Sub Acromial Bursities.

Subacromial bursitis has similar symptoms to Supraspinatus tendinitis with shoulder pain over a 60 degree arc when the arm is lifted sideways.

Bursa around Glenohumeral joint

 

Anatomy

The Supraspinatus muscle runs along the top of the shoulder blade and inserts via the tendon at the top of the arm or humerus bone. This muscle is used to lift the arm up sideways and is also important in throwing sports as it is the muscle that holds the arm in the shoulder when you release what you are throwing.

Anatomy of Glenohumaral joint

 

There are massive forces involved in slowing the arm down after you have thrown something but few people bother to train these muscles preferring to concentrate more on the muscles the accelerate the arm rather than decelerate it.. A heavy fall onto the shoulder can also result in injuring the supraspinatus muscle.

Over the tendon is a bursa or small sack of fluid the purpose of which is to help lubricate the moving tendon. This bursa can become trapped in the shoulder causing pain and inflammation. The athlete is more prone to this injury if they overuse the shoulder particularly in sports where the arm is at or above shoulder level. Or if the athlete has previously had a rupture of the supraspinatus tendon.

Symptoms

Symptoms of subacromial bursitis can be similar to those of supraspinatus inflammation or injury in the shoulder.
There will be pain and weakness in the arm, particularly when it is lifted sideways through a 60 degree arc.
Pain may also be felt when you press in at the inside front of the upper arm.
If it is the tendon that is injured rather than the bursa there is likely to be more pain when the arm is lifted up sideways against resistance.

 

Related symptoms

Gradual onset shoulder pain with overhead movement

Diagnostic Procedures :

Bursitis can often be diagnosed by physically examining of the patient. By (visual) inspection it is possible to notice some redness and warmth, local tenderness or stiffness in the joint with some swelling when the inflammation is worse.
By x-ray it is possible to confirm the presence of gout crystals and calcification (which means that the bursitis is chronic or recurrent).
With bursa fluid puncture is it possible to rule out infections.

The subacromial deltoid bursa comes into conflict with the acromion. By executing the painful arc, pain will be felt between 70 and 120 degrees of abduction. When the test is positive, we speak of a bursitis sub acromiodeltoid. The movement restriction is not in accordance with the capsular pattern. This means that the abduction is more restricted than the exorotation.

The subcoracoid bursa stands in relation with the anterior joint capsule. We speak of an subcoracoid bursa when the passive exorotation in 90 degrees of abduction is negative and the passive exorotation on 0 degrees is positive.

A test for the scapulothoracic bursa focusses on the strength of the scapular muscles—including the trapezius (upper, middle, and lower), levator scapula, serratus anterior, latissimus dorsi, deltoids, and rotator cuff muscles. A loss of muscle tone or an alteration of scapulothoracic rhythm may lead to increased friction between the medial border of the scapula and the rib cage, resulting in crepitus or snapping.
Snapping scapula is a painful crepitus of the scapulothoracic articulation. This crepitus is a grinding or snapping noise with scapulothoracic motion that may or may not accompany pain. This condition is commonly seen in overhead-throwing athletes. Treatment of patients with this syndrome begins with nonoperative methods; when nonoperative treatment fails, several surgical options exist.

Previous to bursitis, there’s always any other pathology which causes bursitis.
It is not rare that people suffering bursitis also have other pathologies. Shoulder bursitis commonly co-exists with different shoulder pathologies (see differential diagnosis), which can make it hard to diagnose. Torn tendons or ligaments can cause as well the irritated bursa.
Shoulder bursitis can be caused due a repeated minor trauma. This can be an overuse of the shoulder joint and muscles according to a more single significant trauma such as a fall for example.
The subacromial bursa lies between the coracoacromial ligament and the supraspinatus muscle. His function is to reduce friction in the space under the acromion. Tests which can include subacromial bursitis are given at the outcome measures.
Bursitis is typically determined by pain or swelling which is localized, tenderness and pain with motion of the affected area tissues. Procedures which can include bursitis or X-ray testing and MRI scanning.
Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area.
X-ray testing can sometime detect calcifications in the bursa when bursitis has been chronic or recurrent. While MRI scanning can be used to identify bursitis, it is not always necessary.

X-ray of Sholder Joint

Test:

Hawkins Test
The examinator has to hold the arm in 90° anteflexion. Next he has to a do passive endoration of the arm by use of his other arm. During this manoeuvre the tuberculum majus appears under the coracoacromial ligament which causes the pain within subacromial bursitis.
The same test is conducted for bankart lesion, which causes pain in the region of the m. deltoid.[15]
Patient stands up, arm alongside the body.
Test: active abduction from 0° to 180°
Test is positive when the patient complains of pain between 60°-120° abduction.
Arm lifted above 120° and the pressure on the bursa decreases.
Background: the subacromial space, becomes smaller during abduction and causes compression of the supraspinatus tendon and the subacromial bursa.

Medical Management:

A common treatment for bursitis is the use of injections with or without the use of ultrasound guidance or palpation. These injections could contain steroids or other analgesic substances.
One study examined the use and effectiveness of botulinum toxin type B in the treatment of subacromial bursitis or shoulder impingement syndrome. The conclusion was that botulinum type B can be a useful strategy and that it has a great potential for replacing steroids as a treatment for subacromial bursitis or shoulder impingement syndrome.
Inflammation can also be treated with anti-inflammatory medications such as Motrin, Advil, Aleve, Celebrex, or one of many others. These all fall within the category of ‘non-steroidal anti-inflammatory medications.’ Taken by mouth, these medications help with the inflammation of the tendons and bursa, and also help reduce the discomfort.
Since the appearance of bursitis is due to another medical condition, treating the cause of this bursitis should be the first step. But since the bursa is still painful, injection is often used to cure this pain. This injection can be in the bursa, or in the muscle itself. A recent study has shown that both methods reduce the pain, but there’s no significant difference between the two methods.

Treatment:

 

Physiotherapy Treatment :

  • Stretching regularly to increase mobility and range of motion.
  • Strength training regularly to condition the surrounding muscle of the shoulder joint.
  • Avoiding prolonged repetitive movements, especially ones where you are lifting up over your head.
  • Avoiding any other movements that you know irritates the area.

The aim of the therapy:

1) Reduce the symptoms
2) Minimize damage
3) Maintain rotator cuff motion and strength

 

Exercise in Shoulder

 

The first step in treating bursitis is applying cold to the bursa. It will help decrease the swelling and redness around the bursa.
Apply ice every day 12-20 minutes.
In the acute stage, also use Codman’s pendulum exercises and AAROM exercises.
Once the inflammation has been reduced, you can begin using ultrasound therapy to continue the healing process.

For the best of the recovery, it is designated to keep the joint in motion. This will prevent that the joint becomes stiff and the recovery process is slowed down.

Rehabilitation program

The following guidelines are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.

Aims of rehabilitation

The aims of subacromial bursitis rehab are to reduce pain and inflammation, improve or maintain mobility, strengthening the shoulder with exercises and finally to gradually return the athlete to full function and fitness.

Before beginning a subacromial bursitis rehabilitation program it is important to be aware that the athletes chance of the injury recurring are increased by any of the following:

If they have an unstable shoulder joint where there is a lot of movement and weakness in the joint for example from previous injury or a shoulder dislocation. If you are not sure, see a sports injury professional. Failure to recognize this may mean the injury is likely to recur.
Poor technique or bad training habits. Overuse or training too hard is just as likely to cause injury as poor technique. If not sure, find a good coach.
Weakness in the rotator cuff muscles. Strengthening exercises should not be neglected just because the pain has gone.
Stage 1: To reduce the pain and inflammation.

Apply cold therapy or ice to the shoulder. This will help reduce pain and inflammation. Apply ice for up to 15 minutes every hour, gradually reducing the frequency of applications as the shoulder improves.
Rest the shoulder. Do not do anything that causes pain. Every time the athlete causes pain, they may be making the injury worse. If necessary, use a sling to restrict movement then do so but only for a few days.
NSAID or anti-inflammatory medication (e.g. ibuprofen) may help in the early stages. Always check with your Doctor before taking medication if you are not sure.
Stage 2: To re-establish range of motion and strength

(usually 5 to 7 days after injury)

Range of motion is done through shoulder mobility exercises, gradually increasing the range of motion the joint will go through pain free and specific stretching exercises to stretch all muscles around the shoulder joint.
Sports massage techniques can help to improve greatly the condition of the rotator cuff muscles, so allowing more joint flexibility and better response to strengthening exercises.
Strengthening exercises concentrate more specifically on the external rotator muscles (the ones that rotate the arm out) and the scapular stabilizers (muscles that support the shoulder blade). It is also important to strengthen the whole joint.
Strengthening exercises must be done pain free and in conjunction with stretching exercises.
Stage 3: To return the athlete to competition or specific training

These exercises need to be specifically tailored to the athletes sport. For example throwers would start throwing a tennis ball against a wall. Five sets of 20 throws gradually increasing the number of sets and number of repetitions assuming no pain during, after or the next day.
How long will it take to heal?

Obviously every injury is different, however the athlete is usually able to resume sports specific training after between 1 and 3 weeks.
If the injury is neglected it can become chronic and be very difficult to treat resulting a cycle of rotator cuff injury and impingement of the shoulder joint.

                                                                             Shoulder Exercises

Stretches & Exercises to Relieve Shoulder Bursitis Symptoms

*Before performing any of these stretches or exercises, please remember:

  • Always consult with your physician before engaging in any new exercise program to ensure it is safe and appropriate for your particular condition.
  • Flexible tissue is more tolerant of the stresses placed on it during activities. Warm up the area before stretching or exercising by either doing 5-10 minutes of moderate aerobic activity (e.g. brisk walking) or applying a heat pad to the affected area.
  • Each stretch should be held for 20 to 30 seconds.
  • A gentle stretching sensation should be felt, but never pain.

    Range of Motion and Stretching Exercises for Shoulder Bursitis and Shoulder Impingement Syndrome

    1. Shoulder Pendulum Stretch

    • You’ll need a 3-5 lb. weight or any 3-5 lb. household object that you can comfortably grasp. Bend at the waist so your afflicted arm is dangling straight down. You may want to hold onto a table or chair with the opposite arm for support. Keeping your dangling arm loose, gently rotate your arm in a circular motion while keeping your arm and shoulder relaxed. Rotate clockwise for 2-3 minutes and then counterclockwise for 2-3 minutes and repeat until your shoulder feels loosened.

      2. Internal Shoulder Rotation Stretch

      • You’ll need a rolled up standard bath towel to perform this stretch. Hold the towel at both ends with your better hand behind your neck and the hand of the arm afflicted by bursitis behind your lower back. Pull your lower arm up the back by pulling up with your higher arm. Hold the stretch for five seconds and then return to the starting position by pulling down with you lower arm. Repeat 10 times and then make sure to switch arms (lower arm up and upper arm down).

      3. Shoulder Flexion Stretch

      • You’ll need a non-weighted bar, or a household item such as a broom handle to perform this stretch. Standing with good posture (core is tight, chest is up, and shoulder blades are back and down) grasp the handle shoulder width apart with your palms down. Then keeping your arms perfectly straight, raise the bar up directly over your head, hold for 5 seconds and then slowly bring it all the way back down to the starting position and repeat 10-20 times in 3-4 sets.

      Strengthening Exercises for Shoulder Bursitis

    • 1. Standing Scapular Elevation

      • You’ll need a pair of 5-10 lbs. dumbbells or any household objects that you can comfortably grasp. Standing with good posture (core is tight, chest is up, and shoulder blades are back and down), shrug your shoulders and traps straight up keeping your arms perfectly straight. Hold for five seconds and then slowly lower your shoulders back down to the starting position. Repeat 10-20 times in 3-4 sets.

    2. Standing Shoulder Scaption

    • You’ll need a pair of 3-5 lbs. dumbbells or any household objects that you can comfortably grasp. Stand with your feet shoulder-width apart with optimal posture and hold a dumbbell in each hand with your palms facing each other in a neutral grip position. Next, bring both dumbbells up into a “Y” formation on a 45-degree angle from your body and hold for 2-3 seconds. Be sure not to raise the dumbbells above shoulder height. Slowly return back down to the starting position and repeat 10-20 times in 3-4 sets.

    3. Upright External Shoulder Rotation

    • You’ll need a 3-5 lbs. dumbbell or any household object that you can comfortably grasp. Stand with the dumbbell positioned out to side of head, elbow bent, and shoulder height with the dumbbell directly above the elbow. Slowly lower the dumbbell forward by rotating at the shoulder until the dumbbell is in line with your shoulder. Return the dumbbell the same way back to the starting position and repeat 10-20 times in 3-4 sets for each shoulder.

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