What are the best approaches to treat a patient who is a swim coach with right shoulder bursitis, a superficial supraspinatus tear, and features of Ehlers-Danlos hypermobility syndrome, and is planned to receive an intra-articular corticosteroid injection?

Treatment Approach for Shoulder Bursitis with Supraspinatus Tear in Ehlers-Danlos Hypermobility

Critical Modification Required: Avoid the Planned Intra-Articular Corticosteroid Injection

The planned intra-articular corticosteroid injection should be reconsidered and replaced with a subacromial bursa injection instead, as this patient has bursitis (not glenohumeral osteoarthritis), and patients with Ehlers-Danlos hypermobility have inherent joint instability that makes intra-articular injections potentially harmful. 1, 2

Why Intra-Articular Injection is Inappropriate Here

• The FDA label for triamcinolone acetonide explicitly states that "corticosteroid injection into unstable joints is generally not recommended" and warns that "intra-articular injection may result in damage to joint tissues." 2
• Patients with Ehlers-Danlos hypermobility have baseline joint instability due to connective tissue laxity, making them particularly vulnerable to joint damage from intra-articular corticosteroids. 1, 3, 4
• The pathology here is subacromial bursitis with a superficial rotator cuff tear, not glenohumeral joint arthritis—the injection target should be the subacromial space, not the joint itself. 5

Correct Injection Approach

If corticosteroid injection is pursued, it must be directed to the subacromial bursa under ultrasound guidance, not into the glenohumeral joint. 6

• The Pan American League of Associations for Rheumatology recommends that local glucocorticoid injections should be performed with imaging guidance (ultrasonography or CT) when available, and specifically notes that both guided and unguided injections may be used by trained caregivers. 6
• For bursitis in patients with stable axial disease and active enthesitis or bursitis despite NSAIDs, local glucocorticoid administration is conditionally recommended. 6

Comprehensive Treatment Algorithm

Step 1: Immediate Activity Modification (Mandatory First-Line)

Immediately cease all painful swimming activities and notify the coaching staff—this is non-negotiable for healing. 5

• The primary cause of swimmer's shoulder is swimming-specific demands that increase performance but decrease shoulder stability through: (1) increased shoulder range of motion, (2) increased internal rotation/adduction strength, and (3) prolonged fatiguing training. 5
• Treatment requires complete avoidance of all painful activities as the foundation of management. 5

Step 2: Conservative Management (2-4 Week Trial)

Initiate a structured 2-4 week course combining NSAIDs, ice, and modified physical therapy specifically designed for Ehlers-Danlos hypermobility. 5, 1

Pharmacologic Management

• NSAIDs: Use selective COX-2 inhibitors preferentially in this patient given the need for prolonged use and to minimize GI toxicity. 6
• Consider acetaminophen up to 3g daily in divided doses for additional pain control. 6
• Avoid opioids completely—the American Academy of Pain Medicine strongly recommends against opioid use in patients with chronic pain, particularly in Ehlers-Danlos syndrome. 1, 7

Physical Therapy Modifications for Ehlers-Danlos Hypermobility

Physical therapy must be specifically modified for hypermobility—standard protocols often cause iatrogenic injury in these patients. 1, 4

• Decrease anterior capsule stretching (which worsens instability) and increase posterior capsule stretching. 5
• Focus on low-resistance exercise to improve joint stability by increasing muscle tone without excessive joint stress. 1
• Emphasize external rotator strengthening over internal rotators to counteract the swimming-induced imbalance. 5
• Include scapular-positioning muscle exercises and training to increase body roll during swimming. 5
• The American College of Rheumatology emphasizes that physical therapy should focus on improving joint stability through therapeutic exercise and motor function training, not aggressive stretching. 1

Step 3: Subacromial Corticosteroid Injection (If Conservative Management Fails)

If symptoms persist after 2-4 weeks of conservative management, proceed with ultrasound-guided subacromial bursa corticosteroid injection—NOT intra-articular injection. 6

Injection Technique Specifications

• Use ultrasound guidance to ensure accurate placement in the subacromial space and avoid the glenohumeral joint. 6
• The AAOS supports intra-articular corticosteroid injections with Level 1B evidence (19 high-quality and 6 moderate-quality studies), but this evidence applies to osteoarthritis, not bursitis with hypermobility. 6
• For knee osteoarthritis (extrapolating to other joints), corticosteroid injections provide effective short-term pain relief, typically lasting 3 months. 6

Critical Safety Considerations in Ehlers-Danlos Patients

Exercise extreme caution with any injection procedure due to tissue fragility and increased complication risk. 1, 7

• The American Medical Association recommends never performing invasive diagnostic procedures unnecessarily in patients with hypermobile Ehlers-Danlos syndrome, as tissue fragility increases complication risk. 1
• The FDA label warns that injection into an infected site must be avoided, and appropriate examination of any joint fluid is necessary to exclude septic process. 2
• Monitor for marked increase in pain, local swelling, further restriction of motion, fever, or malaise—these suggest septic arthritis requiring immediate antimicrobial therapy. 2

Step 4: Gradual Return to Swimming with Permanent Modifications

Once pain-free, implement permanent swimming technique modifications to prevent recurrence. 5

• Maintain equal time stretching posterior and anterior capsules (not favoring anterior). 5
• Continue general rotator cuff exercises with emphasis on external rotators. 5
• Perform ongoing scapular-positioning muscle exercises with emphasis on body roll. 5
• The American College of Sports Medicine recommends swimming as a preferred activity for Ehlers-Danlos patients, but technique must be modified to avoid excessive joint stress. 1

Step 5: Long-Term Monitoring for Ehlers-Danlos Complications

Establish ongoing surveillance for cardiovascular and other systemic complications of Ehlers-Danlos syndrome. 1, 7

• The American Heart Association suggests repeat echocardiography every 2-3 years to monitor for aortic root dilation, which occurs in 25-33% of hypermobile EDS patients. 1, 7
• Screen for postural orthostatic tachycardia syndrome (POTS) by measuring postural vital signs—heart rate increase ≥40 beats/min within 10 minutes of standing without orthostatic hypotension. 1, 7
• The American Gastroenterological Association recommends inquiring about GI symptoms, as up to 98% of hypermobile EDS patients develop gastrointestinal manifestations. 1, 7

Critical Pitfalls to Avoid

Never inject corticosteroids into the glenohumeral joint in a patient with Ehlers-Danlos hypermobility and joint instability. 1, 2

Never allow chronic NSAID use without attempting to control symptoms—this masks ongoing injury. 5

Never use standard aggressive stretching protocols designed for non-hypermobile athletes—these worsen instability. 5, 4

Never prescribe opioids for chronic shoulder pain in Ehlers-Danlos patients. 1, 7

Never perform the injection without ultrasound guidance in a patient with tissue fragility. 6