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Impingement, Subacromial Bursitis and Rotator Cuff Tendinitis

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Ovid: 5-Minute Sports Medicine Consult, The


Impingement, Subacromial Bursitis and Rotator Cuff Tendinitis
Mark E. Lavallee
Emily C. McDevitt
Basics
Description
  • Repetitive shoulder activity causes breakdown in the rotator cuff muscles from tensile overload and results in tendinopathy.
  • Weakness in the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, or subscapularis) results in loss of effective dynamic glenohumeral movement.
  • This causes impingement of the cuff muscles under the acromion, enhancing the pain and inflammation.
  • Synonym(s): Calcific tendonitis of the shoulder; Subacromial bursitis; Shoulder impingement syndrome
Epidemiology
  • Very common in athletes, especially in those with repetitive motion of the arms (ie, throwing, racquet sports, swimming, weight lifting)
  • In individuals <25 yrs of age, impingement is usually related to laxity caused by instability.
  • In those 25–40 yrs of age, impingement is usually due to overuse of the rotator cuff.
  • In those >40 yrs of age, impingement is caused by use of the cuff muscles over threshold. This may result in partial- or full-thickness tears in addition to impingement (1)[C].
Risk Factors
  • Weight lifting (Olympic style)
  • Throwing or racquet sports
  • “Industrial” athletics (repetitive, overhead motion)
  • Shoulder instability
  • Previous shoulder surgery or trauma (to ipsilateral or contralateral shoulder)
  • Individuals with more “hooked” acromions (type III > type II > type I)
  • Smoking
Commonly Associated Conditions
  • Rotator cuff tear (partial or full)
  • Adhesive capsulitis
  • Thoracic outlet syndrome
  • Brachial plexus injury
  • Axillary nerve entrapment
  • Pancoast tumor
Diagnosis
History
  • Rule out cervical spine disease, neck pain.
  • Symptoms: Weakness, crepitation, numbness, “slipped out,” night pain, dead arm (3)[B]
  • Exacerbation: Pain presents more at rest or with activity
  • Duration: Chronic (overuse) versus acute (traumatic)
  • Activation: Right or left handed, type of job, sports, hobby
  • History of previous trauma or surgery
Physical Exam
  • Shoulder pain with overhead activity
  • Weakness in the shoulder musculature
  • Crepitations
  • Numbness/paresthesias (usually between the lateral neck to the elbow)
  • Night pain
  • Pain at rest (usually in more severe cases)
  • Medial upper scapular border or medial upper trapezius pain (2)[C]
  • Observation:
    • How the athlete carries arm/shoulder (ie, recent dislocation, guarding)
    • Deltoid atrophy (ie, C5 plexus injury)
    • Scapular winging (ie, long thoracic nerve palsy) (3)[C]
    • Infraspinatus fossa scalloping (inferior branch of the suprascapular nerve)
  • Palpation:
    • Cervical spinous process: Rule out cervical neck pathology as cause of shoulder pain (4)[A].
    • Subacromial bursa: Distal to acromion
    • Biceps tendon (long head)/bicipital groove
    • Insertion of the deltoid on the humerus: Pain at site but no pain with palpation; axillary nerve pain referral site
    • Coracoid process: Pain referral site for impingement
  • Range of motion (ROM) (2):
    • Abduction (0–180 degrees)
    • Adduction (0–50 degrees)
    • Flexion: Forward (0–180 degrees) and horizontal (0–130 degrees)
    • Extension (0–90 degrees)
    • Internal rotation (0–100 degrees) (adduction and internal rotation: “Bra strap”)
    • External rotation (0–60 degrees) (abduction and external rotation: “Shampoo hair”)
  • Manual muscle testing:
    • Deltoid: Full abduction, resist at 90 degrees
    • Supraspinatus: Abduction to 90 degrees, 30 degrees forward flexion, resist downward pressure
    • Infraspinatus and teres minor: Arm at side, 90 degrees at elbow, resist external rotation (ie, “opening the door”)
    • Subscapularis: Hand behind back, push-off; Gerber's lift-off test
  • Special tests:
    • Hawkin's test: 90 degrees of forward flexion at the shoulder and elbow, support elbow, pain with internal rotation of arm (4)[B]
    • Arc test: Shoulder abduction, gets “stuck” or painful at 60–120 degrees (2)[B]
    • Infraspinatus test: 90 degrees of flexion at the elbow, elbow held against body while patient attempts to externally rotate arm against examiner's resistance, pain in shoulder with external rotation (4)[B]
    • Neer test: Arm straight, thumb down, passive forward flexion (pain at 60–120 degrees) (2)[B]
    • Impingement test: Inject subacromial bursa with lidocaine; helps to differentiate between impingement and tear; after injection, pain, ROM, and strength should improve if impingement and not a tear (2)[B].
    • Drop arm test: Patient cannot hold arm at 90 degrees of abduction; indicates cuff tear (2)[A].
    • Speed test: Arm straight, forward flexion to 90 degrees, palm up, resisted downward pressure; palpate the bicipital tendon at groove; pain indicates bicipital tendonitis (2)[B].
Diagnostic Tests & Interpretation
Imaging
  • Imaging is often not needed in light of good history and physical exam and a straightforward case.
  • Radiography:
    • Anteroposterior (AP) view and axillary (transscapular) views bare minimum to order; radiographs helpful for acute injuries to rule out fractures, dislocations; with impingement, may be helpful to get additional views (1)[C]
    • Internal and external AP rotational views help to visualize humerus (ie, Hill-Sacks lesions) (3)[C].
    • Stryker notch view helps to visualize posterolateral humeral head deformity (ie, Hill-Sacks lesions) (3)[C].
    • West Point (modified axillary) view allows visualization of the anterior/inferior glenoid (ie, Bankhart lesions) (1)[C].
    • Outlet or Alexander view allows for visualization of subacromial space; helpful in elderly patients with severe impingement (3)[C].
    • Calcification on the tendon is associated with bicipital tendonitis or severe impingement.

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  • US:
    • Though dependent on skill and comfort of practitioner, can be cost-effective in-office imaging choice for static and dynamic view of soft tissue structures of the shoulder (ie, rotator cuff muscles, biceps tendons, subacromial bursa, calcification in tendons) (3)[C],(5)[A]
    • Also can be used to guide injections into biceps tendon sheath, subacromial bursa, or intraarticular area
  • MRI:
    • In severe or confusing cases, MRI is helpful in diagnosis of rotator cuff tears, labrum tears, biceps tendon rupture, as well as assessing volume and capsule thickening in adhesive capsulitis.
    • An MRI arthrogram is often useful to further displace a torn labrum, thus improving visualization of the anatomy (1)[C].
  • Electromyography/nerve conduction study: Helpful if there is weakness in addition to an altered neurologic exam (sensation, reflexes) etc.; has the highest sensitivity when symptoms have persisted >3 wks
Differential Diagnosis
  • Rotator cuff tear (partial or full thickness)
  • Adhesive capsulitis
  • Acromioclavicular sprain/injury
  • Labral tear
  • Bicipital tendonitis
  • Thoracic outlet syndrome
  • Brachial plexus injury
  • Fracture: Clavicle, humerus, scapula
  • Subluxation of glenohumeral joint
  • Axillary nerve entrapment
  • Pancoast tumor
  • Bankhart lesion (avulsion fracture of glenoid)
  • Hill-Sacks lesion (impact fracture of humeral head)
  • Septic arthritis
  • Glenohumeral arthritis
  • Thrombosis of subclavian or brachial artery
Treatment
Medication
  • Oral analgesia: NSAIDs, acetaminophen, tramadol; in severe cases, short-term pain relief with narcotics. Prednisone: Short course of 40 mg daily × 5 days (1)[A]
  • Dermal: Topical cream or transdermal patches (NSAID- or lidocaine-based)
  • Injectable: Subacromial bursa injection (5–10 mL 2:2:1 mixture of lidocaine, Marcaine, corticosteroid; use a 22–25-gauge, 1.5-in-long needle) (1)[A]
Additional Treatment
  • Management of acute phase:
    • Relative rest: Decrease use of affected shoulder (1)[C]
    • Home exercise program (HEP): Exercise done daily, 3 sets per exercise
    • ROM: Dangling arm circles, finger wall-walking, broom-handle exercises
    • Strengthening: Sword-from-sheath exercises, posterior dumbbell raises, proprioceptive neuromuscular facilitation (PNF), augmented soft tissue mobilization (ASTM), scapular stabilizing exercises using light weights or flexible elastic cords (1)[C]
  • Rehabilitation for long-term treatment:
    • Formal physical therapy: Pain relief via contrast baths, hydrocollator, ice, mobilization/manipulation, modalities (e-stim, US) (1)[C]
    • ROM strengthening: Deltoid, rotator cuff musculature, scapular stabilizers, biceps
    • ROM flexibility: Biceps, triceps, glenohumeral joint
    • Transmembrane corticosteroid (ie, phono-phoresis, iontophoresis)
    • Return to normal function
    • Sports-specific retraining
Additional Therapies
  • In the younger athlete, impingement is often due to another underlying problem (ie, instability).
  • Certain athletes (ie, mentally challenged, unmotivated, etc.) may need assistance of formal physical therapy without a trial of HEP.
Complementary and Alternative Medicine
Mentioned in literature for recalcitrant cases: Prolotherapy, platelet-rich plasma injections, acupuncture, and topical nitrates
Surgery/Other Procedures
  • Anterior acromioplasty: The acromion is “shaved” to allow more space for the rotator cuff. It is used only if conservative measures fail. There is a less favorable outcome in younger (50% success rate) than older athletes (1)[C].
  • Surgical débridement/repair of rotator cuff: Often accompanies an anterior acromioplasty
  • Surgical débridement/repair of labrum
Ongoing Care
Follow-Up Recommendations
  • Presence of a fever and a tense joint capsule (ie, a potentially septic joint)
  • Severe disease that is refractory to physical therapy, modalities, and steroid injections
  • Rotator cuff tear, full or partial thickness, nonresponsive to conservative care
  • Extra cervical rib, causing shoulder symptoms
  • SLAP lesion
  • Gross instability of shoulder not improved with physical therapy
References
1. Burbank KM, Stevenson JH, Czarnecki GR, et al. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008;77:493–497.
2. McFarland E, Tanaka M, Papp D. Examination of the shoulder in the overhead and throwing athletes. Clin. Sports Med. 2008;(27):553–578.
3. Burbank KM, Stevenson JH, Czarnecki GR, et al. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008;77:453–460.
4. Parker B, Zlatkin M, Newman J, et al. Imaging of shoulder injuries in sports medicine: current concepts and protocols. Clin Sports Med. 2008;(27):579–606.
5. Iannotti J, et al. Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg. 2005;(87-A)6:1305–1311.
Codes
ICD9
  • 726.10 Disorders of bursae and tendons in shoulder region, unspecified
  • 726.11 Calcifying tendinitis of shoulder
  • 726.12 Bicipital tenosynovitis
Clinical Pearls
  • If caught early with no other shoulder pathology and treated with aggressive conservative therapy, many athletes are able to return to their prior level of competition.
  • With cortisone treatment, pain relief is often immediate owing to the analgesia. This will wear off. Cortisone starts working within 3 days.
  • If no other shoulder pathology is present, and the injury is treated with aggressive conservative therapy, most athletes respond and avoid surgery.


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