What are the preferred Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for managing rotator cuff tendinitis?

Preferred NSAIDs for Rotator Cuff Tendinitis Management

Naproxen is the preferred NSAID for managing rotator cuff tendinitis, used at the lowest effective dose for the shortest duration necessary, considering the patient's renal function, age, and comorbidities. 1

First-Line Medication Approach

The American Academy of Orthopaedic Surgeons recommends a multimodal approach to rotator cuff tendinitis management that includes:

1. NSAIDs: Should be administered as a first-line medication along with paracetamol (acetaminophen)

   • Naproxen is specifically recommended by the American Academy of Family Physicians 1
   • NSAIDs have demonstrated superior efficacy compared to acetaminophen for pain relief in rotator cuff tendinitis 2

2. Paracetamol (Acetaminophen): Should be administered regularly to prevent pain escalation

   • While useful as part of multimodal therapy, a 2019 randomized study showed that ibuprofen provided better improvement in pain severity and functional activity compared to acetaminophen 2

Evidence for NSAID Efficacy

The PROSPECT guideline (2019) strongly recommends NSAIDs as part of the systemic analgesia regimen for rotator cuff problems, stating they should be:

• Administered pre-operatively or intra-operatively
• Continued postoperatively
• Used as part of a multimodal approach including paracetamol 3

A comparative study showed that NSAIDs (specifically ibuprofen) provided better improvement in pain severity and functional activity as measured by SPADI and Quick-DASH scores, while acetaminophen showed better improvement in quality of life domains 2.

NSAID Selection Algorithm

When selecting an NSAID for rotator cuff tendinitis:

1. First choice: Naproxen at lowest effective dose

   • Recommended by clinical guidelines 1
   • Good balance of efficacy and safety profile

2. Alternative: Ibuprofen (400-800mg every 6-8 hours)

   • Demonstrated efficacy in randomized trials 2
   • Part of recommended regimen in PROSPECT guidelines 3

3. For patients with GI risk factors:

   • Consider COX-2 selective inhibitors
   • The PROSPECT guideline specifically mentions COX-2 inhibitors as effective 3

Important Considerations and Cautions

• NSAIDs should be used at the lowest effective dose for the shortest duration necessary
• Consider patient's renal function, age, and comorbidities when prescribing NSAIDs 1
• Avoid long-term use of NSAIDs due to potential cardiovascular, renal, and gastrointestinal side effects
• Opioids should be reserved only for rescue analgesia when other methods fail 1

Comprehensive Management Approach

While NSAIDs are the preferred medication, optimal management includes:

• Physical therapy for at least 8-12 weeks 1
• Activity modification to avoid overhead activities 1
• Consider a single corticosteroid injection if pain limits rehabilitation progress, but use with caution as it may impair tendon healing 1, 4
• Surgical intervention only if conservative management fails after 8-12 weeks 1

The evidence consistently supports NSAIDs as more effective than acetaminophen alone for rotator cuff tendinitis, with naproxen being the specifically recommended NSAID according to current guidelines.