What is the initial treatment approach for shoulder bursitis versus tendonitis?

Initial Treatment Approach for Shoulder Bursitis vs Tendonitis

Both shoulder bursitis and tendonitis should be treated initially with the same conservative approach: relative rest, NSAIDs for short-term pain relief, ice application, and early range-of-motion exercises, with subacromial corticosteroid injection reserved for cases where pain is specifically related to subacromial bursal or rotator cuff inflammation. 1

Conservative Management (First-Line for Both Conditions)

Activity Modification and Rest

• Reduce repetitive loading activities that stress the affected shoulder 1
• Avoid overhead movements and activities that reproduce pain 1
• Do not use overhead pulleys, which encourage uncontrolled abduction and can worsen symptoms 1

Cryotherapy

• Apply melting ice water through a wet towel for 10-minute periods 1
• Repeat applications provide acute pain relief and are widely accepted 1
• Ice is effective for both bursitis and tendonitis 1, 2

NSAIDs for Pain Control

• NSAIDs are recommended for short-term pain relief but have no effect on long-term outcomes 1
• Acetaminophen or ibuprofen can be used if no contraindications exist 1, 3
• For acute bursitis/tendonitis, naproxen 500 mg followed by 500 mg every 12 hours (not exceeding 1250 mg first day, then 1000 mg daily thereafter) 4
• Topical NSAIDs are effective and may have fewer systemic side effects 1

Range of Motion Exercises

• Initiate gentle stretching and mobilization techniques early 1
• Focus especially on external rotation and abduction to prevent frozen shoulder 1
• Active range of motion should be increased gradually 1
• Eccentric strengthening is effective for tendinopathy and may reverse degenerative changes 1

When to Consider Corticosteroid Injection

Subacromial Injection Indications

• Use subacromial corticosteroid injections when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1
• Triamcinolone is indicated for acute and subacute bursitis, acute nonspecific tenosynovitis 5
• Locally injected corticosteroids may be more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1

Important Caveat

• Avoid steroid injection into the retrocalcaneal bursa as it may adversely affect tendon biomechanical properties 2
• This principle suggests caution with injections near critical tendons in the shoulder as well

Additional Modalities (Uncertain Benefit)

• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit 1
• Heat and soft tissue massage may be considered 1
• Functional electrical stimulation may help with pain-free lateral rotation 1

Key Clinical Distinction

While the initial treatment is essentially identical for both conditions, the main practical difference lies in injection technique:

• Bursitis: Subacromial corticosteroid injection directly targets the inflamed bursa 1, 5
• Tendonitis: Injection should be peritendinous rather than intratendinous to avoid tendon damage 1, 2

Timeline and Escalation

• Most patients respond to conservative management within 3-6 months 1
• Surgery should be reserved for patients who have failed three to six months of conservative therapy 1
• If symptoms persist beyond 6-8 weeks despite conservative treatment, consider imaging (plain radiographs first) 6

Common Pitfall to Avoid

Do not skip the physical examination in favor of immediate imaging - physical examination findings (painful arc test, Neer and Hawkins-Kennedy tests for impingement, cross-body adduction for AC joint) are more valuable than imaging in diagnosing these conditions 6