What is the treatment plan for mild supraspinatus (supraspinatous) zone tendinitis?

Treatment Plan for Mild Supraspinatus Tendinitis

For mild supraspinatus tendinitis, initiate conservative management with relative rest, NSAIDs, and a structured eccentric exercise program for at least 3-6 months before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest by avoiding overhead activities and movements that reproduce pain 1
• Patients should reduce repetitive loading of the damaged tendon while maintaining some activity 2
• Apply cryotherapy with ice through a wet towel for 10-minute periods immediately after pain-provoking activities 1

Pharmacological Management

• NSAIDs are the cornerstone of initial pharmacological treatment 2, 1
• Start with naproxen 500 mg twice daily for acute tendinitis and bursitis, with initial dose not exceeding 1250 mg/day 3
• NSAIDs provide short-term pain relief but offer no long-term benefit to tendon healing 1
• Consider topical NSAIDs as an alternative to oral formulations 1
• Onset of pain relief typically begins within 1 hour with naproxen 3

Exercise Therapy (Most Critical Component)

• Eccentric strengthening exercises are the cornerstone of conservative treatment and must be continued for at least 3-6 months 1, 4
• Progressive loading should be gradual to avoid symptom exacerbation 1
• Do not start with aggressive exercises; progression must be gradual to prevent symptom worsening 1
• Exercise therapy has beneficial effects for supraspinatus tendinopathy, though more research is needed 4

Adjunctive Therapies (Second-Line Options)

Physical Modalities

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, though expensive 1, 5
• ESWT appears equivalent to radiotherapy in treating chronic supraspinatus tendinitis 5
• Laser, ultrasound, and shock-wave therapy have little and contradictory evidence 4

Injection Therapy (Use with Extreme Caution)

• Corticosteroid injections should be used with extreme caution 1
• They may provide acute pain relief but do not improve long-term outcomes 1
• Corticosteroids may inhibit healing and reduce tendon strength, predisposing to rupture 1
• Never inject corticosteroids into the tendon substance itself; only peritendinous injection may be considered 1
• Local glucocorticoid injections directed to the site of musculoskeletal inflammation may be considered in select cases 2

Monitoring and Follow-Up

Assessment Timeline

• Reassess response to conservative treatment at 6-8 weeks
• Continue conservative management for a minimum of 3-6 months before considering surgical referral 1
• Monitor for development of muscle atrophy, which indicates chronicity 2

Physical Examination Findings to Monitor

• Well-localized tenderness on palpation similar to activity-related pain 2
• Range-of-motion limitations on the symptomatic side 2
• Presence of muscle atrophy (suggests chronic condition) 2
• Swelling, erythema, or asymmetry (commonly noted with pathologic tendons) 2

Surgical Referral Criteria

Refer to orthopedic surgery if:

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

Critical Pitfalls to Avoid

• Avoid corticosteroid injection into the tendon substance 1
• Do not start aggressive exercises early; gradual progression is essential 1
• Do not delay surgical referral beyond 6 months if conservative treatment fails 1
• Do not use long-term systemic glucocorticoids 2
• Avoid premature discontinuation of eccentric exercises before 3-6 months 1