What is the recommended treatment for mild subdeltoid bursitis?

Treatment of Mild Subdeltoid Bursitis

Conservative management with rest, ice, NSAIDs, and activity modification should be the first-line treatment for mild subdeltoid bursitis, reserving corticosteroid injections and more invasive interventions only if conservative measures fail. 1, 2

Initial Conservative Management (First-Line)

Start with the following conservative measures for all patients with mild subdeltoid bursitis:

• Rest and activity modification to reduce pressure and repetitive stress on the affected bursa 1, 2
• Ice application for 10-minute periods through a wet towel to provide pain relief 1, 2
• NSAIDs (such as naproxen 500 mg twice daily) for pain and inflammation control 1, 2, 3
  • For acute bursitis/tendonitis, naproxen can be initiated at 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial total daily dose not exceeding 1250 mg 3
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1

When Conservative Management Fails

If symptoms persist after 4-8 weeks of conservative treatment, consider:

• Ultrasound-guided corticosteroid injection into the subdeltoid bursa 4, 5

  • Evidence shows corticosteroid injection (20 mg triamcinolone) is superior to physiotherapy alone for pain reduction and functional improvement at 8 weeks 4, 5
  • However, corticosteroid injections have higher recurrence rates (36.1%) compared to physiotherapy alone (7.5%) 4

• Physiotherapy with therapeutic exercise as an alternative or adjunct 4

  • An 8-week structured physiotherapy program emphasizing therapeutic exercise has the lowest recurrence rate 4
  • Combining corticosteroid injection with physiotherapy may provide intermediate recurrence rates (17.1%) 4

Critical Diagnostic Caveat

Rule out septic subdeltoid bursitis before initiating any treatment, especially before considering corticosteroid injection. 6

• Septic subdeltoid bursitis presents with more profound inflammatory reaction than other superficial bursitides 6
• If infection is suspected (fever, severe warmth, erythema, systemic symptoms), perform bursal aspiration with Gram stain, culture, cell count, and crystal analysis 7
• Septic bursitis requires antibiotics effective against Staphylococcus aureus rather than conservative management 7

Treatment Algorithm Summary

1. Weeks 0-4: Conservative management (rest, ice, NSAIDs, activity modification) 1, 2
2. Weeks 4-8: If no improvement, continue conservative measures or add physiotherapy 4
3. After 8 weeks: If persistent symptoms, consider ultrasound-guided corticosteroid injection (with understanding of higher recurrence risk) or continue physiotherapy for more durable results 4, 5

Common Pitfalls to Avoid

• Do not perform bursal aspiration for non-infectious microtraumatic bursitis due to risk of iatrogenic septic bursitis 7
• Avoid corticosteroid injection if infection cannot be excluded 7, 6
• Do not use complete immobilization as it leads to deconditioning 1