What is the best initial management strategy for a patient presenting with shoulder tendinitis?

Shoulder Tendinitis Management

Initial Conservative Treatment is the Foundation

For shoulder tendinitis, begin with relative rest, eccentric strengthening exercises, and NSAIDs for pain relief, reserving corticosteroid injections for acute pain that fails initial measures, with surgery only after 3-6 months of failed conservative therapy. 1, 2

First-Line Management Strategy

Immediate Interventions (First 2-4 Weeks)

• Implement relative rest by reducing repetitive overhead activities and movements that reproduce pain, but avoid complete immobilization which accelerates muscle atrophy and deconditioning 1, 2

• Apply ice through a wet towel for 10-minute periods multiple times daily to provide short-term pain relief 1, 2

• Prescribe NSAIDs (oral or topical) for acute pain relief, recognizing they provide symptomatic benefit but do not alter the underlying degenerative process 1, 2, 3

  • Topical NSAIDs are preferred for localized shoulder tendinitis as they provide similar pain relief with fewer gastrointestinal and systemic side effects 1, 2
  • Acetaminophen up to 4g/day can be used as first-line oral analgesic due to favorable safety profile 2

Core Rehabilitation Protocol (Weeks 2-12)

• Initiate eccentric strengthening exercises as the cornerstone of treatment—these have proven beneficial in reversing degenerative tendon changes, reducing symptoms, and increasing strength 1, 2, 4

• Gentle stretching and mobilization techniques focusing especially on external rotation and abduction to prevent frozen shoulder and maintain range of motion 1

  • Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 1

• Avoid overhead pulleys which encourage uncontrolled abduction and may worsen symptoms 1

• Consider physical therapy modalities including therapeutic ultrasound, heat, and soft tissue massage, though evidence for consistent benefit is weak 1, 2

When to Escalate Treatment

Corticosteroid Injections (If Pain Persists Beyond 4-6 Weeks)

• Subacromial corticosteroid injections provide better acute pain relief than oral NSAIDs when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1, 3

• Use with caution: Corticosteroids provide short-term pain relief (1-8 weeks) but show no long-term benefit beyond 12 weeks and may inhibit healing and reduce tensile strength 4, 3

• Limit to 2-3 injections maximum to avoid tendon weakening 5, 6

• Never inject directly into tendon substance—only into the subacromial space or tendon sheath 6

Advanced Interventions for Refractory Cases

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathy refractory to other treatments, though expensive and evidence for optimal protocols is still evolving 1, 2, 4

• Botulinum toxin injections into the subscapularis and pectoralis muscles can be used when pain is thought to be related to spasticity (primarily in post-stroke hemiplegic shoulder pain) 1

Surgical Consideration

• Surgery is reserved for carefully selected patients who have failed 3-6 months of appropriate conservative management 1, 2, 4

• Surgery remains the last option due to morbidity and inconsistent outcomes 4

Critical Clinical Pearls and Pitfalls

Accurate Diagnosis is Essential

• Most chronic shoulder tendon problems are degenerative tendinopathy ("tendinosis"), not inflammatory "tendinitis"—this distinction affects treatment approach as anti-inflammatory treatments eventually fail in degenerative conditions 1, 5, 6

• Look for well-localized tenderness on palpation that reproduces the patient's activity-related pain 2, 6

• Presence of joint effusions is uncommon with tendinopathy and should raise suspicion for intra-articular pathology requiring different management 2, 6

Special Considerations

• If multiple tendons are symptomatic simultaneously, evaluate for underlying rheumatic disease rather than isolated mechanical overuse 5, 6

• Calcific tendinitis is a distinct entity: acute calcific tendinitis responds well to conservative treatment and rarely requires surgery, while chronic calcific tendinitis often requires surgical intervention 7, 8

  • Conservative treatment for calcific tendinitis shows 72% excellent or good results regardless of location, radiologic type, or size of deposits 9

• Protect the shoulder from trauma during rehabilitation, as injuries can contribute to shoulder-hand syndrome 1

Expected Outcomes

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 1, 2

• If symptoms persist beyond 6 months despite well-managed conservative therapy, surgical consultation is warranted 1, 2