What is the recommended treatment for a patient with shoulder bursitis?

Treatment of Shoulder Bursitis

For shoulder bursitis, begin with NSAIDs (naproxen 500 mg twice daily) combined with a structured exercise program emphasizing external rotation and abduction stretching, while strictly avoiding overhead pulleys. 1, 2

Initial Conservative Management

Pharmacological Treatment

• Start with NSAIDs as first-line therapy: Naproxen 500 mg twice daily, or 250 mg every 6-8 hours for acute bursitis, with initial doses not exceeding 1250 mg/day 1
• Consider acetaminophen or tramadol for patients with cardiovascular risk factors or contraindications to NSAIDs 3
• NSAIDs provide short-term symptomatic relief but do not address underlying mechanical causes 2

Exercise Therapy (Critical Component)

• Implement gentle stretching and mobilization techniques focusing specifically on external rotation and abduction - these motions are most significantly related to preventing persistent shoulder pain 3, 2
• Progress to active range of motion exercises gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 3
• Focus on neck, rotator cuff, and posterior shoulder girdle strengthening while addressing anterior shoulder girdle flexibility 3
• Strictly avoid overhead pulleys, which encourage uncontrolled abduction and dramatically increase risk of shoulder pain 3, 2

Adjunctive Modalities

• Apply ice, heat, or soft tissue massage for symptomatic relief 3
• Activity modification to avoid repetitive overhead movements or positions that provoke symptoms 4, 5
• Consider functional electrical stimulation to improve shoulder lateral rotation and prevent pain 3

Second-Line Interventions

Corticosteroid Injections

• Subacromial corticosteroid injections can be used when pain is thought related to inflammation of the subacromial bursa, providing effective short-term pain relief 3, 6
• Triamcinolone intra-articular injections demonstrate significant effects on pain reduction 3
• Important caveat: Steroid effects are restricted to short-term relief, repeated injections are frequently required and contribute to tendon weakening 2
• Recent evidence shows corticosteroid injection has 36.1% recurrence rate versus 7.5% with physiotherapy alone 6

Combined Approach

• Combination of corticosteroid injection plus physiotherapy shows superior short-term outcomes compared to physiotherapy alone, with intermediate recurrence rates (17.1%) 6
• This approach balances immediate pain relief with addressing mechanical causes 6

Critical Pitfalls to Avoid

Mechanical Factors Contributing to Recurrence

• External rotation limitation relates most significantly to onset and persistence of shoulder pain, yet stretching programs often neglect this specific motion 2
• Complete immobilization causes muscular atrophy and deconditioning, while inadequate rest allows ongoing damage 2
• Overhead pulleys dramatically increase risk and should never be used 3, 2

Understanding Pathophysiology

• Chronic bursitis often involves collagen disorientation and degenerative changes rather than acute inflammation, meaning anti-inflammatory treatments alone miss underlying pathology 2
• Treatment must address both symptomatic relief and mechanical causes to prevent recurrence 2

When to Consider Advanced Imaging or Referral

• If symptoms persist beyond 6-8 weeks of conservative treatment, consider ultrasonography (useful for detecting rotator cuff tears and tendon thickening) or MRI (95% sensitivity/specificity for rotator cuff pathology) 2
• Surgical intervention may be required for recalcitrant bursitis not responsive to conservative management 4, 5
• If septic bursitis is suspected (acute onset, fever, marked erythema), perform bursal aspiration with Gram stain and culture, and initiate antibiotics effective against Staphylococcus aureus 5

Monitoring and Follow-up

• Reassess at 2-4 weeks to determine if exercise modifications or dose adjustments are needed 1
• Physiotherapy-based approaches show lowest recurrence rates (7.5%) compared to injection alone (36.1%), emphasizing importance of continued exercise even after symptom improvement 6
• For elderly patients or those with renal/hepatic impairment, use lowest effective NSAID dose and monitor closely 1