Shoulder - Bursitis and Tendonitis

Get the Right Treatment for Shoulder Bursitis and Tendonitis

Written by Jeff Behar, MS, MBA

Many patients seek medical attention for shoulder pain, and a common diagnosis given is 'shoulder bursitis,' or 'shoulder tendonitis’. Shoulder bursitis and rotator cuff tendonitis are all ways of saying there is inflammation of a particular area within the shoulder joint that is causing a common set of symptoms. The best terminology for these symptoms is 'Impingement Syndrome.' Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons. Shoulder Impingement Syndrome (aka shoulder bursitis/ tendonitis) Impingement Syndrome is a common condition affecting the shoulder. It is most commonly seen in aging adults. Impingement syndrome refers to impingement of the rotator cuff tendons, especially the supraspinatus tendon, under the subacromial arch. The biceps tendon or the subacromial bursa may also be impinged under the subacromial arch. Impingement Syndrome is closely related to shoulder bursitis and rotator cuff tendonitis. It is not uncommon for these conditions to occur in combination. It is not clear whether rotator cuff muscle/ tendon overload precedes impingement or is caused by it. (References: Souza TA, ed. Sports Injuries of the Shoulder. New York, NY:Churchill Livingstone; 1994., 56.Sharkey NA, Marder RA. The rotator cuff opposes superior translation of the humeral head. Am J Sports Med. 1995; 23(3): 270-275.). How Impingement Occurs When an injury (be it directly or through overuse) occurs to the rotator cuff muscles, they respond by swelling. The pressure within the muscles increases, which results in compression because the muscles in the shoulder are surrounded by bone. When this compression occurs there is a loss of blood flow in the small blood vessels. When blood flow decreases to the muscle repetitive motions fray the muscle. Radiographs of the fray muscle show a picture much like a frayed rope.  Once this damage occurs routine motions such as reaching up behind the back and reaching up overhead may cause pain.  Additionally, weakness of shoulder muscles may also occur. If the blood flow to the area continues to be constricted or stress injures the muscle, the muscle can actually tear in two. This is what is referred to as a rotator cuff tear. Symptoms of a rotator cuff tear include significant weakness of the shoulder, and often difficulty in elevating the arm. If the impingement is left untreated, bicep rupture may also occur. A major factor in shoulder impingement injuries in weight lifters is muscle imbalance. Many bodybuilders tend to train the pectorals and the lats significantly. These exercises tend to produce internal rotation of the shoulders. Exercises that strengthen the external shoulder rotators (the infraspinatus and the teres minor), and stretches to relieve the tightness to the internal rotators are often neglected. This results in overly tight shoulder internal rotators and weak shoulder external rotators, which can lead to impingement. Other contributory factors to impingement for bodybuilders is the amount of sets performed doing exercises that put a considerable amount of stress imposed on the rotator cuff muscles such as the bench press. Often you will see weightlifters doing upwards of 15 sets this bodybuilding staple (Incline, decline, flat, and smith machine). Too many sets of exercises for the same body part with excessive weight can result in fatigue and overload injury to the rotator cuff. Therefore, weight lifters should be encouraged to perform fewer sets of exercises that can result in fatigue and overload injury to the rotator cuff. What are the symptoms of shoulder impingement? Routine motions such as reaching up behind the back and reaching up overhead may cause pain.  Additionally, weakness of shoulder muscles may also occur. If the blood flow to the area continues to be constricted or stress injures the muscle, the muscle can actually tear in two. This is what is referred to as a rotator cuff tear. Symptoms of a rotator cuff tear include significant weakness of the shoulder, and often difficulty in elevating the arm. If the impingement is left untreated, bicep rupture may also occur. How is Shoulder Impingement Syndrome diagnosed? Diagnosis begins with a medical history and physical examination by your doctor. Strength tests will initially be taken to determine if significant weakness is present. X-rays will often be taken to rule out arthritis, bone spurs, changes to bone contour or changes in the bone calcification that indicate injury of the muscle. Impingement may be suspected when an injection of a small amount of an anesthetic into the space under the shoulder bones relieves pain. An MRI or arthrogram may also be taken to identify impingement and rule out a rotator cuff tear. How is shoulder Impingement Syndrome treated? The vast majority of people who have impingement syndrome are successfully treated with anti-inflammatory medication, stretching exercises and temporary avoidance of repetitive overhead activity until the condition settles down.  Only a minor percentage of people who have impingement syndrome eventually require surgery. Anti-inflammatory medications coupled with the use of ice to reduce inflammation and rest is the most common treatment plan for this condition. Anti-inflammatory medicines are medications prescribed to reduce inflammation (a protective action of the body as a response to trauma, injury). There are two types of anti-inflammatory medications. They are : Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen (Aleve) or ibuprofen (Motrin, Nuprin), Steroidal drugs Anti-inflammatory medications are particularly useful not only because they help decrease pain, but they also help control swelling and inflammation. NSAIDs are available both over-the-counter and as a prescription, while steroidal ant--inflammatory drugs are available by prescription.  It is important to note that ALLl medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Other common side effects may include nausea, vomiting, diarrhea, constipation, decreased appetite, dizziness, rashes, headache, and drowsiness. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. NSAIDs can cause ulcers in the stomach and promote bleeding. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'. NSAIDs may also cause fluid retention, leading to edema. The most serious side effects are kidney failure, and liver failure. When taking NSAIDs, it is also important to realize that people may respond differently to medication. It is difficult to predict which medications will most benefit a given individual. Therefore the best way to determine which NSAID is best for you is to try different options. If adequate relief of symptoms is not obtained within several weeks of treatment, your surgeon should prescribe a different NSAID. Newer NSAIDs Hit the Market There are several new NSAIDS (the so-called COX-2 inhibitors) on the market. There has been no study showing that newer NSAIDs treat pain or swelling any better than more traditional NSAID medications such as aspirin and ibuprofen. One of the best reasons to consider some of the newer medications, however such as Celebrex, is that these may be taken as once-a-day doses rather than three or four times daily, and the COX-2 inhibitors are thought to have fewer side-effects on the stomach. Additionally COX-2 inhibitors may be the medicine of choice if there is a need to take medication for several months or longer. Reference: Berger, RG "Nonsteroidal Anti-inflammatory Drugs: Making the Right Choices" J. Am. Acad. Ortho. Surg., Oct 1994; 2: 255 - 260. Steroidal Anti-inflammatory Injections If you have persistent symptoms, despite the use of oral anti-inflammatory medications, your doctor may consider a anti-inflammatory injection such as cortisone. Injectable cortisone is synthetically produced and has many different trade names (e.g. Celestone, Kenalog, etc.), but is a close derivative of your body's own product. The difference being synthetic cortisone is a potent anti-inflammatory medication. Cortisone injections usually work within a few days, and the effects can last up to several weeks. The most common side-effect is a 'cortisone flare,' a condition where the injected cortisone crystallizes and can cause a brief period of extreme pain that usually lasts a day or two and is best treated by icing the injected area. Another common side effect is lightening of the skin where the injection is given. This can be quite pronounced in people with darker skin. The steroidal anti-inflammatories can also have serious side effects in addition the symptoms experienced with NSAIDs, such as: Loss of bone (if you are on these for a long time, ask your provider about taking calcium supplements), Swelling and weight gain, Mood changes, Problems with your bone marrow, where blood cells are produced, High blood pressure, and Decreased ability to fight infection Cortisone should be used only when necessary because it can result in weakening of muscles and tendons which then may subject to tearing. In addition to taking anti-inflammatory medications, ice should be used after any activity that may cause irritation.  Daily controlled stretching in a warm shower may also help. Repetitive motion activities with your injured arm should be avoided.  Motion where the elbow would move above shoulder level should also be avoided. Shoulder Impingement Recovery Post-surgical care for impingement and rotator cuff tears are similar (see above), but with some slight differences, such as Rehabilitation programs for impingement and rotators cuff surgery differ slightly. Impingement rehabilitation begins almost immediately. Exercises to regain shoulder motion usually begin with a physical therapist in the first week after surgery and continue only for about 6 weeks. At 6 weeks, most patients have regained full range of motion. Impingement recovery is generally quicker and requires less supervision. Patient is typically assigned home exercise program at six weeks. Full recovery time after surgery varies; most patients have greatly improved at three months and are close to normal by six months. In cases where other shoulder and tendon issues occur recovery may be longer.