What is the initial treatment for mild subacromial and subdeltoid bursitis?

Initial Treatment for Mild Subacromial and Subdeltoid Bursitis

Begin with a 3-6 month trial of structured physical therapy targeting rotator cuff and scapular stabilizer strengthening combined with NSAIDs, as this represents the evidence-based standard of care before considering any invasive interventions. 1, 2

First-Line Conservative Management

Therapeutic Exercise Program

• Implement rotator cuff strengthening exercises targeting the supraspinatus, infraspinatus, subscapularis, and teres minor muscles 2
• Include scapular stabilizer strengthening as a critical component, since scapular dyskinesis contributes significantly to impingement pathology and bursitis 1, 2
• Add periscapular muscle strengthening to address the mechanical dysfunction causing the painful arc 2
• Gradually increase range of motion with gentle stretching and mobilization techniques, focusing on external rotation and abduction 3

Pharmacologic Management

• Prescribe NSAIDs concurrently with the exercise program as recommended initial treatment 1, 2, 3
• For acute tendonitis and bursitis, naproxen dosing is 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required, with initial total daily dose not exceeding 1250 mg 4
• Use the lowest effective dose for the shortest duration consistent with treatment goals 4

Adjunctive Therapies

• Apply thermal interventions (locally applied heat or cold) for symptomatic relief 3
• Do NOT use massage therapy, as the American College of Rheumatology/Arthritis Foundation conditionally recommends against massage for shoulder conditions due to lack of evidence demonstrating benefit 3

Second-Line Options (If No Improvement After 4-8 Weeks)

Corticosteroid Injection Considerations

• Consider subacromial corticosteroid injection when pain is thought to be related to inflammation of the subacromial region 5, 3
• The injection can be performed under ultrasound guidance for improved accuracy 2
• Important caveat: Five level II studies show variable and inconsistent results for corticosteroid injections between 2-6 weeks, highlighting the temporary nature of this intervention 1, 2
• Recent evidence from 2023 shows corticosteroid injection provides superior short-term pain relief compared to physiotherapy alone, but has a significantly higher recurrence rate (36.1% vs 7.5%) 6
• A 2021 randomized controlled trial demonstrated corticosteroid injection was more effective than hyaluronic acid or normal saline at 8 weeks for chronic subacromial bursitis 7

Special Consideration for Refractory Cases

• If significant bursal fluid distension is present on imaging and pain remains intractable despite conservative management, consider combined ultrasound-guided aspiration of bursal fluid with corticosteroid injection, as this has shown effectiveness in case reports 8

Treatment Duration and Monitoring

• Continue conservative treatment for 3-6 months before considering surgical evaluation 2, 3
• Reassess response to treatment regularly, adjusting exercise intensity and NSAID dosing based on clinical response 4

Critical Pitfalls to Avoid

• Avoid direct Achilles tendon injection if treating posterior heel bursitis, as this can cause tendon rupture 5
• Do not rush to 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 conservative treatments 1, 2, 3
• Be aware that septic bursitis, including methicillin-resistant Staphylococcus aureus infection, is a rare but serious complication of subacromial injections 9
• Adjust NSAID dosing in elderly patients, those with renal impairment (avoid if creatinine clearance <30 mL/min), or hepatic impairment 4

Algorithm Summary

1. Weeks 0-12: Structured exercise program + NSAIDs + thermal therapy
2. Weeks 4-8: If inadequate response, consider adding corticosteroid injection (recognizing higher recurrence risk)
3. Months 3-6: Continue conservative measures; only consider surgical evaluation if complete failure of conservative treatment
4. Throughout: Avoid massage therapy, avoid premature surgery, monitor for adverse effects