Steroid and Muscle Relaxant Dosing for Bursitis and Capsulitis
For bursitis and capsulitis, intra-articular corticosteroid injection is the preferred initial treatment, with triamcinolone acetonide 20-40 mg for larger joints or 2.5-15 mg for smaller joints, and muscle relaxants are not indicated as they provide no therapeutic benefit for these inflammatory conditions. 1, 2
Corticosteroid Dosing for Bursitis
Intra-articular Injection (Preferred Route)
- For larger joints (shoulder, hip): Triamcinolone acetonide 20-40 mg as a single injection 1, 2
- For smaller joints: Triamcinolone acetonide 2.5-15 mg depending on joint size 1
- Maximum total dose: Up to 80 mg when injecting multiple joints in a single session 1
The evidence strongly supports intra-articular injection over other routes. For trochanteric bursitis, one or two local corticosteroid injections provided excellent response in two-thirds of patients, with improvement in the remaining cases 3. However, avoid steroid injection into the retrocalcaneal bursa, as it may adversely affect Achilles tendon biomechanical properties 4.
Systemic Corticosteroids (Alternative for Extensive Disease)
- Oral prednisone: 0.5 mg/kg/day (typically 30-40 mg daily) for short-term use 5
- Intramuscular triamcinolone acetonide: 60 mg as a single deep gluteal injection, adjustable to 40-80 mg based on response 1
- Duration: Use the shortest duration possible, typically 5-10 days, then taper or discontinue 5
For acute inflammatory conditions, oral prednisone at 0.5 mg/kg/day for 5-10 days followed by discontinuation is recommended 5. The American College of Rheumatology emphasizes using systemic glucocorticoids as temporary adjunct therapy, not long-term treatment 5.
Corticosteroid Dosing for Adhesive Capsulitis
Intra-articular Injection Protocol
- Triamcinolone hexacetonide 40 mg administered under fluoroscopic guidance is the gold standard 6
- Alternative: Triamcinolone acetonide 20 mg shows identical outcomes to 40 mg 2
- Injection site: Both subacromial and glenohumeral injections demonstrate similar efficacy 2
A single intra-articular corticosteroid injection combined with home exercises is effective for improving shoulder pain and disability in adhesive capsulitis, with significant improvement evident at 6 weeks 6. The injection provides superior short-term relief (up to 12 weeks) compared to physiotherapy alone 2.
Timing and Efficacy
- Early stage (pain-predominant): Corticosteroid injection is most effective when pain is the predominant presentation 2
- Response timeline: Significant improvement in pain and disability scores occurs by 6 weeks, with continued benefit at 3 months 6
- Long-term outcomes: By 12 months, all treatment modalities show similar improvement 6
Why Muscle Relaxants Are NOT Indicated
Muscle relaxants have no role in treating bursitis or capsulitis because these are inflammatory conditions of bursal sacs and joint capsules, not muscular disorders. The pathophysiology involves inflammation of synovial-lined structures, not muscle spasm or tension 4, 2.
What Actually Works Instead
- NSAIDs: Use for pain and inflammation control as adjunctive therapy 5, 4
- Activity modification and ice: First-line conservative measures 4
- Physiotherapy: For capsulitis, adding supervised physiotherapy to corticosteroid injection provides faster improvement in shoulder range of motion 6
Critical Administration Technique
Injection Safety
- Strict aseptic technique is mandatory 1
- Avoid subcutaneous injection: Inject deeply into the joint space or bursa to prevent subcutaneous fat atrophy 1
- Fluoroscopic guidance: Recommended for shoulder injections to ensure accurate intra-articular placement 6
- Aspiration: If excessive synovial fluid is present, aspirate some (but not all) before injection 1
Common Pitfalls to Avoid
- Do not inject into tendon substance: For tenosynovitis, inject into the tendon sheath, not the tendon itself 1
- Avoid retrocalcaneal bursa injection: Risk of Achilles tendon damage 4
- Do not use prolonged systemic steroids: Limit to shortest duration necessary due to cardiovascular, gastrointestinal, and metabolic risks 5
Recurrence Management
For bursitis, approximately 25% of patients experience recurrence within 2 years after initial successful treatment 3. For subacromial bursitis specifically, corticosteroid injection has a 36% recurrence rate compared to 7.5% with physiotherapy alone 7. When recurrence occurs, repeat injection at the same dosage is appropriate 1.
Alternative Therapies When Steroids Fail
If corticosteroid injection provides inadequate relief:
- Repeat injection: A second injection may be needed for adequate symptom relief 4
- Surgical intervention: Consider for refractory cases, particularly trochanteric bursitis 4
- Combination therapy: For subacromial bursitis, combining corticosteroid injection with physiotherapy reduces recurrence compared to injection alone 7