What is the recommended treatment for a patient with subacromial and subdeltoid bursitis?

Treatment of Subacromial and Subdeltoid Bursitis

Begin with therapeutic exercises targeting scapular stabilization and rotator cuff strengthening combined with NSAIDs, reserving corticosteroid injections for symptoms persisting beyond 4-6 weeks of conservative treatment. 1, 2

Initial Conservative Management (First 4-6 Weeks)

Non-Pharmacological Interventions

• Implement supervised physical therapy twice weekly focusing on scapular retraction exercises and progressive rotator cuff strengthening at low intensity and high frequency 2
• Apply thermal interventions (locally applied heat or cold for 15-20 minutes several times daily) to reduce inflammation 1, 2
• Mandate consistent home exercise programs between supervised sessions, as this is crucial for recovery 2
• Restrict overhead lifting and reaching activities for approximately 4 weeks to allow inflammation to subside 2
• Avoid sleeping on the affected shoulder and any activities that provoke pain during the recovery period 2

Pharmacological Management

• Prescribe NSAIDs alongside exercises as first-line pharmacological treatment for pain control 1, 2
• Use acetaminophen or ibuprofen for analgesia if there are no contraindications 1, 2
• Avoid opioids for subacromial pain syndrome, as evidence shows limited benefit with worse outcomes compared to nonopioid strategies 2

Management of Persistent Symptoms (After 4-6 Weeks)

Corticosteroid Injection

• Administer ultrasound-guided subacromial-subdeltoid corticosteroid injection when pain persists despite initial conservative measures and is thought to be related to inflammation of the subacromial region 1, 2, 3
• Corticosteroid injection (20 mg triamcinolone or equivalent) is superior to hyaluronic acid and normal saline for treating chronic subacromial bursitis, with significantly lower pain scores at 8 weeks (pain VAS 2.56 vs 4.71 for placebo, P < 0.001) 3
• Combined corticosteroid injection plus physiotherapy is superior to physiotherapy alone for pain relief and patient satisfaction, though physiotherapy alone has the lowest recurrence rate (7.5% vs 36.1% for injection alone) 4

Important Caveat About Recurrence

The evidence reveals a critical trade-off: while corticosteroid injection provides faster and more complete pain relief than physiotherapy alone, the recurrence rate is substantially higher (36.1% for injection alone vs 7.5% for physiotherapy alone) 4. This suggests that combining injection with continued physiotherapy may optimize both immediate relief and long-term outcomes (17.1% recurrence rate for combined treatment) 4.

Interventions to Avoid

• Do not use massage therapy as a primary treatment—the American College of Rheumatology/Arthritis Foundation conditionally recommends against it due to high risk of bias in studies, small patient numbers, and lack of demonstrated benefit for specific outcomes 1
• Do not consider surgical intervention (arthroscopic subacromial decompression) as routine treatment, as high-quality evidence demonstrates no clinically important improvement compared to placebo surgery or conservative treatment 2

Treatment Algorithm

1. Weeks 0-4: Therapeutic exercises + NSAIDs + thermal interventions + activity modification 1, 2
2. Weeks 4-6: Continue conservative measures; assess response 2
3. Week 6+: If inadequate response, add ultrasound-guided corticosteroid injection (20 mg triamcinolone) while continuing physiotherapy 4, 3
4. Weeks 8-12: Continue progressive therapeutic exercises regardless of injection status 2, 4
5. Beyond 12 weeks: Re-evaluate for other potential causes if no improvement 1

Clinical Caveats

• Most patients recover well without surgery when proper conservative treatment is implemented and maintained 2
• Monitor for warning signs requiring immediate evaluation: sudden increase in pain or swelling, new arm weakness, or fever and redness around the shoulder suggesting infection 2
• Implement workplace modifications when complaints persist longer than 6 weeks, addressing repetitive occupational motions that contribute to symptoms 2
• Emphasize proper shoulder mechanics and strength maintenance after recovery to prevent recurrence 2