What is the initial treatment for supraspinatus tendinitis?

Initial Treatment for Supraspinatus Tendinitis

Begin with relative rest, NSAIDs for pain control, and eccentric strengthening exercises as the cornerstone of conservative management, continuing for at least 3-6 months before considering surgical referral. 1, 2

First-Line Conservative Management

Immediate Phase (First 2-4 Weeks)

Activity Modification:

• Avoid overhead activities and movements that reproduce pain while maintaining some activity to prevent muscular atrophy and deconditioning 1, 2
• Complete immobilization should be avoided as tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Pain Control:

• NSAIDs (oral or topical) are first-line for pain relief, though they provide no long-term benefit beyond symptom control 1, 2
• Topical NSAIDs eliminate the gastrointestinal hemorrhage risk associated with systemic NSAIDs 1
• Cryotherapy: Apply ice through a wet towel for 10-minute periods immediately after pain-provoking activities to reduce swelling and pain 1, 2

Progressive Rehabilitation Phase (Weeks 2-24)

Exercise Therapy - The Critical Component:

• Eccentric strengthening exercises are the cornerstone of treatment and must be continued for at least 3-6 months 1, 2, 3
• Eccentric exercise has proven beneficial in tendinopathies by stimulating collagen production 1
• Progressive loading should be gradual to avoid symptom exacerbation 2
• Stretching exercises are widely accepted and thought to be helpful 1

Adjunctive Therapies to Consider

Physical Therapy:

• Active physical therapy interventions (supervised exercise) are preferred over passive modalities like massage, ultrasound, or heat 1
• Land-based interventions are preferred over aquatic therapy 1

Extracorporeal Shock Wave Therapy (ESWT):

• Safe and potentially effective for pain relief, though expensive 2, 4
• Evidence shows equivalence to other conservative treatments at 12-week and 52-week follow-up 4

Critical Warnings About Corticosteroid Injections

Use corticosteroids with extreme caution or avoid entirely:

• May provide acute pain relief but do not improve long-term outcomes 1, 2
• Can inhibit healing and reduce tendon tensile strength, predisposing to spontaneous rupture 1, 2
• Never inject into the tendon substance itself - only peritendinous injection may be considered, and even this should be used cautiously 1, 2
• The role of inflammation in tendinopathies is unclear, making anti-inflammatory effects potentially counterproductive 1

When to Refer for Surgical Evaluation

Refer to orthopedic surgery if:

• Pain persists despite 3-6 months of well-managed conservative treatment 1, 2
• Significant functional limitations persist despite conservative measures 2

Critical timing consideration: Do not delay surgical referral beyond 6 months of failed conservative treatment, as chronic tears may develop muscle atrophy and fatty degeneration that worsen surgical outcomes 2

Common Pitfalls to Avoid

• Do not start with aggressive exercises - progression must be gradual to prevent symptom worsening 2
• Do not rely solely on passive modalities (ultrasound, massage, heat) without active exercise components 1
• Do not use corticosteroid injections as routine first-line treatment given the risk of tendon weakening and rupture 1, 2
• Do not continue failed conservative treatment beyond 6 months without surgical consultation, as this allows progressive muscle degeneration 2