Shoulder Bursitis and Impingement Syndrome

Shoulder Pain from Rotator Cuff Tendonitis, Bursitis, and Impingement Syndrome

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Many people seek help from their orthopedist for shoulder pain, and a common diagnosis given is 'shoulder bursitis,' or 'rotator cuff tendonitis.' These words are often used interchangeably, but they can cause confusion for people who wonder which of these conditions they may have or if they are actually the same condition.

Tendonitis or Bursitis Are Combined in Impingement Syndrome

Shoulder bursitis and rotator cuff tendonitis are different ways of saying there is inflammation of a particular area within the shoulder joint that is causing a common set of symptoms.

The proper terminology for these symptoms is 'impingement syndrome.' Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons. There is a difference between tendonitis and bursitis, but there is a combination of these problems in most cases of impingement syndrome.

Where Is The Problem?

The shoulder is a complex joint where several bones, muscles, and ligaments connect the upper extremity to the chest. Impingement syndrome occurs when there is inflammation between the top of the humerus (arm bone) and the acromion (tip of the shoulder blade). Between these bones are the tendons of the rotator cuff, and the bursa that protects these tendons. Normally, these tendons slide effortlessly within this space—called the subacromial space.

Causes of Shoulder Bursitis and Impingement Syndrome

Impingement syndrome is a descriptive term for the pinching of the tendons and bursa of the rotator cuff between the bones.

In many individuals with this problem, the shape of their bones is such that they have less space than others. Therefore, small thickenings of the tendons or bursa can cause symptoms. Eventually, this space becomes too narrow to accommodate the tendons and the bursa, and every time these structures move between the bones they are pinched.

Often there is an initial injury that sets off the process of inflammation. After that, the problem can be self-exacerbating. Inflammation causes a thickening of the tendons and bursa. The thickening then takes up more space, and therefore the tendons and bursa become are pinched even more. This causes more inflammation, and more thickening of the tendons and bursa, and so on.

Symptoms of Shoulder Bursitis

Common symptoms of shoulder bursitis include:

  • Pain with overhead activities (arm above head height)
  • Pain while sleeping at night
  • Pain over the outside of the shoulder/upper arm

Making the diagnosis of impingement syndrome can usually be accomplished with a thorough physical exam. It is important to be examined by a doctor familiar with different causes of shoulder pain, as other problems can have similar symptoms. Making an accurate diagnosis is necessary for proper treatment. X-rays are usually performed to assess the bony anatomy of the shoulder. An MRI may be considered to ensure there is no sign of a rotator cuff tear.

Impingement syndrome and a rotator cuff tear are different problems, and although they are related, the treatment is different.  Rotator cuff tears are more likely to require surgical intervention, although the truth is that the majority of rotator cuff tears can also be managed with noninvasive treatments.

Treatment of Shoulder Bursitis

Most patients with shoulder bursitis can find relief with some simple, non-surgical treatments. Only in rare circumstances is surgery necessary for the treatment of shoulder bursitis. Specific treatments may differ depending on the preferences of the patients, their expectations, and their response to treatment.

Many people find relief with resting from specific activities, physical therapy, and anti-inflammatory medications. One of the most common uses of a cortisone injection is for the treatment of impingement syndrome. If you want to pursue any of these treatments for your impingement syndrome, it is worthwhile to discuss with your doctor.

If the treatments have been tried for at least three to six months without improvement in symptoms, a surgical procedure called a subacromial decompression might be considered.

Subacromial Decompression Surgery

Subacromial decompression is an arthroscopic surgery performed using instruments inserted through small incisions. Depending on the location of the inflammation and the extent of work that needs to be done, usually two to four small (1 centimeter) incisions are made. A small tube called a cannula is inserted into each incision to allow easy passage of instruments in and out of the shoulder without damaging the surrounding tissues. One of the instruments inserted into the shoulder is a video camera about the size of a pencil. Another instrument called a shaver is inserted through another cannula. The shaver is used to remove the inflamed bursa. Once the bursa is removed, the rotator cuff is inspected to look for any signs of a tear.

The bone above the rotator cuff (the point of the shoulder) is called the acromion. Many people with bursitis of the shoulder have a bone spur that forms on the undersurface of the acromion. Depending on the bone of the acromion, a burr may be used to remove the spur to create more space for the rotator cuff tendons. The benefit of removing the bone spur is a subject of debate among orthopedic surgeons. Some surgeons believe the spur is a major cause of inflammation by taking up space around the rotator cuff tendons, while others contend that removing the bone spur has never been shown to improve the results of patients who have this surgery.

Post-Surgical Rehab

Patients are placed in a shoulder sling following subacromial decompression, but they can begin shoulder motion quickly. Unlike surgery for a rotator cuff tear, there is no need for a period of restricted motion to allow for tendon healing. In cases of an isolated subacromial decompression, patients can begin gentle motion immediately after surgery. Strengthening can begin within a few weeks, and sports can resume after the swelling has subsided.

Because a subacromial decompression is often a part of another surgical procedure (such as a rotator cuff repair or labral repair surgery), the rehab may be very different under these circumstances. Therefore, any patient should discuss their rehab progression with their own surgeon.

Complications of Shoulder Arthroscopy

Complications after subacromial decompression are uncommon but can occur. The most common problems are pain and stiffness that usually resolve with physical therapy and time. However, there are more serious complications including infection, nerve injury, and cartilage damage, all of which can cause long-term problems.  It is important to take steps to prevent these complications to ensure the best possible result of surgery.

Source:

Aaron DL, et al. "Four Common Types of Bursitis: Diagnosis and Management" J Am Acad Orthop Surg June 2011; 19:359-367.

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