Treatment of Supraspinatus Tendinitis
Begin with NSAIDs and eccentric strengthening exercises as first-line treatment, reserving corticosteroid injections for select refractory cases, and refer to orthopedic surgery only after 3-6 months of failed conservative management. 1, 2
Initial Conservative Management (First 6-8 Weeks)
Activity Modification
- Implement relative rest by avoiding overhead activities and movements that reproduce pain, but maintain some activity to prevent muscle atrophy 1, 2
- Reduce repetitive loading of the damaged tendon while avoiding complete immobilization 1, 3
Pharmacological Treatment
- NSAIDs are the cornerstone of initial treatment, providing short-term pain relief 1, 3
- Consider topical NSAIDs as an alternative to oral formulations, offering similar efficacy with fewer systemic side effects 1, 3
- Paracetamol up to 4g/day may be used as first-line oral analgesic due to favorable safety profile 3
Physical Modalities
- Apply cryotherapy with ice through a wet towel for 10-minute periods immediately after pain-provoking activities 1, 2, 3
- Eccentric strengthening exercises are the cornerstone of conservative treatment and should be continued for at least 3-6 months 2, 4
- Progressive loading must be gradual to avoid symptom exacerbation 2, 3
Second-Line Interventions (If Initial Treatment Fails)
Corticosteroid Injections
- Local glucocorticoid injections directed to the site of musculoskeletal inflammation may be considered in select cases 5, 1
- Critical caveat: Never inject corticosteroids into the tendon substance itself—only peritendinous injection may be considered 2, 3
- Use with extreme caution as they provide acute pain relief but do not improve long-term outcomes, may inhibit healing, and can reduce tendon strength predisposing to rupture 2
Extracorporeal Shock Wave Therapy (ESWT)
- ESWT is safe and potentially effective for pain relief in chronic cases, though expensive 1, 2, 3
- Evidence suggests equivalence to other conservative treatments 6
Novel Therapies
- Percutaneous electrolysis appears more effective than trigger point dry needling for pain relief and range of motion improvement at one-year follow-up 7
- Transdermal nitroglycerin patches showed significant pain reduction in a small controlled trial 8
Monitoring and Reassessment
- Reassess response to conservative treatment at 6-8 weeks 1
- Continue conservative management for a minimum of 3-6 months before considering surgical referral 1, 2, 3
- Monitor for development of muscle atrophy, which indicates chronicity and worsens surgical outcomes 1
- Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 3
Surgical Referral Criteria
Refer to orthopedic surgery if:
- Pain persists despite 3-6 months of well-managed conservative treatment 1, 2, 3
- Significant functional limitations persist despite conservative measures 2
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, 2, 3
Critical Pitfalls to Avoid
- Never inject corticosteroids into the tendon substance—only peritendinous injection with extreme caution 2, 3
- Do not start with aggressive exercises early—gradual progression is essential 1, 2, 3
- Do not completely immobilize the shoulder, as this accelerates muscle atrophy and deconditioning 3
- Do not delay surgical referral beyond 6 months if conservative treatment fails 1, 2, 3
- Do not use long-term systemic glucocorticoids for axial disease 5, 1
Important Clinical Context
Recognize that most tendinopathies are degenerative (tendinosis) rather than inflammatory (tendinitis) in nature, which explains why anti-inflammatory treatments provide only symptomatic relief without altering long-term outcomes 3, 4. The healing process involves structural and biological changes that continue over time, requiring patience with conservative management 4.