How to manage subacromial tendinopathy?

Management of Subacromial Tendinopathy

Subacromial tendinopathy should be managed primarily with conservative treatment including NSAIDs for pain relief, eccentric strengthening exercises, and relative rest, with subacromial corticosteroid injection reserved for persistent symptoms beyond 6 weeks. 1, 2

Initial Conservative Management (First 6 Weeks)

Pain Control

• NSAIDs (such as ibuprofen) are first-line for short-term pain relief, though they do not affect long-term outcomes 1
• Topical NSAIDs provide equivalent pain relief while eliminating gastrointestinal hemorrhage risk associated with oral formulations 1
• Cryotherapy through a wet towel for 10-minute periods provides effective short-term pain relief 1

Activity Modification

• Relative rest is essential—avoid activities that worsen pain while maintaining activities that don't aggravate symptoms 1, 2
• Complete immobilization must be avoided as it causes muscular atrophy and deconditioning 1
• For athletes and manual laborers, technique modification to minimize repetitive overhead stresses is critical 3

Exercise Therapy

• Eccentric strengthening exercises are the cornerstone of rehabilitation, proven beneficial in multiple tendinopathies 1
• Exercise should be low intensity and high frequency, combining eccentric training with attention to posture and relaxation 2
• Codman's pendulum exercises are appropriate during the acute phase (first 15 days) 4
• Myofascial trigger point treatment including muscle stretching may be considered 2

Management of Persistent Symptoms (After 6 Weeks)

Diagnostic Imaging

• Ultrasound examination is the recommended imaging modality after 6 weeks of symptoms to exclude rotator cuff rupture 2
• MRI may be used but ultrasound is preferred as first-line imaging 2

Corticosteroid Injection

• Subacromial corticosteroid injection is indicated for persistent or recurrent symptoms beyond 6 weeks 2
• Two injections of 40 mg methylprednisolone with 10 cc of 1% lidocaine, given 10 days apart, provide additional short-term benefit when combined with NSAIDs and exercise 4
• Important caveat: Corticosteroid injections provide short-term relief but do not improve long-term outcomes and may have deleterious effects on tendon healing 1
• Avoid direct injection into the tendon substance as this inhibits healing and may predispose to rupture 5

Occupational Interventions

• Workplace modifications are useful when complaints persist longer than 6 weeks 2

Advanced Conservative Options (Chronic Cases)

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and effective for chronic tendinopathies, though it can be expensive 1
• Further research is needed to clarify optimal treatment strategies 3

Specialized Rehabilitation

• Consider rehabilitation in a specialized unit for chronic, treatment-resistant cases with pain-perpetuating behavior 2

Emerging Evidence: Platelet-Rich Plasma (PRP)

• The most recent high-quality evidence shows PRP injection provides superior pain relief and functional outcomes compared to corticosteroids at 12 months 6
• PRP demonstrated significantly better VAS scores (1.68 vs 2.3), ASES scores (89.8 vs 78.0), and lower failure rates (12% vs 30%) compared to corticosteroids 6
• This represents a potential paradigm shift, though PRP is not yet included in standard guidelines 6

Surgical Consideration

• Surgery should only be considered after 3-6 months of well-managed conservative treatment failure 1, 2
• There is no convincing evidence that surgical treatment is more effective than conservative management 2
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring 3
• Asymptomatic rotator cuff tears have no indication for surgical treatment 2

Critical Pitfalls to Avoid

• Do not use strict immobilization or aggressive mobilization techniques—both are contraindicated 2
• Avoid multiple corticosteroid injections as they may weaken tendon structure despite short-term symptom relief 1
• Do not proceed to surgery without adequate conservative trial of at least 3-6 months 1, 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1