SUBACROMIAL BURSITIS

arm, particularly abduction due to the compression that occurs in the shoulder joint and subacromial space ● Characteristically this condition gives a muddle of signs i.e. some passive tests and some resisted tests produce the symp- toms

Treatment Practical advice ● Consider the mechanisms responsible for the condition and how these may be corrected ● Postural changes may need to be implemented and correcting muscle imbalance can improve symptoms considerably. The encouragement of normal shoulder movement patterns avoids excessive superior translation of the humeral head ● Training advice may be required in order to modify overhead throwing techniques

Corticosteroid injection Ideally this is the treatment of choice since physiotherapeutic modalities, such as electrotherapy, often cannot satisfactorily affect the relevant anatomy. However, physiotherapy does have an important role since treatment results, particularly if an injection is given, will be disappointing if the cause of the problem is not also addressed, for the reasons stated above.

Treating without eliminating the cause will lead to disappointing treatment results and recurrences.

Figure 2: Point and direction of injection

upwards with respect to the acromion ● A guidance dosage is 20 mg of corticosteroid such as 2 mls of Adcortyl made up to a total volume of 7 ml with a 0.5% solu- tion of lidocaine. The relatively large volume with help to inflate and ‘splint’ the painful bursa ● Deliver the injection as a bolus having detected an area of less resistance ● Synovial folds and adhesions within the bursa may present a resistance to the injection and it may be necessary to deliver the injection by a ‘peppering technique’ ie. a series of with- drawals and re-insertions via one skin puncture ● Advise the patient to maintain a period of relative rest for approximately two weeks following the injection. However, the postural advice and exercises recommended by the physiothera- pist, are most important to the successful outcome of treatment of this condition

Other treatment The condition can be resistant to treatment, particularly if con- genital abnormalities of the acromion restrict the space, and advice may be needed from the specialist orthopaedic surgeon where decompression of the subacromial space may be necessary.

Injection technique ● Explain the injection procedure to the patient and conduct

the injection using an aseptic, no touch technique ● Put the patient in a comfortable sitting position with the arm resting at the side ● Identify the lateral border of the acromion and insert the nee- dle just below this lateral border at a slightly oblique angle

Differential diagnosis

Capsulitis (or ‘frozen shoulder’) may present as a primary lesion, but may be secondary to other pathology such as subacromial bursitis. The patient complains of gradually increasing pain and stiffness in the shoulder. Functional activities such as reaching into the back pocket or doing/undoing a bra are restricted which draws the patient’s attention to the lack of mobility.

Passive

shoulder movements will be limited and the end-feel will be hard- er than normal.

Arthritis or sprain of the acromioclavicular joint presents with pain felt specifically over the joint. Pain is produced at the end of range of all passive movements, but the diagnosis is confirmed by a positive ‘scarf test’ (pain on passive flexion and adduction of the shoulder joint).

Acute subacromial bursitis is a completely different condition to chronic subacromial bursitis.

It presents suddenly with acute pain felt in the area of the C5 dermatome, with no apparent rea- SportEX 39 son for the onset. active movement particularly into abduction.

Severe twinges of pain are experienced on The condition is

usually self-limiting and the patient feels more comfortable with- in 7-10 days, the condition is fully resolved by approximately six weeks. Pain relief, possibly in the form of corticosteroid injec- tion, and management advice is much appreciated by the patient.

Rotator cuff lesions vary from simple tendinitis to degeneration and partial or full thickness tears. On examination pain is repro- duced by the appropriate resisted test and there may be localis- ing signs such as a painful arc or positive scarf test.

Passive

movements are usually full range, but the opposite passive move- ment and/or end range passive elevation may produce pain by stretching or compressing the tendinous insertion respectively.

Tendinitis of the long head of the biceps will give pain felt at the shoulder on resisted elbow flexion.

Monica Kesson MCSP and Elaine Atkins MCSP are authors of Orthopaedic Medicine a Practical Approach (Butterworth Heinemann, 1998) from which the above article is an extract. They are both course principals for the Society of Orthopaedic Medicine, which runs course on the diagnosis and treatment of non-surgical musculoskeletal lesions.

For more information about these courses telephone 01795 535168.

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