Treatment for Subacromial Bursitis with Impingement and Tendinopathy
The recommended first-line treatment for subacromial bursitis with impingement and tendinopathy is a conservative approach including relative rest, NSAIDs, physical therapy with eccentric strengthening exercises, and corticosteroid injections if symptoms persist. 1, 2
Initial Conservative Management
Rest and Activity Modification
- Relative rest and reduced activity to prevent further damage and promote healing 1
- Avoid complete immobilization to prevent muscular atrophy 1
- Modify technique for athletes and manual laborers to minimize repetitive stresses on tendons 1
Pain Management
- NSAIDs (oral or topical) for short-term pain relief
- Cryotherapy (ice) for acute pain relief
- Apply ice through a wet towel for 10-minute periods 1
Physical Therapy Interventions
Exercise Therapy
- Eccentric strengthening exercises are recommended to:
- Reduce symptoms
- Increase strength
- Promote tendon healing 1
- Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
- Stretching exercises for the rotator cuff muscles 1
Other Physical Therapy Modalities
- Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
- Hyperthermia has shown moderate evidence of effectiveness compared to exercise therapy or ultrasound in the short term 4
- Deep transverse friction massage may help reduce pain 1
Injection Therapy
Corticosteroid Injections
- Subacromial corticosteroid injection is effective for short-term pain relief when conservative measures fail 5
- Triamcinolone acetonide (5-15 mg) can be injected into the subacromial space 6
- Benefits include:
- Substantial decrease in pain
- Increased range of motion of the shoulder 5
- Caution: Corticosteroid injections into the tendon substance should be avoided as they may weaken the tendon and predispose to rupture 1
Ultrasound-Guided Injections
- Ultrasound guidance can ensure accurate placement of injections into the subacromial bursa 1
- Rated highly appropriate (9/9) for bursitis management according to ACR criteria 1
Advanced Treatment Options
Extracorporeal Shock Wave Therapy (ESWT)
- May reduce pain and promote tendon healing
- Appears to be safe and effective, though further research is needed 1
Iontophoresis and Phonophoresis
- Uses electric and ultrasonic impulses to deliver topical NSAIDs and corticosteroids
- Widely used but lacks strong evidence from well-designed RCTs 1
Surgical Consideration
- Surgery should be considered only if pain persists despite 3-6 months of well-managed conservative treatment 2
- Surgical techniques typically include:
- Excision of abnormal tendon tissue
- Longitudinal tenotomies to release areas of scarring and fibrosis 1
- No high-quality evidence shows superior outcomes with surgery compared to conservative treatment 7
Treatment Algorithm
First 4-6 weeks:
- Relative rest and activity modification
- NSAIDs (oral or topical)
- Ice therapy
- Begin physical therapy with eccentric strengthening exercises
If inadequate improvement after 4-6 weeks:
- Consider corticosteroid injection (triamcinolone 5-15 mg) into subacromial space
- Continue physical therapy
If symptoms persist after 3-6 months of conservative treatment:
- Consider referral to orthopedic surgeon for surgical evaluation 2
Common Pitfalls and Caveats
- Avoid complete immobilization as it leads to muscle atrophy and deconditioning 1
- Corticosteroid injections should not be placed directly into the tendon substance due to risk of tendon weakening and rupture 1
- Supraspinatus tendinopathy often coexists with subacromial bursitis and should be addressed in the treatment plan 1
- Recognize that 10% of rotator cuff tears are asymptomatic and may be incidental findings 1
- Consider underlying anatomical factors that may contribute to impingement, such as acromial morphology 1