Bursitis, tendinitis and shoulder impingement syndrome

A tendon is a whitish structure that attaches muscle to bone. When the muscle contracts, it causes the bone to move or, alternatively, it works together with another muscle called an “antagonist” to stabilize the bone.

The rotator cuff is formed by the tendons of four muscles that attach to the scapula. The four muscles are the subscapularis (at the front of the shoulder, rotates the arm internally), the supraspinatus (on the top part of the scapula, moves the arm up and away from the body), the infraspinatus and the teres minor (on the posterior part of the scapula, rotate the arm externally). The combined action of these four muscles keeps the head of the humerus centred in the glenoid (i.e., the arm in front of the scapula) to allow the different power muscles (such as the deltoid, pectoralis major and latissimus dorsi) to move the arm.

The rotator cuff is a network that forms a covering around the humeral head. It lies under a bony mass made up of the distal clavicle and the acromion (an extension of the scapula). A thin layer of tissue called the “bursa” acts as a “cushion” and permits smooth gliding between the cuff and these bony structures.

What is “impingement” and how is it diagnosed?

Impingement (or subacromial conflict) is a painful pinching of the rotator cuff (and the bursa covering it) that occurs during large movements of the shoulder when there is compression by overlying bony structures (the acromion and/or distal clavicle). This phenomenon occurs mainly in people who have bone spurs on the anterior part of the acromion (type II or III acromion) or on the distal clavicle (for example in osteoarthritis). These bone spurs are either structural (genetic) or develop gradually with age (after 40 years of age). Impingement is fairly rare in people under 30 years of age, when it is usually due to a glenohumeral joint instability problem (ligament hyperlaxity).

These compression phenomena can occur when the arm is fully or repeatedly elevated to the front or the side (abduction) in combination with certain rotation movements. These situations can occur at work or when practising certain sports. Impingement can also occur at night, especially when lying on the stomach. The pain wakes the person up and the lack of restorative sleep sometimes causes chronic ill-humour.

When impingement occurs over a long period of time, it can cause inflammation of the rotator cuff or the bursa covering it (bursitis, peritendinitis). It can also cause gradual abrasion of the rotator cuff that will degenerate to a tear (partial or full thickness).

The bony morphology can be seen on certain X-ray profile views. But since impingement is a mechanical phenomenon related to movement, it can only be diagnosed following an appropriate physical examination that reproduces the movement causing the impingement (which will also rule out the possibility of adhesive capsulitis, often missed) or by dynamic ultrasound imaging.

Nonsurgical treatment

Initial episodes of bursitis or “tendinitis” can be treated nonsurgically: rest, ice, oral anti-inflammatories, physiotherapy, etc. Yet the most appropriate treatment is to simply avoid activities that cause impingement. Cortisone injections are effective in the short term but should ideally be given after imaging of the bony structures (to rule out the possibility of a tumour) and soft tissues (ultrasound or MRI to rule out a diagnosis of rotator cuff tears).

If there is calcium build-up in the bursa or cuff, needle aspiration is sometimes attempted (in radiology under fluoroscopy or ultrasound guidance). Shock wave therapy can also be helpful but is often poorly tolerated.

If symptoms do not improve after several weeks of conservative treatment, a more in-depth investigation should be carried out and other problems considered, such as adhesive capsulitis (characterized by a loss of movement), osteoarthritis, arthritis or neoplasias.

Arthroscopic surgery

In cases of chronic impingement syndrome (over six consecutive months of symptoms that are not resolved by nonsurgical treatment), arthroscopic surgery (bursectomy, acromioplasty with or without resection of the distal clavicle) may be considered. The goal is to increase the space between the rotator cuff and the overlying bony structures by removing the coraco-acromial ligament and a layer of bone a few millimetres thick to allow the elevation, rotation and abduction of the arm without tendon-bone contact. I prefer to perform this surgery with the patient awake, under local or regional block, in a semi-seated position. The arthroscope (camera) is inserted through a minor incision behind the shoulder and the shoulder is filled with water. Through another tiny lateral incision, I insert instruments to aspirate the debris, I make an incision in the tissues and trim the underside of the acromion bone. The entire procedure takes around 30 minutes. An hour or so later, the patient is allowed to leave with the person who is accompanying him. Before leaving, he will be given an information kit and a prescription for pain medication.

After surgery

Six to twelve hours after surgery, the anesthesia starts to wear off. The patient will need to take pain medication during the first few days and should start moving the arm the day after surgery. The limb can be used for light activities (e.g., eating, getting dressed, using a computer, driving an automatic car, writing) a few days after surgery and physiotherapy is sometimes suggested. Sutures in the skin are removed the second week after surgery. The success rate (that is, the percentage of patients who say they are satisfied with the result) of the intervention is 90%, whereas the rate of complications is less than 1%. (The complications mentioned in the scientific literature include infections, permanent stiffness, broken material, vascular and neurological lesions, etc.). Convalescence (3 to 12 months) varies greatly from person to person and even after 15 years of practice, it is still very hard to predict.

After having severe pain and being dehumanized by the public system, I sought out Dr. Beauchamp to repair a massive tear of my right totator cuff. The whole experience was eve beyond 5 star. My shoulder is now completely healed, no more pain. Thank you Dr. Beauchamp for giving me my life back!! “