What is the recommended treatment for Subacromial Bursitis or Rotator Cuff Tendinitis?

Treatment of Subacromial Bursitis and Rotator Cuff Tendinitis

Exercise therapy and NSAIDs should be the initial treatment for patients with subacromial bursitis or rotator cuff tendinitis, with corticosteroid injections reserved for those who don't respond adequately to first-line treatment. 1

First-Line Treatment Options

Exercise Therapy

• Implement eccentric strengthening exercises focusing on:
  • Rotator cuff strengthening (particularly external rotators)
  • Scapular stabilization exercises
  • Either supervised or home-based physical therapy programs
• Several level II studies demonstrate that exercise therapy decreases pain and improves function in patients with rotator cuff-related symptoms 2
• Exercise programs should continue for at least 8-12 weeks for optimal results

Pharmacological Management

• NSAIDs (such as naproxen) are recommended as first-line pharmacological treatment 1, 3
  • Start with lowest effective dose (e.g., naproxen 250-500mg twice daily)
  • Use for shortest duration necessary to control symptoms
  • Consider patient's renal function, age, and comorbidities when prescribing
• Acetaminophen can be used for regular administration to prevent pain increases, particularly in patients who cannot tolerate NSAIDs 1

Activity Modification

• Avoid overhead activities and positions that exacerbate symptoms
• Implement technique modification for athletes and manual laborers
• Complete immobilization should be avoided as it can lead to muscle atrophy 1

Second-Line Treatment Options

Corticosteroid Injections

• Consider for patients who don't respond adequately to exercise and NSAIDs
• Evidence regarding efficacy is mixed:
  • Moderate evidence supports short-term improvement in pain and function 1
  • Some studies show conflicting results for durations between 2-6 weeks 2
• A recent randomized controlled trial (2023) showed corticosteroid injections were superior to physiotherapy alone for pain relief and improving range of motion 4
• However, recurrence rates are higher with corticosteroid injections alone (36.1%) compared to physiotherapy alone (7.5%) 4

Combination Therapy

• Combined approach (corticosteroid injection plus physiotherapy) shows superior outcomes to physiotherapy alone with moderate recurrence rates (17.1%) 4
• This approach may be particularly beneficial for patients with significant pain that limits their ability to participate effectively in physiotherapy

Additional Treatment Considerations

Adjunctive Therapies

• Evidence is limited or inconclusive for:
  • Hyaluronic acid injections
  • Deep transverse friction massage
  • Ultrasound therapy
  • Extracorporeal shock wave therapy
  • Pulsed electromagnetic field therapy (PEMF) 2, 1
• No strong evidence supports or refutes the use of iontophoresis, phonophoresis, TENS, ice, heat, or massage 2

Surgical Management

• Consider only after failure of 3-6 months of appropriate conservative treatment 1
• Arthroscopic subacromial decompression has not shown clinically important benefits over non-operative care or placebo surgery 2
• Rotator cuff repair may be considered for full-thickness tears when conservative measures fail 1

Prognosis

• Most rotator cuff injuries (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment 1
• Better outcomes are associated with:
  • Younger age
  • Absence of comorbidities (particularly diabetes)
  • Early implementation of appropriate exercise therapy
  • Adherence to treatment plan

Treatment Algorithm

1. Initial Management (0-6 weeks):

   • Exercise therapy + NSAIDs + activity modification
   • Reassess at 4-6 weeks

2. If inadequate response after 6 weeks:

   • Add corticosteroid injection
   • Continue modified exercise program
   • Reassess at 12 weeks

3. If still inadequate response after 12 weeks:

   • Consider combination therapy (injection + specialized physiotherapy)
   • Reassess at 24 weeks

4. If persistent symptoms beyond 24 weeks:

   • Consider surgical referral, particularly for full-thickness tears

Common Pitfalls to Avoid

• Relying solely on corticosteroid injections without addressing underlying biomechanical issues through exercise
• Prescribing complete rest or immobilization, which can lead to muscle atrophy
• Failing to modify activities that exacerbate symptoms
• Using high-dose NSAIDs for prolonged periods without monitoring for adverse effects
• Rushing to surgical intervention before adequate trial of conservative management