What helps relieve shoulder bursitis?

Treatment of Shoulder Bursitis

For shoulder bursitis, NSAIDs (such as naproxen) combined with a structured exercise program emphasizing external rotation and abduction stretching should be the initial treatment approach, with corticosteroid injections reserved for cases unresponsive to conservative management. 1, 2

First-Line Conservative Management

NSAIDs for Symptomatic Relief

• Naproxen is FDA-approved specifically for bursitis, with an initial dose of 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours, not exceeding 1250 mg on the first day and 1000 mg daily thereafter. 2
• NSAIDs provide short-term symptomatic relief but do not address the underlying mechanical causes of bursitis. 1
• Topical NSAIDs should be considered first for mild to moderate pain to minimize systemic side effects. 3

Exercise and Physical Therapy

• Eccentric strengthening exercises and stretching programs emphasizing external rotation and abduction are critical because external rotation limitation relates most significantly to persistent shoulder pain. 1
• Active range of motion should be increased gradually while restoring alignment and strengthening weak shoulder girdle muscles. 3
• Local heat application before exercise provides symptomatic relief. 3

Activity Modification and Rest

• Avoid complete immobilization, as it causes muscular atrophy and deconditioning, but inadequate rest allows ongoing damage. 1
• Never use overhead pulleys, which encourage uncontrolled abduction and dramatically increase the risk of shoulder pain. 1, 3

Second-Line Treatment: Corticosteroid Injections

When to Consider Injections

• Subacromial corticosteroid injections should be used when pain is related to injury or inflammation of the subacromial region and conservative measures have failed. 3
• Evidence for corticosteroid injections is conflicting: some studies show short-term pain relief (2-6 weeks), but repeated injections contribute to tendon weakening. 4, 1
• In chronic subacromial bursitis, corticosteroid injection (with or without physiotherapy) was superior to physiotherapy alone for pain relief and function, but had a 36% recurrence rate compared to 7.5% with physiotherapy alone. 5

Injection Protocol

• Two subdeltoid corticosteroid injections can be administered, but the recurrence rate is significantly higher (36%) compared to physiotherapy alone (7.5%). 5
• Combination therapy (hydrodilatation with corticosteroid injection plus mobilization and PT) showed superior outcomes compared to PT alone, with effects persisting for 6 months. 6

Critical Pitfalls to Avoid

Mechanical Causes Often Missed

• Chronic bursitis involves collagen disorientation and degenerative changes rather than acute inflammation, meaning anti-inflammatory treatments alone miss the underlying pathology. 1
• Stretching programs often neglect external rotation, yet this specific motion limitation is most significant for persistent pain. 1

Imaging When Conservative Treatment Fails

• Ultrasonography is useful for detecting moderate to full-thickness rotator cuff tears and showing tendon thickening in chronic tendinopathy that perpetuates bursitis. 1
• MRI demonstrates 95% sensitivity and specificity for rotator cuff tears, degeneration, and partial tears. 1
• Standard shoulder radiographs (AP views in internal/external rotation plus axillary or scapula-Y view) should be obtained if trauma is suspected. 4

Treatment Algorithm Summary

1. Initial treatment (4-8 weeks): NSAIDs (naproxen per FDA dosing) + structured exercise program emphasizing external rotation/abduction + activity modification (avoid overhead pulleys). 1, 2

2. If inadequate response: Add local heat before exercise, consider topical NSAIDs if systemic NSAIDs contraindicated. 3

3. If still unresponsive (after 8 weeks): Consider subacromial corticosteroid injection (maximum 2 injections), but counsel patient about 36% recurrence risk and potential tendon weakening with repeated use. 1, 5

4. If recurrent or persistent: Obtain imaging (ultrasonography first, MRI if needed) to identify underlying rotator cuff pathology or other structural causes. 1