What is the recommended treatment for a patient with mild tendinosis in the supraspinatus tendon and subacromial/subdeltoid bursitis, with few cystic lesions in the head of the humerus?

Treatment for Supraspinatus Tendinosis and Subacromial/Subdeltoid Bursitis

Begin with conservative management consisting of relative rest, cryotherapy, NSAIDs for pain relief, and eccentric strengthening exercises, with corticosteroid injection into the subacromial-subdeltoid bursa reserved for acute pain relief when conservative measures are insufficient. 1, 2

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest by reducing repetitive overhead activities and movements that load the supraspinatus tendon, but avoid complete immobilization which causes muscle atrophy and deconditioning 1, 2
• Allow continuation of activities that do not worsen pain 2

Cryotherapy

• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief and reduce bursal inflammation 1, 2
• This reduces tissue metabolism and blunts the inflammatory response in acute bursitis 1

Pharmacologic Pain Management

• Prescribe NSAIDs for short-term pain relief, recognizing they provide symptomatic benefit but do not alter long-term outcomes 1, 2
• Topical NSAIDs offer similar pain relief with reduced gastrointestinal hemorrhage risk compared to systemic NSAIDs 1, 2

Rehabilitation Protocol (Essential Component)

Eccentric Strengthening Exercises

• Initiate eccentric exercises for the supraspinatus tendon as they stimulate collagen production, guide normal alignment of newly formed collagen fibers, and may reverse degenerative changes 1, 2
• Tensile loading has proven beneficial in tendinosis and should be the foundation of rehabilitation 1

Stretching

• Include stretching exercises as they are widely accepted and generally helpful in tendinopathies 1

Corticosteroid Injection (When Conservative Measures Insufficient)

Indications and Efficacy

• Corticosteroid injection into the subacromial-subdeltoid bursa is more effective than oral NSAIDs for acute pain relief, though it does not alter long-term outcomes 1, 2, 3
• Combined corticosteroid injection with physiotherapy shows superior outcomes compared to physiotherapy alone in chronic subacromial bursitis 3

Important Caveats

• Use corticosteroid injections with caution as they may inhibit healing and reduce tensile strength of the tendon if injected into the tendon substance 1
• Inject into the subacromial-subdeltoid bursa (peritendinous), NOT into the tendon itself 1, 4
• Ultrasound guidance is recommended to ensure accurate placement and avoid vascular structures, nerves, and tendons 4
• Recurrence rates are higher with corticosteroid injection alone (36.1%) compared to physiotherapy alone (7.5%) or combined treatment (17.1%) 3

Regarding the Cystic Lesions in Humeral Head

• The few cystic lesions noted in the humeral head are likely degenerative changes and do not alter the primary treatment approach for tendinosis and bursitis 1
• These do not represent Hill-Sachs or reverse Hill-Sachs lesions, which would indicate instability requiring different management 1

Treatment Algorithm

1. Weeks 0-6: Relative rest, cryotherapy, NSAIDs, and initiate eccentric strengthening exercises 1, 2
2. If inadequate pain relief at 2-4 weeks: Consider corticosteroid injection into subacromial-subdeltoid bursa (preferably ultrasound-guided) combined with continued physiotherapy 4, 3
3. Weeks 6-12: Continue eccentric exercises and progressive strengthening 1, 2
4. If symptoms persist beyond 3-6 months: Refer to orthopedic surgery for evaluation 1, 2

Common Pitfalls to Avoid

• Never completely immobilize the shoulder as this accelerates muscle atrophy and deconditioning 1, 2
• Do not inject corticosteroids directly into the supraspinatus tendon substance as this may predispose to spontaneous rupture 1
• Recognize that approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 5
• The presence of bursitis indicates an inflammatory component that may respond well to corticosteroid injection, but long-term outcomes depend on addressing the underlying tendinosis with eccentric exercises 1, 3