What is the recommended treatment for a patient with subacromial bursitis and impingement, presenting with 2 months of right shoulder pain, limited flexion, and painful abduction?

Treatment Recommendation for Subacromial Bursitis with Impingement

Begin with a 3-6 month trial of conservative management consisting of structured physical therapy targeting rotator cuff and scapular stabilizer strengthening combined with NSAIDs, before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

The American Academy of Orthopaedic Surgeons establishes conservative treatment as the standard initial approach for subacromial impingement syndrome. 1 This patient's ultrasound findings—moderate bursal thickening with symptomatic impingement, mild supraspinatus tendinosis with calcification, and AC joint changes—align perfectly with this conservative-first strategy.

Structured Exercise Program

• Implement rotator cuff strengthening exercises targeting the supraspinatus (which shows tendinosis in this case), infraspinatus, subscapularis, and teres minor. 1

• Include scapular stabilizer strengthening as a critical component, since scapular dyskinesis contributes significantly to impingement pathology and this patient demonstrates limited abduction. 1

• Add periscapular muscle strengthening to address the mechanical dysfunction causing the painful arc and positive impingement signs. 1

Pharmacologic Management

• Prescribe NSAIDs concurrently with the exercise program as recommended by the American Academy of Orthopaedic Surgeons for initial treatment. 1

Corticosteroid Injection Considerations

The evidence for subacromial corticosteroid injections shows conflicting results, but they may be considered if conservative measures provide insufficient relief. 1

When to Consider Injection

• If pain significantly limits participation in physical therapy after 4-6 weeks of conservative treatment, ultrasound-guided corticosteroid injection into the subacromial-subdeltoid bursa can provide pain relief. 2

• Corticosteroid injection (20 mg triamcinolone) is superior to both hyaluronic acid and normal saline for treating chronic subacromial bursitis at 8 weeks, with significant reductions in pain VAS scores (2.56 vs 4.71 for saline, P<0.001). 2

• The injection can be performed under ultrasound guidance (as noted in the ACR guidelines), which this patient has already undergone for diagnostic purposes. 3

Important Caveat About Injection Timing

• Peak therapeutic benefit occurs by 2 weeks post-injection with gradual loss of effect thereafter, so this should be viewed as an adjunct to facilitate physical therapy participation rather than definitive treatment. 4

• Five level II studies show variable results for corticosteroid injections between 2-6 weeks, highlighting the inconsistent and temporary nature of this intervention. 1

Surgical Considerations (Only After Failed Conservative Treatment)

Surgery should NOT be considered until after 3-6 months of failed conservative treatment. 1

Critical Evidence Against Early Surgery

• The British Medical Journal states that current evidence does not support subacromial decompression surgery as first-line treatment, as it does not provide clinically important improvements in pain, function, or quality of life compared to other treatments. 1

• Multiple randomized clinical trials demonstrate no benefit for arthroscopic subacromial decompression as initial treatment in patients with subacromial bursitis. 5

• Arthroscopic subacromial decompression is indicated only for refractory subacromial bursitis that has failed conservative management. 5

Treatment Algorithm for This Patient

1. Weeks 0-6: Structured physical therapy (rotator cuff and scapular stabilizer strengthening) + NSAIDs. 1

2. Week 4-6 assessment: If pain significantly limits therapy participation, consider ultrasound-guided corticosteroid injection (20 mg triamcinolone) to facilitate continued physical therapy. 2

3. Weeks 6-12: Continue intensive physical therapy regardless of injection status. 1

4. Month 3 assessment: If no improvement, continue conservative treatment through month 6. 1

5. Month 6 assessment: Only if complete failure of conservative treatment should surgical evaluation be considered, though evidence does not clearly support surgery over continued conservative care. 1, 5

Special Considerations for This Case

• The small calcification in the mid supraspinatus tendon may contribute to symptoms but does not change the initial conservative management approach. 6

• The AC joint capsular bulging without focal tenderness suggests this is not the primary pain generator and does not require specific intervention at this time. 3

• The rotator cuff interval thickening is consistent with the overall impingement syndrome and should respond to the same conservative measures. 3