What is shoulder bursitis?

A bursa is essentially small sack or pocket of tissue. It is found in various places of the body. They are found where there is movement of skin over bone or tendon over bone. A bursa acts like small cushion and assists with gliding movements. In the shoulder, a bursa is found between the tendons which elevate the arm below and the bone which forms the roof of the shoulder joint above. This is called the subacromial bursa.

If the bursa becomes inflamed it may cause shoulder pain. Sometimes this can be severe enough to prevent sleep at night. The location of the pain is usually just to the side of the top of the shoulder. It often radiates down the side of the arm. When you try and lift your arm the bursa and underlying tendon can get pinched by the acromion above. This results in a painful arc of movement. This is called shoulder impingement.

What causes shoulder bursitis?

Shoulder bursitis is commonly caused by overuse. This may be due to repetitive overhead activities. An injury or a fall may also cause the problem. Anatomical differences in the shape of the bone plays a key role in determining the development of bursitis. Infection, gout and certain medical conditions such as diabetes and thyroid dysfunction can also play a role.

How do you diagnose shoulder bursitis?

Often shoulder bursitis can be diagnosed clinically. A shoulder surgeon like myself will examine your shoulder completely. The diagnosis is suggested if you have a painful arc when lifting the arm or if you have signs of impingement. To test for impingement the arm is placed in various positions of elevation and rotation. The inflamed bursa will be “pinched” against the acromion and cause pain.

X-ray for shoulder bursitis

And x-ray is invariably taken. The reason for the x-ray is twofold.

1. The first is to exclude other causes of pain is such as osteoarthritis of the shoulder / acromioclavicular joint (ACJ), or calcific tendinitis.
2. The second reason for the x-ray is to analyse the shape of the bones in the shoulder. The acromion, which can be thought of as the roof, is located just above the bursa and tendons. Some individuals have a curvature to this bone and in some people the curvature is quite severe. It can end in a sharp point or hook at the front of the shoulder. Shoulder bursitis can take longer to resolve in these people and there is a higher likelihood that surgery may be required.

Ultrasound for shoulder bursitis

An ultrasound scan is another very useful investigation. An ultrasound scan is a non-invasive and inexpensive scan which makes use of sound waves to form a picture of the various tissues in the shoulder. A large, fluid-filled inflamed bursa, is usually easily identifiable. Sometimes impingement can be seen during the ultrasound scan. The ultrasonographer rotates the arm and looks for areas where the bone is pinching the underlying tendon and bursa.

Another reason to have an ultrasound scan is to rule out a tear of the tendons which elevate and rotate the shoulder (the rotator cuff tendons). If a rotator cuff tear is found during the scan more urgent treatment may be required. (see: Two signs that may mean you have a rotator cuff tear)

How do you treat shoulder bursitis?

The first thing to do is to rest the shoulder adequately. You should stop any activities which are exacerbating the pain. Icing may help occasionally and sometimes anti-inflammatories are prescribed. Physiotherapy may be of use to improve posture and reduce pressure on the inflamed bursa.

As a shoulder surgeon, patients normally present to me for further treatment options once these measures have failed. An injection of cortisone into the inflamed bursa is very often successful. This is often the only treatment required. Cortisone is a steroid medication which acts as a strong, localised anti-inflammatory. Occasionally it may take two or three injections for the bursitis to settle completely.

Surgery for shoulder bursitis

Surgery for shoulder bursitis is considered when these other treatment options have not been successful. As a shoulder surgeon I perform the procedure arthroscopically (minimally invasive or keyhole surgery).

Arthroscopic picture of an acromioplasty

The shoulder operation is performed as a day case procedure which means that you do not have to sleep in hospital. A thorough inspection is made of the shoulder joint to rule out any other abnormalities. The inflamed bursa is then removed. In most instances it is found that the overlying bone (acromion) is pinching or rubbing against the bursa and tendon. This happens usually in the front and side areas. The portion of bone in these parts of the acromion is smoothed off and made flat. This procedure is called an acromioplasty and is performed to increase the space between the bone and the underlying tendon. Although the bursa is removed a new one will eventually grow back in its place.

In summary

Shoulder bursitis is a common cause of shoulder pain. Therefore, if you think you may have bursitis it is recommended that you see a shoulder surgeon to discuss further treatment options. You may need investigations if the pain has lasted more than a couple of weeks and initial treatments such as anti-inflammatories have not helped.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

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The post I have shoulder pain – could this be shoulder bursitis? appeared first on Dr Warren Matthee.

What is calcific tendinitis?

Calcific tendinitis of the shoulder is a painful condition associated with calcium deposits in the rotator cuff. The rotator cuff is a group of tendons which control lifting and rotation of the arm. In some people calcium deposits may appear inside the tendon. These may be small enough to be seen on ultrasound scan only. Sometimes the deposits are quite large and are easily seen on x-ray.

Calcific tendinitis commonly occurs in patients in their 30’s and 40’s and is more common in women.

What causes calcific tendinitis?

A deposit of calcium in the rotator cuff

There are several theories as to why calcific tendinitis develops but no one knows for sure, however. It is thought that there is a change in the nature of the affected tendon cells. This occurs in the area where the calcium develops, but why this happens is not clear. There may be an association with trauma. Diabetes, thyroid disorders, and autoimmune diseases may also be associated with this condition.

Why is it so painful?

Calcific tendinitis can cause severe pain. The pain is worse with overhead activities and rotational movement of the arm. It can interfere with sleep. It may be difficult to lie on the affected shoulder.

The cause of the pain is not always clear. Many people have calcium deposits discovered by chance on an X-ray – these people may never have had any shoulder pain.

Studies have found an increase in blood vessel growth and pain receptor formation in the area of the calcium deposits. This may explain the pain in symptomatic individuals.

Inflammation surrounding the calcium deposit, causing pain

Just above the rotator cuff tendon in the shoulder is the bursa. The bursa is tissue which helps with gliding movements in the shoulder. It may become inflamed as a result of a large underlying calcium deposit (read: I have shoulder pain – could this be shoulder bursitis?). This can cause pain and secondary impingement. Impingement is a type of pinching caused by the bone which forms the roof of the shoulder, the acromion (read: What does shoulder impingement surgery involve?).

All these factors may combine to cause a painful shoulder. Some episodes of severe pain are thought to be due to calcium leaking into the surrounding tissues. This can cause further inflammation and discomfort.

Will it go away?

Calcific tendinitis may disappear on its own. It may take many months or years to resolve. In some instances the calcific deposits do not disappear on x-ray. Despite this, the individual may become asymptomatic.

What is the treatment for calcific tendinitis?

Needling of the calcific deposit

Initial treatment consists of rest and anti-inflammatories; occasionally physiotherapy helps. If there is bursal inflammation (bursitis), an injection of cortisone into the inflamed tissue will help treat the pain.

If the calcific tendinitis does not respond to conservative measures, other treatments may be tried. Needling may be used to break down the calcium deposit. This also causes a local inflammatory/healing response and is done through the skin under ultrasound guidance.

Another treatment is extracorporeal shock-wave therapy (ESWT). This involves high-energy sound waves similar to those used to treat patients with kidney stones. Several sessions are used to break down the calcium and to simulate a local healing response.

Surgery for calcific tendinitis

Calcium extruding from the rotator cuff

Surgery may be needed if the calcium deposit is large or has not responded to other treatments. The calcium is removed arthroscopically “keyhole surgery”. This can be done as a day-case procedure. This means you do not have to spend the night in hospital. During the arthroscopy the shoulder joint is evaluated. It may be easy to see a large calcium deposit in the rotator cuff, ultrasound and x-ray in theatre is also useful to confirm the location. The calcium is needled under direct vision and the calcium in the deposit is removed. The painful, inflamed bursa can be removed as well. Often, a small bony procedure is performed if impingement is found (acromioplasty).

How long does calcific tendinitis take to heal?

With conservative treatment healing time is extremely variable may take from as little as a few weeks to many months. After surgery, healing is expected within 2 to 4 weeks. A sling is usually worn for about two weeks after the operation. If a very large deposit was removed it may be needed for longer. Post-operative physiotherapy may assist with quicker recovery and rehabilitation. Patients who have surgery often report a significant and rapid resolution of their symptoms.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms.

The post Calcific tendinitis of the rotator cuff appeared first on Dr Warren Matthee.

What is shoulder impingement?

Shoulder impingement refers to “pinching” on the tendons and tissues in the shoulder. Above the humerus lie the rotator cuff tendons. These allow you to lift your arm. Above these tendons is a bony part of the shoulder called the acromion. The acromion can be thought of as the roof of the shoulder joint.

Between the acromion and the rotator cuff tendons is a small amount of tissue called a bursa. This helps with gliding movements in the joint. The space between the top of the humerus and the acromion is very narrow. When you lift or rotate your arm this space can become even more narrow. Impingement occurs when the acromion starts to rub on the tissues in the shoulder (bursa and rotator cuff). This causes pain and further inflammation. An inflammation of the bursa results in a shoulder bursitis. For further reading on bursitis see: I have shoulder pain – could this be shoulder bursitis?.

If shoulder impingement continues this may cause a rotator cuff tear. A rotator cuff tear can cause weakness and loss of function in the arm. For further reading on rotator cuff tears see: Two signs that may mean you have a rotator cuff tear.

Investigating the cause of shoulder impingement

If you suspect that you may have shoulder impingement you should see an orthopaedic surgeon. This should ideally be a shoulder surgeon or someone who has training and experience in treating shoulder conditions. During the examination special tests are performed to determine if you may have impingement.

X-ray

After an examination you will need investigations. X-rays are taken to rule out any other causes of the shoulder pain. An x-ray will also show the shape of the bones in your shoulder. The undersurface of the acromion may either be flat or slightly curved. In some people who have a curve this may end in a sharp “hook” in the front area of the bone. These people are particularly prone to impingement and bursitis.

Ultrasound

An ultrasound scan is also recommended. This can be done while you move the arm in certain positions. If there is impingement it may be visible on the scan. Other abnormalities can be picked up at the same time such as a rotator cuff tear or a bursitis.

Surgery for shoulder impingement

Surgery to treat shoulder impingement may be necessary if it does not respond to non-operative measures. Initially physiotherapy can be tried to improve your posture and increase the space underneath your acromion. Anti-inflammatories and cortisone injections to the shoulder may also help. Surgery is performed when these interventions are not working.

Surgery for shoulder impingement is done arthroscopically. This is another term for “keyhole surgery” or “minimally invasive surgery”. It is done in the safe and controlled environment of a hospital operating theatre. You will need to be admitted to hospital and prepared for theatre. As with all operations you need to be starved for six hours before the surgery. You may sip clear fluids such as water, black tea and black coffee for up to 2 hours before the surgery.

You may take any chronic medications on the morning of the operation. The exception is any diabetic medications – these should not be taken. If you are a diabetic your glucose will be checked on admission to the ward. Insulin may be used to control your blood sugars during your hospital stay. You should also not be on any blood thinning agents like warfarin. The timing of stopping of these medications will have been discussed with you before the surgery.

The procedure

Arthroscopic view of the undersurface of the acromion after an acromioplasty

After you have been prepared in the ward a porter will take into the operating theatre. In the operating theatre a general anaesthetic will be administered by the anaesthetist. You will be lying comfortably on your back on the operating table. When you are asleep you are placed in an upright position. This is called the “beach chair position” and is the position that I prefer for doing this procedure.

A routine acromioplasty may only involve two small “stab” incisions on the back and side of the shoulder. The joint is filled with water and a camera is inserted. Inspection is made of the shoulder joint. A camera is then inserted into the tight space under the acromion.

The diagnosis of impingement can be confirmed by direct vision. A special arthroscopic shaver is inserted into the space. This is used to remove any inflamed tissue (bursa) which could be causing pain. The undersurface of the acromion is cleared of soft tissue. A specialised arthroscopic burr is inserted and used to flatten the undersurface of the bone.

The advantage of doing the procedure arthroscopically is that it is minimally invasive. It is associated with faster recovery times and minimal scarring. Another advantage is that it allows for a complete inspection of the joint. The benefit of this is that any undiagnosed abnormalities can be seen and treated the same time. The wounds are closed with a “dissolving” stitches and waterproof dressings applied.

After the surgery

After the anaesthetist has woken you up, you are transferred back to the ward. The physiotherapist will see you once you are fully awake and have had something to eat, drink and you do not have nausea. The physiotherapist will help you with basic exercises. They will also show you how to use your arm sling and assist you with advice on dressing and undressing.

You will need to wear the sling for 2 or 3 weeks but this may be removed as soon as you are comfortable to do so. It is usual to follow up with me in my consulting rooms for a wound check about 10 days after the surgery. At this stage I usually measure your range of movement and refer you for ongoing physiotherapy if necessary.

Success rates

Arthroscopic acromioplasty for shoulder impingement is usually a low-risk procedure and is associated with very good outcomes. There is usually no restriction in range of movement after the surgery, and you can begin using your arm normally as soon as comfort allows. Return to work is usually possible quite soon after the operation. Recurrence of symptoms is rare.

In conclusion

As an orthopaedic surgeon with a special interest in shoulder surgery, I see and treat many patients who have a shoulder impingement. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms.

The post What does shoulder impingement surgery involve? appeared first on Dr Warren Matthee.

Two signs that may indicate that your rotator cuff is torn are:

1. Pain – pain when trying to lift or rotate the arm could indicate a rotator cuff tear. Patients often also complain of pain at night when lying on the shoulder
2. Weakness – loss of power in the arm, especially when trying to lift the arm out to the side, may also be a sign of a rotator cuff tear. True weakness can be difficult to determine. This is because pain also contributes to limited movement. Some patients find they cannot lift their arm, but if they use the other arm to help they can do so.

What should I do if I think I have a tear?

I would advise that you see a shoulder surgeon as soon as possible. It is important to rule out other causes of shoulder pain (read: I have shoulder pain – could this be shoulder bursitis?).

If a rotator cuff tear is left untreated, you may develop significant functional impairment. In the long term you may develop a painful arthritis. A repairable tear may become irreparable if it is not treated soon. This is because the muscle begins to degenerate with time. The tendon also retracts and becomes shorter.

An X-ray and ultrasound scan are baseline investigations required to help diagnose rotator cuff tears.

I have spent many years training in the highly specialised field of arthroscopic shoulder surgery. It is advisable to be treated by a surgeon who has had the correct training and experience in this field. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

mailto:admin@drmatthee.com

The post Two signs that may mean you have a rotator cuff tear appeared first on Dr Warren Matthee.