What is subacromial impingement/bursitis
The space above the glenohumeral (ball and socket) joint and under the acromion (bony tip of the shoulder) is the subacromial space. This area has a fluid filled sac in place, which can become painful and inflamed over time with repetitive movements of the arm. In persistent cases, this can eventually lead to a rotator cuff tear.
What causes subacromial impingement/bursitis?
This can occur following an injury to the shoulder although this is relatively uncommon. It has been suggested that repetitive strenuous activity can cause the accumulation of inflammatory tissue within the subacromial space. This can then continue to spiral into a cycle of inflammation and lead to tears within the rotator cuff tendons, which pass through this space.
What problems does subacromial impingement/bursitis cause?
The symptoms vary widely between individuals and are not always proportional to the severity of inflammation or surrounding tissue damage. If symptoms occur they may include:
Pain
Pain is most commonly felt over the top and front of the shoulder joint and often in the upper part of the arm below the shoulder. Pain is often particularly severe when attempting to lift the arm overhead. Pain may be present at night, particularly if lying on the affected shoulder.
Limitation of movement
In some individuals there is no stiffness but movements are painful and this pain may limit movement, although one should be aware that this may be the sign of a rotator cuff tear.
Mechanical symptoms
There may be popping, clicking, crunching or grinding felt when moving the shoulder. Despite having a full range of movement there may be varying degrees of weakness.
Will I need any further investigations?
An X-ray is the first investigation to help rule out other causes of pain and restriction in the movement of your arm. Following this an ultrasound scan of the shoulder may be used to view the tendons and assess if they are torn and how retracted these tendons are.
What can be done to treat subacromial impingement/bursitis?
Every patient with subacromial impingement/bursitis is different and responses to treatments vary between individuals.
Treatments can be divided into those involving surgery and those not involving surgery:
Non-surgical treatment:
Physiotherapy
A skilled physiotherapist advises with a variety of exercises to improve range of movement and strengthen the rotator cuff and other shoulder muscles.
Painkillers
Painkilling tablets, especially anti-inflammatory medication, often improve pain around the shoulder.
Injections
Injections of cortisone into the subacromial space often improve symptoms. These are most effective when combined with a course of physiotherapy. In many cases symptoms are permanently alleviated. If the effects of the injection wear off it can be repeated, although if injections only have a very brief effect, an alternative treatment may be more appropriate.
Surgical treatment:
Subacromial decompression
Most commonly performed through a keyhole (arthroscopy) under a general anaesthetic (with or without a nerve block) this procedure involves removing inflamed tissue from around the rotator cuff tendons (bursectomy) and shaving away bone from above the tendons (acromioplasty) increasing the space through which the tendons pass. Pain relief is seldom immediate and it is normal to have some degree of discomfort for six to nine months after surgery.
What is the recovery after surgery?
You will have a sling to wear for comfort after the surgery that is usually discarded as soon as possible. You can safely use the shoulder within your comfort zone. Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will see a therapist prior to discharge from the hospital. You will be given painkillers to take home after surgery. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. There are no sutures to be removed. The pain will gradually settle and you will regain the movement in the shoulder over the next few weeks although it can take several months before you fully recover from the surgery.
