Subacromial bursa is a thin, protective layer of tissue found between the top of the rotator cuff and below the acromion. Bursa exists in an effort to keep the rotator cuff from rubbing on the undersurface of the acromion. Bursa can become inflamed and thickened, decreasing the space between the rotator cuff and the acromion, resulting in symptoms of rotator cuff inflammation.
Bursitis generally occurs as a result of overuse of the rotator cuff or repetitive overhead motion and less commonly from injury. Patients with occupations that frequently require them to lift their arms over their heads (plumbers, painters, electricians and carpenters) are at risk for bursitis. Athletes who play overhead sports, such as baseball, softball, volleyball and tennis will often develop symptoms as well. Abnormalities in the structure of the acromion (“hooked” acromion) or that have developed AC joint osteoarthritis and associated bone spurs on the underside of the AC joint often have bursitis caused by impingement syndrome.
Bursitis typically causes referred pain on the side of the shoulder, though the inflammation is deep within the shoulder. Patients may feel pain at the AC joint if arthritis is present. Pain at night while sleeping is a common symptom, often leading to the patient to say “I slept on my shoulder wrong”. Pain from bursitis is worse when reaching overhead, across the body or behind the back. Patients may also feel clicking and popping while moving the shoulder.
Your surgeon will perform a thorough history and physical exam, which typically includes X-rays of the shoulder. Based on some of the shoulder tests your surgeon performs and the presence of AC joint arthritis or acromion structure abnormality, no further workup is necessary. If your pain is accompanied by a significant loss of strength, indicative of a rotator cuff tear, your surgeon may order an MRI.
Non-operative treatment of bursitis/impingement syndrome is usually the first line of treatment. Your surgeon may recommend anti-inflammatory medicine, physical therapy, and or cryotherapy to help reduce the pain and inflammation. An injection into the space above the rotator cuff may help resolve the pain. Non-operative treatment is minimally effective for bursitis cause by bone spurs or acromion abnormality.
If non-operative treatment fails to relieve the pain, your surgeon may suggest surgery. A subacromial decompression and/or AC joint resection can be performed through a minimally-invasive arthroscopic surgery or large open incision. Surgery removes the inflamed and thickened bursa, as well as corrects any bone abnormalities of the acromion or spurs at the AC joint that cause the bursitis. After the surgery, physical therapy is restarted to restore motion and strength to the shoulder.
Subscapular bursa is a thin, protective layer of tissue found between the shoulder blade and the rib cage on the back. Bursa exists in an effort to keep the shoulder blade from rubbing on the rib cage. Bursa can become inflamed and thickened, resulting in pain in and around the shoulder blade.
Bursitis generally occurs as a result of overuse or repetitive overhead motion and less commonly from injury. Patients with occupations that frequently require them to lift their arms over their heads (plumbers, painters, electricians and carpenters) are at risk for bursitis. Athletes who play overhead sports, such as baseball, softball, volleyball and tennis will often develop symptoms as well. Alternatively, any shoulder injury or motion that causes the patient to use the shoulder in an abnormal way can cause subscapular bursitis.
Subscapular bursitis causes pain along the inside border of the shoulder blade and upper back. Clicking may be felt under the shoulder blade.
Your surgeon will perform a thorough history and physical exam, which typically includes X-rays of the shoulder. Typically there is no bone abnormality. Your surgeon will look for similar appearance and motion of the shoulder blades, as well as scapular winging (when the shoulder blade lifts off of the rib cage). Your surgeon may also feel clicking around the inflamed bursa.
Non-operative treatment of subscapular bursitis is usually successful. Your surgeon will recommend anti-inflammatory medicine, physical therapy to strengthen the muscles that move and support the shoulder blade, and cryotherapy to help reduce the pain and inflammation. An injection under the shoulder blade may help resolve the pain.
If non-operative treatment fails to relieve the pain, the surgeon will recommend excision of the bursa from underneath the shoulder blade. This can be done through a minimally-invasive arthroscopic procedure or through an open incision. Physical therapy is restarted following the procedure to restore motion and strength.
The biceps muscle has two origin points around the shoulder: the long head starts on the glenoid and the short head on the coracoid. The long head is more commonly injured/inflamed as it exits the “ball and socket” joint near the rotator cuff in the front of the shoulder.
Biceps tendinitis occurs as a result of overuse of the shoulder or from an injury, such as a fall. Because the tendon is closely associated with the rotator cuff, injuries to rotator cuff tendons in the front of the shoulder will place more stress on the biceps, leading to inflammation or injury. It is more common for biceps tendonitis to occur with another injury than by itself.
Biceps tendinitis causes pain in the front of the shoulder, which may radiate into the arm. The biceps may be tender to the touch, especially near the top, front aspect of the shoulder. Raising the arm overhead and towards the front of the body usually increases the pain.
Your surgeon will perform a thorough history and physical examination that typically includes an X-ray. Your surgeon may perform maneuvers that stress the biceps muscle as well as the rotator cuff to elicit pain. An MRI or ultrasound may be performed to assess the biceps and surrounding rotator cuff muscles for injury.
Non-operative treatment of biceps tendinitis typically starts with physical therapy, anti-inflammatory medication, cryotherapy and avoiding painful activities. An injection can be given into the sheath surrounding the long head of the biceps to reduce inflammation.
In cases which do not improve with non-operative treatment, your surgeon may recommend an operation to relieve the pain. Your surgeon can perform a minimally-invasive arthroscopic procedure to evaluate the biceps and surrounding structure. At that time, your surgeon may choose to release the tendon from its attachment at the top of the shoulder socket (biceps tenotomy). This provides pain relief and a quick recovery with no postoperative precautions. Because the tendon has a second attachment on the shoulder blade, there is no loss of function or strength. A cosmetic deformity called “popeye deformity”, may occur as the tendon retracts down the arm. Muscle spasms and weakness with flexing the elbow and rotating the hand may occur as a result of biceps tenotomy.
Alternatively at the time of surgery, your surgeon may reposition the long head of the biceps from its attachment inside the shoulder joint, to a location outside of the joint (biceps tenodesis). This provides pain relief, with no muscle spasm, no cosmetic deformity, and no loss of function.
Frozen shoulder is a thickening and inflammation of the layer of tissue/capsule surrounding the glenohumeral joint.
Frozen shoulder can occur after an injury, in which the patient is unable to move the shoulder for an extended period of time. However, the majority of cases occur without a pre-existing injury or known cause. Research has demonstrated that women between the ages of 40-60 years old, patients with diabetes or thyroid disease or patients that have had a recent viral infection may be at higher risk.
Frozen shoulder can be classified into three phases. In the first phase, patients experience pain associated with and without movement, night pain and a progressive loss of motion, particularly moving the arm away from the body and rotating the shoulder joint. The second phase typically sees a decrease in the pain and severe losses of motion in the planes previously described in the first phase. Phase three is the gradual restoration of motion and no pain. There is usually no or minimal loss of strength in any phase, which differentiates frozen shoulder from bursitis or rotator cuff tendon damage.
Your surgeon will perform a thorough history and physical examination to evaluate shoulder motion. Loss of both active (when the patient lifts the arm on his own) and passive (when the doctor moves the shoulder without help from the patient) motion indicates a frozen shoulder. Strength in all the muscles is preserved. X-rays are usually taken and show no abnormality. An MRI may show inflammation around the “ball and socket” joint.
Your surgeon may prescribe anti-inflammatory medication, cryotherapy and activity modification to decrease pain and inflammation. An injection into the “ball and socket” joint may be helpful in decreasing the progression of the disease in the first phase and shorten the course of the inflammation (9-12 months). Physical therapy is usually not indicated in the first two phases, as overstretching may increase the inflammation. Frozen shoulder is usually self-limiting and resolves in 12-18 months.
Patients that do not improve over 12-18 months may be candidates for surgery. Your surgeon may perform a manipulation under anesthesia before or after surgery (forced motion to break up scarred tissue), and a minimally-invasive arthroscopy to remove the thickened and inflamed tissue. After surgery, immediate physical therapy in the hospital with continuous pain medication into and around the shoulder is initiated to maintain motion before scar tissue has an opportunity to reform.