What is the initial management for a patient with subacromial bursitis and elbow pain?

Initial Management of Subacromial Bursitis with Elbow Pain

Begin with plain radiographs of both the shoulder and elbow to exclude fractures, heterotopic ossification, loose bodies, or other osseous pathology, followed by conservative management consisting of rest, activity modification, NSAIDs, and physical therapy, reserving corticosteroid injections for persistent symptoms beyond 4-6 weeks. 1, 2

Diagnostic Workup

Initial Imaging

• Obtain plain radiographs of both affected joints as the mandatory first-line imaging to exclude fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, and osteoarthritis 1
• Radiographs may reveal joint effusions (indicated by fat pad elevation in the elbow), avulsion fractures, or calcific tendinosis that directly impact treatment decisions 1
• Comparison views with the contralateral asymptomatic side are often useful for detecting subtle abnormalities 1

Advanced Imaging (If Initial Radiographs Normal)

• Consider MRI without contrast if radiographs are normal or nonspecific and symptoms persist beyond 6 weeks, particularly to evaluate for rotator cuff tears in the shoulder or tendon/ligament pathology in the elbow 2, 3
• Ultrasound examination is the recommended imaging modality to exclude rotator cuff rupture in subacromial pain syndrome 3

Conservative Management (First-Line Treatment: 0-6 Weeks)

Activity Modification and Rest

• Implement relative rest with avoidance of overhead activities and movements that provoke pain, while maintaining gentle range of motion to prevent stiffness 1, 2, 3
• Activity modification is a cornerstone of conservative management and should be emphasized from the outset 1, 2

Pharmacologic Management

• Initiate NSAIDs for pain relief and anti-inflammatory effect 1, 2, 4
• For acute bursitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required (initial daily dose should not exceed 1250 mg, thereafter not exceeding 1000 mg daily) 5
• Use the lowest effective dose for the shortest duration to minimize gastrointestinal and cardiovascular risks 5

Physical Therapy

• Begin specific exercise therapy emphasizing low-intensity, high-frequency exercises combining eccentric training, attention to posture and relaxation, and stretching 3
• Functional rehabilitation focusing on motion restoration and progressive strengthening is preferred over immobilization 4
• Avoid strict immobilization and aggressive mobilization techniques 3

Adjunctive Measures

• Apply ice (cryotherapy) for 10-minute periods through a wet towel, 3-4 times daily to reduce pain and swelling 2, 4
• Consider compression wrap or padding for comfort, ensuring it doesn't compromise circulation 2, 4

Second-Line Treatment (Persistent Symptoms at 4-6 Weeks)

Corticosteroid Injections

• Subacromial corticosteroid injection is indicated for persistent or recurrent symptoms despite adequate conservative management 3
• For subacromial bursitis, ultrasound-guided subdeltoid injection improves accuracy and outcomes 6, 7
• Important caveat: Corticosteroid injections provide effective short-term pain relief but have higher recurrence rates (36% in one study) compared to physiotherapy alone (7.5% recurrence) 6
• Use with caution due to potential complications including skin atrophy, infection risk (including rare methicillin-resistant Staphylococcus aureus septic bursitis), and tendon weakening 2, 8
• The therapeutic benefit typically peaks by 2 weeks post-injection with gradual loss of effect over time 9

Combined Approach

• Combination of corticosteroid injection with continued physiotherapy may provide superior outcomes compared to either treatment alone, particularly for pain reduction and functional improvement at 3 months 6
• This combined approach balances the rapid pain relief from injection with the lower recurrence rate associated with exercise therapy 6

Occupational Considerations

• Implement occupational interventions when complaints persist longer than 6 weeks, particularly for work-related activities 3

Refractory Cases (>6-12 Months)

Specialized Rehabilitation

• Consider referral to a specialized rehabilitation unit for chronic, treatment-resistant cases with pain-perpetuating behavior 3

Surgical Consultation

• Surgical intervention should only be considered after failure of 6-12 months of appropriate conservative management 2, 3
• Critical evidence gap: There is no convincing evidence that surgical treatment for subacromial pain syndrome is more effective than conservative management 3
• Surgery may be indicated for severe or refractory cases with specific structural pathology (collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities in the elbow) 1

Common Pitfalls to Avoid

• Do not rush to corticosteroid injection before adequate trial of conservative management (minimum 4-6 weeks), as this increases recurrence risk 6, 3
• Do not use repeated corticosteroid injections due to cumulative side effects and diminishing returns 6, 7
• Do not immobilize the joint as this leads to stiffness and worse functional outcomes 3
• Do not overlook septic arthritis in patients with joint effusion and systemic signs of infection, which requires urgent aspiration and culture 10
• Do not assume both conditions are related—evaluate each joint independently as they may have different etiologies requiring distinct treatment approaches 1