatment 1

Monitoring and Follow-up

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan if no improvement after 8-12 weeks of consistent therapy
• Over 90% of cases have good prognosis with appropriate conservative management
• Complete resolution typically requires 3-6 months 1

Advanced Interventions (if conservative measures fail)

• Ultrasound-guided prolotherapy may be considered as an alternative to corticosteroid injections with similar efficacy but fewer side effects 3
• Surgical consultation if pain persists despite 3-6 months of well-managed conservative treatment 1

Important Considerations

• MRI is the preferred imaging modality for confirming diagnosis and ruling out full-thickness tears 1, 5
• Biomechanical dysfunction of the rotator cuff and glenohumeral complex contributes to the pathophysiology and should be addressed in therapy 6
• Diabetic patients may respond less favorably to conservative measures and may require modified approaches 1
• The presence of acromioclavicular joint degeneration may complicate the clinical picture and require additional management strategies 1

Remember that even with optimal management, resolution typically requires 3-6 months of consistent treatment. Patience and adherence to the treatment plan are essential for successful outcomes.