Subacromial bursitis | |
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Shoulder joint | |
Specialty | Rheumatology |
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.
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]
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 ]
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]
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]
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
In any case, the magnitude of pathological findings does not correlate with the magnitude of the symptoms. [11]
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).
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 ]
Initial phase of physiotherapy rehabilitation | |||
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Goals of treatment |
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Treatment | Justification | ||
Advice and education | Educate the patient about their condition and advise to avoid painful activities and the importance of relative rest of the shoulder | Prevention of pain and impingement which delays the healing process | |
Educate the patient about the importance of correct posture | Puts muscles in the optimal length tension relationship, reducing impingement | ||
Manual therapy | Grade 1 and 2 accessory mobilisations of the glenohumeral joint | Has a neurophysiological effect reducing pain and improving synovial fluid flow, improving healing | |
Soft tissue massage | Lengthens tight muscles and reduces muscle spasm | ||
Therapeutic exercise | Gentle pendulum range of motion exercises | Maintenance of range of motion and prevention of adhesive capsulitis | |
Scapular exercises such as shoulder shrugs and shoulder retraction exercises | Improve muscular control and scapular coordination | ||
Centering of humeral head | Helps 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 abduction | Improves rotator cuff strength which is integral to the stability of the shoulder and functional activities | ||
Electrophysical modalities | Ice | To reduce inflammation and pain | elevate |
Low intensity pulsed ultrasound (3 megaHz) | To reduce inflammation and facilitate healing | ||
External physical aids | May use head of humerus repositioning tape | To maintain the head of humerus in its central position for optimal muscle recruitment |
Intermittent phase of physiotherapy rehabilitation | ||
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Goals of treatment |
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Treatment | Justification | |
Advice and education | Advise the patient that they must perform all activities and exercises pain free | To prevent reinjury and damage to the bursa |
Manual therapy | Grade 3 and 4 accessory mobilizations of the glenohumeral joint | Improves range of motion and increases synovial fluid movement, improving healing |
Proprioceptive neuromuscular facilitation (PNF) in functional diagonal patterns | Strengthens muscles, improves motor control and scapulohumeral rhythm | |
Mobilization with movement e.g. caudal glide with active abduction | Improves range of motion and decreases pain | |
Therapeutic exercise | Specific 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 resistance | Improves 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 manoeuvre | Help 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 theraband | Improves strength of rotator cuff and improves mobility in internal and external rotation | |
Electrophysical modalities | Heat | Improves muscle extensibility |
Low intensity pulsed ultrasound (3 megaHz) | Facilitates healing | |
External physical aids | May use head of humerus repositioning tape if necessary | To maintain the head of humerus in its optimal position for optimal muscle recruitment |
Return to function phase of physiotherapy rehabilitation | ||
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Goals of treatment |
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Treatment | Justification | |
Education and advice | Education about the importance of a home based exercise program in the late stage of rehabilitation | Ensures patient compliance |
Correction of techniques performed | Ensures that the correct target muscles are being used | |
Education to ensure that the patient performs activities and exercises within pain free limits | This reduces the chance that the patient may work too hard and cause reinjury | |
Manual therapy | PNF functional patterns with increasing resistance | Continues to strengthen muscles, improves motor control and scapulohumeral rhythm |
Therapeutic exercise | Exercises specific for the patient’s functional needs e.g. functional reaching | To improve the patients functional ability |
Proprioception exercises e.g. Wall push ups with the hands resting on medicine balls or dura disks | Improves 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 functional | Adding speed and load to exercises ensures that the patient is prepared for more functional tasks and activities | |
Electrophysical modalities | Ice after exercise | May assist to reduce any inflammation post exercise |
External physical aids | May use head of humerus repositioning tape if necessary | May assist with return to function |
In 1997 Morrison et al. [13] published a study 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 67% (413 patients) of the patients improved, while 28% did not improve and went to surgical treatment. 5% did not improve and declined further treatment.[ citation needed ]
Of the 413 patients who improved, 74 had a recurrence of symptoms during the observation period and their symptoms responded to rest or after resumption of the exercise program.[ citation needed ]
The Morrison study shows that the outcome of impingement symptoms varies with patient characteristics. Younger patients (20 years or less) and patients between 41 and 60 years of age, fared better than those who were in the 21 to 40 years age group. This may be related to the peak incidence of work, job requirements, sports and hobby related activities, that may place greater demands on the shoulder. However, patients who were older than sixty years of age had the "poorest results". It is known that the rotator cuff and adjacent structures undergo degenerative changes with ageing.[ citation needed ]
The authors were unable to posit an explanation for the observation of the bimodal distribution of satisfactory results with regard to age. They concluded that it was "unclear why (those) who were twenty-one to forty years old had less satisfactory results". The poorer outcome for patients over 60 years old was thought to be potentially related to "undiagnosed full-thickness tears of the rotator cuff". [13]
The rotator cuff is a group of muscles and their tendons that act to stabilize the human shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are:
Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.
The human shoulder is made up of three bones: the clavicle (collarbone), the scapula, and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The shoulder joint, also known as the glenohumeral joint, is the major joint of the shoulder, but can more broadly include the acromioclavicular joint. In human anatomy, the shoulder joint comprises the part of the body where the humerus attaches to the scapula, and the head sits in the glenoid cavity. The shoulder is the group of structures in the region of the joint.
Bursitis is the inflammation of one or more bursae of synovial fluid in the body. They are lined with a synovial membrane that secretes a lubricating synovial fluid. There are more than 150 bursae in the human body. The bursae rest at the points where internal functionaries, such as muscles and tendons, slide across bone. Healthy bursae create a smooth, almost frictionless functional gliding surface making normal movement painless. When bursitis occurs, however, movement relying on the inflamed bursa becomes difficult and painful. Moreover, movement of tendons and muscles over the inflamed bursa aggravates its inflammation, perpetuating the problem. Muscle can also be stiffened.
Rotator cuff tendinopathy is a process of senescence. The pathophysiology is mucoid degeneration. Most people develop rotator cuff tendinopathy within their lifetime.
Adhesive capsulitis, also known as frozen shoulder, is a condition associated with shoulder pain and stiffness. It is a common shoulder ailment that is marked by pain and a loss of range of motion, particularly in external rotation. There is a loss of the ability to move the shoulder, both voluntarily and by others, in multiple directions. The shoulder itself, however, does not generally hurt significantly when touched. Muscle loss around the shoulder may also occur. Onset is gradual over weeks to months. Complications can include fracture of the humerus or biceps tendon rupture.
The supraspinatus is a relatively small muscle of the upper back that runs from the supraspinous fossa superior portion of the scapula to the greater tubercle of the humerus. It is one of the four rotator cuff muscles and also abducts the arm at the shoulder. The spine of the scapula separates the supraspinatus muscle from the infraspinatus muscle, which originates below the spine.
The shoulder joint is structurally classified as a synovial ball-and-socket joint and functionally as a diarthrosis and multiaxial joint. It involves an articulation between the glenoid fossa of the scapula and the head of the humerus. Due to the very loose joint capsule that gives a limited interface of the humerus and scapula, it is the most mobile joint of the human body.
The shoulder girdle or pectoral girdle is the set of bones in the appendicular skeleton which connects to the arm on each side. In humans it consists of the clavicle and scapula; in those species with three bones in the shoulder, it consists of the clavicle, scapula, and coracoid. Some mammalian species have only the scapula.
Snapping hip syndrome, also referred to as dancer's hip, is a medical condition characterized by a snapping sensation felt when the hip is flexed and extended. This may be accompanied by a snapping or popping noise and pain or discomfort. Pain often decreases with rest and diminished activity. Snapping hip syndrome is commonly classified by the location of the snapping as either extra-articular or intra-articular.
The coracoacromial ligament is a strong triangular ligament between the coracoid process and the acromion. It protects the head of the humerus. Its acromial attachment may be repositioned to the clavicle during reconstructive surgery of the acromioclavicular joint.
Greater trochanteric pain syndrome (GTPS), a form of bursitis, is inflammation of the trochanteric bursa, a part of the hip.
Calcific tendinitis is a common condition where calcium phosphate deposits form in a tendon, sometimes causing pain at the affected site. Deposits can occur in several places in the body, but are by far most common in the rotator cuff of the shoulder. Around 80% of those with deposits experience symptoms, typically chronic pain during certain shoulder movements, or sharp acute pain that worsens at night. Calcific tendinitis is typically diagnosed by physical exam and X-ray imaging. The disease often resolves completely on its own, but is typically treated with non-steroidal anti-inflammatory drugs to relieve pain, rest and physical therapy to promote healing, and in some cases various procedures to breakdown and/or remove the calcium deposits.
Shoulder surgery is a means of treating injured shoulders. Many surgeries have been developed to repair the muscles, connective tissue, or damaged joints that can arise from traumatic or overuse injuries to the shoulder.
The subacromial bursa is the synovial cavity located just below the acromion, which communicates with the subdeltoid bursa in most individuals, forming the so-called subacromial-subdeltoid bursa (SSB).
Shoulder impingement syndrome is a syndrome involving tendonitis of the rotator cuff muscles as they pass through the subacromial space, the passage beneath the acromion. It is particularly associated with tendonitis of the supraspinatus muscle. This can result in pain, weakness, and loss of movement at the shoulder.
The drop arm test is designed to determine a patient's ability to sustain humeral joint motion through eccentric contraction as the arm is taken through the full motion of abduction to adduction. It will determine if the patient has an underlying rotator cuff dysfunction.
The Neer Impingement Test is a test designed to reproduce symptoms of rotator cuff impingement through flexing the shoulder and pressure application. Symptoms should be reproduced if there is a problem with the supraspinatus or biceps brachii. This test is also associated with the Hawkins-Kennedy Test and Jobe's Test.
A shoulder examination is a portion of a physical examination used to identify potential pathology involving the shoulder. It should be conducted with both shoulders exposed to assess for asymmetry and muscle wasting.
The Hawkins–Kennedy Test is a test used in the evaluation of orthopedic shoulder injury. It was first described in the 1980s by Canadian Drs. R. Hawkins and J. Kennedy, and a positive test is most likely indicative of damage to the tendon of the supraspinatus muscle.