Subacromial bursitis

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Subacromial bursitis
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Shoulder joint
Specialty Rheumatology   OOjs UI icon edit-ltr-progressive.svg

Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle. [1] The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.

Contents

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. [2]

Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions such as rheumatoid arthritis, crystal deposition disorders such as gout or pseudogout, calcific loose bodies, and infection. [1] More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury. [3]

In 1983 Neer described three stages of impingement syndrome. [4] He noted that "the symptoms and physical signs in all three stages of impingement are almost identical, including the 'impingement sign'..., arc of pain, crepitus, and varying weakness". The Neer classification did not distinguish between partial-thickness and full-thickness rotator cuff tears in stage III. [4] This has led to some controversy about the ability of physical examination tests to accurately diagnose between bursitis, impingement, impingement with or without rotator cuff tear and impingement with partial versus complete tears.

In 2005, Park et al. published their findings which concluded that a combination of clinical tests were more useful than a single physical examination test. For the diagnosis of impingement disease, the best combination of tests were "any degree (of) a positive Hawkins–Kennedy test, a positive painful arc sign, and weakness in external rotation with the arm at the side", to diagnose a full thickness rotator cuff tear, the best combination of tests, when all three are positive, were the painful arc, the drop-arm sign, and weakness in external rotation. [5]

Signs and symptoms

Subacromial bursitis often presents with a constellation of symptoms called impingement syndrome. Pain along the front and side of the shoulder is the most common symptom and may cause weakness and stiffness. [3] If the pain resolves and weakness persists other causes should be evaluated such as a tear of the rotator cuff or a neurological problem arising from the neck or entrapment of the suprascapular nerve. The onset of pain may be sudden or gradual and may or may not be related to trauma. Night time pain, especially sleeping on the affected shoulder, is often reported. Localized redness or swelling are less common and suggest an infected subacromial bursa. Individuals affected by subacromial bursitis commonly present with concomitant shoulder problems such as arthritis, rotator cuff tendinitis, rotator cuff tears, and cervical radiculopathy (pinched nerve in neck).[ citation needed ]

Impingement may be brought on by sports activities, such as overhead throwing sports and swimming, or overhead work such as painting, carpentry, or plumbing. Activities that involve repetitive overhead activity, or directly in front, may cause shoulder pain. Direct upward pressure on the shoulder, such as leaning on an elbow, may increase pain.[ citation needed ]

Pathophysiology

The literature on the pathophysiology of bursitis describes inflammation as the primary cause of symptoms. Inflammatory bursitis is usually the result of repetitive injury to the bursa. In the subacromial bursa, this generally occurs due to microtrauma to adjacent structures, particularly the supraspinatus tendon. The inflammatory process causes synovial cells to multiply, increasing collagen formation and fluid production within the bursa and reduction in the outside layer of lubrication. [6]

Less frequently observed causes of subacromial bursitis include hemorrhagic conditions, crystal deposition and infection.[ citation needed ]

Many causes have been proposed in the medical literature for subacromial impingement syndrome. The bursa facilitates the motion of the rotator cuff beneath the arch, any disturbance of the relationship of the subacromial structures can lead to impingement. These factors can be broadly classified as intrinsic such as tendon degeneration, rotator cuff muscle weakness and overuse. Extrinsic factors include bone spurs from the acromion or AC joint, shoulder instability and neurologic problems arising outside of the shoulder. [3]

Diagnosis

It is often difficult to distinguish between pain caused by bursitis or that caused by a rotator cuff injury as both exhibit similar pain patterns in the front or side of the shoulder. [7] Subacromial bursitis can be painful with resisted abduction due to the pinching of the bursa as the deltoid contracts. [8] If the therapist performs a treatment direction test and gently applies joint traction or a caudal glide during abduction (MWM), the painful arc may reduce if the problem is bursitis or adhesive capsulitis (as this potentially increases the subacromial space).[ citation needed ]

The following clinical tests, if positive, may indicate bursitis:

Irritation or entrapment of the lower subscapular nerve, which innervates the subscapularis and teres major muscles, will produce muscle guarding at the shoulder that will restrict motion into external rotation, abduction, or flexion. The aforementioned tests will assist in diagnosing bursitis over other conditions. The diagnosis of impingement syndrome should be viewed with caution in people who are less than forty years old, because such individuals may have subtle glenohumeral instability. [10]

Imaging

X-rays may help visualize bone spurs, acromial anatomy and arthritis. Further, calcification in the subacromial space and rotator cuff may be revealed. Osteoarthritis of the acromioclavicular (AC) joint may co-exist and is usually demonstrated on radiographs.[ citation needed ]

MRI imagining can reveal fluid accumulation in the bursa and assess adjacent structures. In chronic cases caused by impingement tendinosis and tears in the rotator cuff may be revealed. At US, an abnormal bursa may show

  1. fluid distension,
  2. synovial proliferation, and/or
  3. thickening of the bursal walls. [11]

In any case, the magnitude of pathological findings does not correlate with the magnitude of the symptoms. [11]

Special considerations

In patients with bursitis who have rheumatoid arthritis, short term improvements are not taken as a sign of resolution and may require long term treatment to ensure recurrence is minimized. Joint contracture of the shoulder has also been found to be at a higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).

Treatment

Many non-operative treatments have been advocated, including rest; oral administration of non-steroidal anti-inflammatory drugs; physical therapy; chiropractic; and local modalities such as cryotherapy, ultrasound, electromagnetic radiation, and subacromial injection of corticosteroids. [12]

Shoulder bursitis rarely requires surgical intervention and generally responds favorably to conservative treatment. Surgery is reserved for patients who fail to respond to non-operative measures. Minimally invasive surgical procedures such as arthroscopic removal of the bursa allows for direct inspection of the shoulder structures and provides the opportunity for removal of bone spurs and repair of any rotator cuff tears that may be found.[ citation needed ]

Early / initial

Initial phase of physiotherapy rehabilitation
Goals of treatment
  • Reduce inflammation
  • Reduce pain
  • Prevent weakness and atrophy of muscles as a result of disuse
  • Increase the patient’s awareness of bursitis
  • Prevent/reduce impingement and further tissue damage
TreatmentJustification
Advice and educationEducate the patient about their condition and advise to avoid painful activities and the importance of relative rest of the shoulderPrevention of pain and impingement which delays the healing process
Educate the patient about the importance of correct posturePuts muscles in the optimal length tension relationship, reducing impingement
Manual therapyGrade 1 and 2 accessory mobilisations of the glenohumeral jointHas a neurophysiological effect reducing pain and improving synovial fluid flow, improving healing
Soft tissue massageLengthens tight muscles and reduces muscle spasm
Therapeutic exerciseGentle pendulum range of motion exercisesMaintenance of range of motion and prevention of adhesive capsulitis
Scapular exercises such as shoulder shrugs and shoulder retraction exercisesImprove muscular control and scapular coordination
Centering of humeral headHelps to facilitate adequate muscle timing and recruitment
Stretching of tight muscles such as the levator scapulae, pectoralis major, subscapularis and upper trapezius muscle To lengthen tight muscles which may improve scapulohumeral rhythm, posture and increase the subacromial space
Rotator cuff strengthening - isometric contractions in neutral and 30 degrees abductionImproves rotator cuff strength which is integral to the stability of the shoulder and functional activities
Electrophysical modalitiesIceTo reduce inflammation and painelevate
Low intensity pulsed ultrasound (3 megaHz)To reduce inflammation and facilitate healing
External physical aidsMay use head of humerus repositioning tapeTo maintain the head of humerus in its central position for optimal muscle recruitment

Middle / intermittent

Intermittent phase of physiotherapy rehabilitation
Goals of treatment
  • Improve muscle control
  • Improve scapulohumeral rhythm
  • Improve active and passive range of motion
  • Restore strength of scapular and rotator cuff muscles
TreatmentJustification
Advice and educationAdvise the patient that they must perform all activities and exercises pain freeTo prevent reinjury and damage to the bursa
Manual therapyGrade 3 and 4 accessory mobilizations of the glenohumeral jointImproves range of motion and increases synovial fluid movement, improving healing
Proprioceptive neuromuscular facilitation (PNF) in functional diagonal patternsStrengthens muscles, improves motor control and scapulohumeral rhythm
Mobilization with movement e.g. caudal glide with active abductionImproves range of motion and decreases pain
Therapeutic exerciseSpecific muscle strengthening exercises especially for scapular stabilization (serratus anterior, rhomboids and lower trapezius muscles) e.g. strengthening lower trapezius muscle - bilateral external rotation using a theraband, strengthening of serratus anterior, punching with theraband resistanceImproves stability during scapular motion which may decrease impingement of the bursa in the subacromial space.
Active assisted range of motion - creeping the hand up the wall in abduction, scaption and flexion and door pulley manoeuvreHelp to improve active range of motion and gravity assists with shoulder depression
Active internal and external rotator exercises with the use of a bar or a therabandImproves strength of rotator cuff and improves mobility in internal and external rotation
Electrophysical modalitiesHeatImproves muscle extensibility
Low intensity pulsed ultrasound (3 megaHz)Facilitates healing
External physical aidsMay use head of humerus repositioning tape if necessaryTo maintain the head of humerus in its optimal position for optimal muscle recruitment

Late / return to function

Return to function phase of physiotherapy rehabilitation
Goals of treatment
  • Return the patient to their previous level of function
  • Achieve full active and passive range of motion
TreatmentJustification
Education and adviceEducation about the importance of a home based exercise program in the late stage of rehabilitationEnsures patient compliance
Correction of techniques performedEnsures that the correct target muscles are being used
Education to ensure that the patient performs activities and exercises within pain free limitsThis reduces the chance that the patient may work too hard and cause reinjury
Manual therapyPNF functional patterns with increasing resistanceContinues to strengthen muscles, improves motor control and scapulohumeral rhythm
Therapeutic exerciseExercises specific for the patient’s functional needs e.g. functional reachingTo improve the patients functional ability
Proprioception exercises e.g. Wall push ups with the hands resting on medicine balls or dura disksImproves proprioception important to reduce reinjury as return to function/sport
Strengthen the shoulder elevators – deltoid, flexors and also latissimus dorsi.Important in this phase of the rehabilitation following strengthening of the shoulder depressors
Progress strengthening exercises to incorporate speed and load to make more functionalAdding speed and load to exercises ensures that the patient is prepared for more functional tasks and activities
Electrophysical modalitiesIce after exerciseMay assist to reduce any inflammation post exercise
External physical aidsMay use head of humerus repositioning tape if necessaryMay assist with return to function

Prognosis

In 1997 Morrison et al published a study [13] that reviewed the cases of 616 patients (636 shoulders) with impingement syndrome (painful arc of motion) to assess the outcome of non-surgical care. An attempt was made to exclude patients who were suspected of having additional shoulder conditions such as, full-thickness tears of the rotator cuff, degenerative arthritis of the acromioclavicular joint, instability of the glenohumeral joint, or adhesive capsulitis. All patients were managed with anti-inflammatory medication and a specific, supervised physical-therapy regimen. The patients were followed up from six months to over six years. They found that

Most patients improve with conservative therapy, [14] and experience symptoms for only a few weeks. [15]

References

  1. 1 2 Salzman KL, Lillegard WA, Butcher JD (1997). "Upper extremity bursitis". Am Fam Physician. 56 (7): 1797–806, 1811–2. PMID   9371010.
  2. Arcuni SE (2000). "Rotator cuff pathology and subacromial impingement". Nurse Pract. 25 (5): 58, 61, 65–6 passim. doi:10.1097/00006205-200025050-00005. PMID   10826138.
  3. 1 2 3 Bigliani LU, Levine WN (1997). "Subacromial impingement syndrome" . J Bone Joint Surg Am. 79 (12): 1854–68. doi:10.2106/00004623-199712000-00012. PMID   9409800.
  4. 1 2 Neer CS (1983). "Impingement lesions". Clin. Orthop. Relat. Res. (173): 70–7. PMID   6825348.
  5. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG (2005). "Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome" . J Bone Joint Surg Am. 87 (7): 1446–55. doi:10.2106/JBJS.D.02335. PMID   15995110.
  6. Ishii et al., 1997.
  7. Hartley, 1990
  8. 1 2 Buschbacher & Braddom, 1994.
  9. 1 2 Starr & Harbhajan, 2001.
  10. Jobe FW, Kvitne RS, Giangarra CE (1989). "Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement". Orthop Rev. 18 (9): 963–75. PMID   2797861.
  11. 1 2 Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Free chapter on ultrasound findings of subacromial-subdeltoid bursitis at ShoulderUS.com
  12. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD (1996). "Efficacy of injections of corticosteroids for subacromial impingement syndrome" . J Bone Joint Surg Am. 78 (11): 1685–9. doi:10.2106/00004623-199611000-00007. PMID   8934482. S2CID   36977069.
  13. 1 2 Morrison DS, Frogameni AD, Woodworth P (1997). "Non-operative treatment of subacromial impingement syndrome" . J Bone Joint Surg Am. 79 (5): 732–7. doi:10.2106/00004623-199705000-00013. PMID   9160946. S2CID   30707675.
  14. Faruqi, Taha; Rizvi, Tara J. (May 1, 2025). StatPearls. StatPearls Publishing. PMID   31082140 via PubMed.
  15. "How Do I Get Rid of Bursitis in My Shoulder?". Cleveland Clinic.

Further reading