Treatment for Subacromial Bursitis with Impingement
Begin with a 3-6 month trial of structured physical therapy targeting rotator cuff and scapular stabilizer strengthening combined with NSAIDs before considering any invasive interventions. 1, 2
Initial Conservative Management (First-Line Treatment)
The American Academy of Orthopaedic Surgeons establishes conservative treatment as the standard initial approach for subacromial impingement syndrome. 1, 2 This is critical because your patient has moderate bursal thickening and limited abduction, both of which typically respond to conservative measures.
Structured Exercise Program
Implement a comprehensive strengthening protocol that addresses the mechanical dysfunction causing your patient's limited abduction and impingement: 1, 2
- Rotator cuff strengthening: Target the supraspinatus, infraspinatus, subscapularis, and teres minor muscles 1
- Scapular stabilizer strengthening: This is a critical component since scapular dyskinesis contributes significantly to impingement pathology 1, 2
- Periscapular muscle strengthening: Address the mechanical dysfunction causing the painful arc and positive impingement signs 1
Exercise forms the base for conservative treatment and has demonstrated statistically significant improvement in pain, range of motion, and functional outcomes. 3
Pharmacologic Management
Prescribe NSAIDs concurrently with the exercise program for initial treatment. 1, 2 The combination of NSAIDs with range of motion exercises represents the standard conservative approach. 4
Corticosteroid Injection Considerations
If conservative management provides insufficient relief, consider ultrasound-guided subacromial corticosteroid injection, but recognize its limitations: 1, 5
- Five level II studies show variable results for corticosteroid injections between 2-6 weeks, highlighting the inconsistent and temporary nature of this intervention 1, 2
- Ultrasound-guided injection produces significantly greater improvements in passive shoulder abduction compared to palpation-guided injection 5
- The injection can be performed under ultrasound guidance as noted in ACR guidelines 6, 1
Important caveat: Triamcinolone acetonide injection demonstrates superior efficacy compared to alternative agents like rilonacept at 4 weeks post-injection. 7
Special Considerations for Your Patient's Specific Findings
The bony irregularity suggesting a possible Hill-Sachs lesion requires attention: 6
- If instability is suspected based on the bony irregularity, MR arthrography is the most appropriate imaging modality (rated 9/9 by ACR) 6
- The pathological biceps sheath fluid and bony irregularity may indicate prior instability episodes that contributed to the current impingement syndrome 6
The normal AC joint, supraspinatus, and infraspinatus are favorable prognostic indicators that suggest the impingement is primarily bursitis-related rather than structural rotator cuff pathology. 1
Surgical Considerations (Only After Failed Conservative Treatment)
Do NOT consider surgery until after 3-6 months of failed conservative treatment. 1, 2 The British Medical Journal states that current evidence does not support subacromial decompression surgery as first-line treatment, as it does not provide clinically important improvements in pain, function, or quality of life compared to other treatments. 1, 2
Common Pitfalls to Avoid
- Avoid premature surgical referral: The 3-6 month conservative trial is mandatory before surgical evaluation 1, 2
- Avoid ultrasound therapy as an adjunct: Double-blind trials show ultrasound therapy provides no additional benefit when combined with ROM exercises and NSAIDs 4
- Avoid laser therapy: Research demonstrates laser treatment is not superior to exercise alone in treating subacromial impingement 3
- Avoid repeated corticosteroid injections: The effect is relatively restricted to short-term relief and repeated injections contribute to unwanted side effects 8