What is the recommended treatment for bilateral shoulder bursitis pain lasting greater than 3 months?

Treatment of Bilateral Shoulder Bursitis Pain >3 Months

For chronic bilateral shoulder bursitis lasting over 3 months, initiate a structured multimodal conservative program combining NSAIDs (naproxen 500mg twice daily), physical therapy with gentle stretching/mobilization techniques focusing on external rotation and abduction, and progressive strengthening of rotator cuff and scapular stabilizers over 12-16 weeks before considering corticosteroid injections or surgical options. 1, 2, 3

First-Line Conservative Management

Pharmacologic Treatment

• Start NSAIDs at maximum tolerated doses: Naproxen 500mg twice daily (or 250mg every 6-8 hours for acute flares), with initial doses up to 1250mg/day tapering to maintenance of 1000mg/day maximum for chronic bursitis 4, 5
• Acetaminophen or ibuprofen can be used as alternatives if NSAIDs are contraindicated 1, 3
• Topical NSAIDs provide moderate pain relief with fewer systemic side effects for mild-to-moderate pain 3
• Evaluate response at 2-4 weeks: If insufficient response, consider NSAID rotation or advance to second-line treatment 1

Physical Therapy Protocol (12-16 weeks standard duration)

• Gentle stretching and mobilization techniques specifically targeting external rotation and abduction to address impingement and prevent frozen shoulder 1, 2, 3
• Gradual progression of active ROM while restoring proper shoulder alignment and strengthening weak muscles in the shoulder girdle 1, 3
• Avoid overhead pulleys as they encourage uncontrolled movement and may worsen pain 3
• Apply ice or heat before exercises for symptomatic relief 3
• Soft tissue massage to reduce pain and improve tissue elasticity 3

Critical Timeline Considerations

• Standard post-operative and chronic shoulder rehabilitation requires 12-16 weeks (3-4 months) of skilled therapy 2
• Re-evaluate at 12 weeks: If no significant functional improvement after 25 visits or 3-4 months, consider alternative approaches or discharge from physical therapy 2
• The evidence emphasizes that treatment should demonstrate "reasonable expectation that condition will improve significantly in a reasonable and generally predictable period" 2

Second-Line Treatment Options

Corticosteroid Injections

• Subacromial corticosteroid injections can be used when pain is thought to be related to inflammation of the subacromial region (rotator cuff or bursa) 1
• Evidence is limited (Grade I) for glenohumeral corticosteroid injections specifically for shoulder osteoarthritis, though they are used widely in clinical practice 1
• For chronic inflammatory bursitis (e.g., gout, rheumatoid arthritis), intrabursal corticosteroid injections are often used after addressing the underlying condition 5
• Caution: High-quality evidence demonstrating benefit for intrabursal corticosteroid injections in microtraumatic bursitis is unavailable, and aspiration carries risk of iatrogenic septic bursitis 5

Viscosupplementation

• Injectable viscosupplementation (hyaluronic acid preparations) is an option for chronic shoulder pain, though evidence is limited to industry-supported studies (Grade C, Level IV) 1
• Typical protocol involves three weekly injections with reassessment at 1,3, and 6 months 1

Intermediate Phase (6-12 weeks)

• Progress to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 3
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles 3
• Address scapular dyskinesis through specific exercises, as this is essential for successful outcomes 3
• Continue flexibility work for the shoulder capsule 3

Advanced Phase (12-16 weeks)

• Focus on return to work/sport-specific activities with proper mechanics 3
• Implement graduated programs for overhead activities 3
• Ensure complete resolution of symptoms before returning to full activity 3

When to Consider Surgery

• Surgery should only be considered after 3-6 months of failed conservative management 1, 6
• Clear diagnosis and structural information from imaging are required before surgical consideration 6
• Surgical intervention may be required for recalcitrant bursitis refractory to conservative measures 7
• The proportion of patients with shoulder pain requiring surgery is generally small 6

Critical Pitfalls to Avoid

• Do not perform bursal aspiration for chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 5
• Do not continue physical therapy indefinitely: After 25 visits or 12-16 weeks without clear functional improvement, alternative approaches should be considered 2
• Do not inject corticosteroids into retrocalcaneal bursa as this may adversely affect biomechanical properties of adjacent tendons 7
• Rule out septic bursitis if infection is suspected: perform bursal aspiration with Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 5

Special Considerations for Bilateral Presentation

• Bilateral shoulder bursitis warrants consideration of underlying systemic inflammatory conditions (rheumatoid arthritis, gout, SLE) that may require treatment of the primary condition 5, 8
• Address underlying causes of chronic microtrauma (occupational factors, repetitive activities) to prevent recurrence 5, 7
• Activity modification and relative rest are essential components of conservative management 7, 9