From the Guidelines
Subacromial bursitis should be treated with conservative measures, including rest, ice application, and over-the-counter NSAIDs, with consideration of corticosteroid injections for persistent symptoms, as this approach prioritizes reduction of morbidity, mortality, and improvement of quality of life. The treatment of subacromial bursitis typically involves a multi-faceted approach, focusing on reducing inflammation, relieving pain, and restoring function.
- Conservative management is the first line of treatment, including:
- Rest and avoidance of activities that exacerbate the condition
- Ice application for 15-20 minutes several times daily to reduce inflammation and pain
- Over-the-counter NSAIDs, such as ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily), for 1-2 weeks to reduce inflammation and pain 1
- Physical therapy should be initiated after acute pain subsides, usually within 1-2 weeks, focusing on gentle stretching and strengthening exercises to improve range of motion and strength
- For persistent symptoms, a corticosteroid injection into the bursa may provide relief, as suggested by the Canadian stroke best practice recommendations, which support the use of subacromial corticosteroid injections for pain related to injury or inflammation of the subacromial region (rotator cuff or bursa) in the hemiplegic shoulder 1
- Imaging studies, such as ultrasound or MRI, may be warranted if symptoms persist beyond 6-8 weeks despite conservative management, to rule out rotator cuff tears or other structural problems 1
- Surgery is rarely needed and reserved for cases that don't respond to conservative treatment. It is essential to note that the treatment approach should prioritize the reduction of morbidity, mortality, and improvement of quality of life, and the most recent and highest quality study should guide the recommendation 1.
From the FDA Drug Label
Management of Pain, Primary Dysmenorrhea, and Acute Tendonitis and Bursitis Because the sodium salt of naproxen is more rapidly absorbed, naproxen sodium is recommended for the management of acute painful conditions when prompt onset of pain relief is desired. The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.
The recommended dose of naproxen for acute bursitis is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required, with a maximum initial total daily dose of 1250 mg and a maximum total daily dose thereafter of 1000 mg 2.
From the Research
Subacromial Bursitis Treatment Options
- Corticosteroid injection into the subacromial-subdeltoid bursa has been proven to be effective and superior to hyaluronic acid and normal saline injection for treating chronic subacromial bursitis 3
- Combination of corticosteroid subdeltoid injections and physiotherapy was more effective than either treatment alone in chronic subacromial bursitis 4
- Ultrasonographic observation of subacromial bursitis can help predict better outcomes with subacromial corticosteroid injection 5
Comparison of Treatment Outcomes
- Corticosteroid injection showed significant improvement in pain visual analogue scale (VAS) scores and Shoulder Pain and Disability Index (SPADI) scores compared to hyaluronic acid and normal saline injection 3
- Physiotherapy alone showed lower recurrence rates compared to corticosteroid injection and combined treatment 4
- Subacromial injection of nonsteroidal anti-inflammatory drugs (NSAIDs) had equivalent outcomes with steroid injection at the 12-week follow-up 6
Diagnostic and Management Considerations
- Subacromial impingement/pain syndrome is a common cause of shoulder pain that encompasses a spectrum of pathology of the subacromial bursa and rotator cuff tendons 7
- Magnetic resonance imaging study and ultrasonography may be useful to evaluate for soft tissue pathology, depending on the level of clinical concern regarding rotator cuff tear 7
- Management of rotator cuff conditions depends on multiple factors, including chronicity, underlying anatomic and biomechanical factors, age, and the presence and degree of tendon tears 7