February 2003 Bulletin

Shoulder impingement (Bursitis, Tendinitis)

Excessive rubbing of the rotator cuff and the top part of the shoulder blade (the acromion) causes shoulder impingement syndrome, which can begin with participation in activities that require excessive overhead motion.

Shoulder impingement syndrome involves one or a combination of problems including inflammation of the lubricating sac (bursa) located just over the rotator cuff, a condition called bursitis; inflammation of the cuff itself, called tendinitis; and calcium deposits in tendons caused by wear and tear or injury.

A torn rotator cuff is a potential outcome of shoulder impingement, which may be caused by continuing overhead activity despite bursitis or tendinitis, or by falling on an outstretched arm.

Who gets it?

Athletes, industrial workers, home maintenance buffs and zealous gardeners are especially prone to shoulder impingement syndrome.

Bursitis: Frequent extension of the arm at high speed under high load (i.e., pitching a baseball) can cause bursitis. Nonsports activities (i.e., painting, hanging wallpaper or drapes or washing windows) also can cause it. Medical research shows that the older you get, the more likely you are to develop bursitis.

Tendinitis: Tendinitis develops over time and is likely to occur when a person whose muscles are not in good condition starts an overly aggressive training program. In younger athletes, the causes of tendinitis are similar to those of bursitis. Tendinitis can be harder to pinpoint in older people.

Torn rotator cuff: Professional athletes can suffer torn rotator cuffs, but the injury is most common in members of the general public over age 40.

What are the signs and symptoms?

Patients frequently try to ignore the first signs of shoulder problems. There is usually no single episode of the shoulder giving way and, at first, a person may notice only minor pain and a slight loss of strength. Loss of range of motion, especially the ability to lift the arm overhead, may be ignored for awhile.

Bursitis: Symptoms of shoulder bursitis include mild to severe pain and limited movement.

Tendinitis: Inability to hold the arm in certain positions indicates tendinitis is present. Recurrent episodes of tendinitis may indicate a rotator cuff tear.

Torn rotator cuff: A partially or completely torn rotator cuff is diagnosed (and distinguished from bursitis and tendinitis) by a patient’s inability to maintain holding the arm in certain positions. Sometimes it is necessary for a physician to inject a dye into the affected area and examine how it spreads to provide conclusive proof that a tear exists.

What is initial treatment?

Bursitis: Once bursitis is diagnosed, rest is the recommended treatment. If necessary, icepacks can also be prescribed, as well as anti-inflammatory drugs, steroid injections and ultrasound therapy. Some patients require temporary use of a sling. After inflammation subsides, the patient should do shoulder strengthening exercises.

Tendinitis: Acute tendinitis usually passes if the activity that caused it is avoided long enough to give the shoulder sufficient rest. Later, a patient can gradually resume the activity, incorporating gentle heat and prescribed stretching beforehand and icepacks afterward. More severe cases may require anti-inflammatory drugs or a cortisone injection.

Torn Rotator Cuff: Treatment of an acute rotator cuff tear includes a period of rest, observation and anaesthetic injections. Surgery is often required for acute or chronic tears and may be recommended after two weeks of observation. Early surgical repair of a torn rotator cuff usually results in better overall recovery of arm and shoulder function than does later reconstruction.

If initial treatment doesn’t work, what’s next?

Bursitis: Severe bursitis can require surgery.

Tendinitis: A physician may perform additional diagnostic tests to rule out other conditions before surgery is advised.

Torn rotator cuff: When a rotator cuff is torn, it is sewn back together. Thickened or fibrous tissue may be removed to ensure that the joint can move more freely.

How can further injury be prevented?

Overuse injuries require attention. However in many cases, people do not seek medical care for their shoulder inflammation and think they can "work through the pain."

Don’t play tennis or golf in an attempt to "loosen up" tightness. When a shoulder injury is ignored, it can become the source of chronic problems.

If your shoulder is sore after you use it actively, especially at the limits of your reach, give it some rest. If pain persists or worsens, consult your orthopaedist.

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