Do Not Inject The Bursa

R subacromial bursa

I was very surprised when I came across the following findings from a research paper. Whether an accurate placement of corticosteroid injection into the subacromial bursa for subacromial pain (or shoulder impingement) resulted in decreasing shoulder pain and disability (Chung et al, 2022)

A bursa is small sac (or bag) filled with fluid. They act like thin shock absorbers between the bones and other moving parts of the body like muscles and tendons to reduce friction. When a bursa gets irritated (or inflamed) it fills up with more fluid resulting in a condition called bursitis. We have many bursae (plura for bursa) in our hip, elbow and knee joints.

Researchers reviewed video images of ultrasound guided corticosteroid injections to rate the accuracy of injection into 3 groups. Group 1: Definitely/ probably not in the subacromial bursa. Group 2: Probably in the subacromial bursa and Group 3: Definitely in the subacromial bursa. 

There were a total of 114 subjects. 22 were categorised in Group 1, 21 into Group 2 and 71 in Group 3. I definitely expected the subjects in Group 3 to have the best result, but I was wrong. 

Results showed that there were no significant differences between the 3 groups at 6 weeks. So, no clear evidence that accurately injecting the subacromial bursa under ultrasound guidance is better than missing it. Even if the injections were done *blind versus guidance by ultrasound! 

*Blind means the injection is done at the point where the patient says the pain is versus using ultrasound to guide the injection into the correct inflamed area.

The authors concluded that the accuracy of injection placement in shoulder impingement did not influence pain and function suggesting that improvements in patients' outcome did not require ultrasound guidance.

Perhaps there is no difference in outcomes possibly because neither 'blind' nor ultrasound guided corticosteroid injections work in the medium to long term. The sample size is small and follow-up period is too short. Plus y'all know how I feel about steroid injections.

Another systematic review also investigated ultrasound guided versus landmark injections for rotator cuff related pain (Adamson et al, 2022) and came to the same conclusions.

Will these findings affect the doctors/ surgeons who charge more using ultrasound guided injections compared to doing the injections 'blind'?

And another paper (Marshall et al (2023) showed that the subacromial bursa promoted an early inflammatory response in an injured tendon to help healing. Using a rat to model rotator cuff injury and repair, the bursa protected the tendon adjacent to the injured tendon and maintained the structure of the underlying bone. 

I do not normally consider results from obtained from animal studies usually (rats in this case), but am persuaded in this case as every time a 'diseased' or damaged body part is deemed worthy of removal or function suppressed, we find out later it is a bad idea. Like our tonsils and meniscus.

Inflammation and healing are definitely misunderstood. Our busae release essential inflammatory fluid/ cells for help our injured tendons recover. Injecting them with cortisone/ steroids means hindering the body's own healing process and harming your own tendons. Think of it as the human body is being programmed to sort out its own injuries.

References

Adamson N, Tsuro M and Adams N (2022). Ultrasound-Guided Versus Landmark-Guided Subacromial Corticosteroid Injections For Rotator Cuff Related Shoulder Pain: A Systematic Review Of Randomised Controlled Trials. Musc Care. 20(4): 784-795. DOI: 10.1002/msc.1643

Chean CS, Raval P, Ogollah RO et al (2022). Accuracy Of Placement Of Ultrasound-Guided Corticosteroid Injection For Subacromial Pain (Impingement) Syndrome Does Not Influence Pain And Function: Secondary Analysis Of A Randomised Controlled Trial. Musc Care. 20(4): 831-838. DOI: 10.1002/msc.1634

Marshall BP, Ferrer XE, Kunes JA et al (2023). The Subacromial Bursa Is A Key Regulator Of The Rotator Cuff And A New Therapeutic Target For Improving Repair. bioRxiv (Preprint). July 2. DOI: 10.1101/2023.07.01.547347

4 Exercises To Avoid If You Have Shoulder Pain

We've seen quite a few patients in our clinic recently with shoulder injuries after exercising at gyms. Often, the patients will ask how soon they can get back to their regular gym exercise routine. 

I haven't found any published evidence for what I'm suggesting. They are based purely on my personal observations, treating many patients with shoulder pain and of course doing the same exercises myself.

So here are a few exercises to avoid in the gym (at least until the pain ceases) if you currently have shoulder pain.

First up is the behind neck Lat (Latissimus Dorsi) pull downs. The bar behind the head position potentially creates a situation where the humerus (arm bone) can move too much in front. Majority of the time, it is due to lack of scapular retraction. This creates a scenario whereby they need more than average shoulder extension to get their elbows behind the body so the bar  can clear the back of their head. This places high loads on the front of the shoulder  and can potentially damage the anterior glenohumeral ligaments and the Biceps Brachii tendon. 

Next is behind the neck shoulder press. This is similar to the Lat pull down, but more damaging. When pressing up, the Deltoid muscles have to work, whereas during a pull, the Latissimus Dorsi works. The Deltoid abducts the shoulder and also elevates the humerus into the acromion process. So a pulling movement with the Latissimus Dorsi will pull the humerus away from the acromion and reduce shoulder impingement. However, the behind the neck shoulder press can potentially cause shoulder impingement.

The upright row. A lot of people 'cheat' by extending their lower back to get the bar up when the weight is too heavy for them. At the top of the pull, the elbows are in a higher position than the arms putting the shoulders into abduction and internal rotation. This position can cause or worsen shoulder impingement since our shoulder should naturally externally rotate with shoulder abduction. 

Dips. I used to do lots of parallel bar dips as a kid, but I hardly do them now. Try it yourself, when dipping, there are super high tensile loads on the front of the shoulder at the bottom of the dip. The Biceps tendon, anterior shoulder capsule, and Subscapularis tendon are all under huge loads. The scapula is also tilting anteriorly at the bottom of the dip. Much worse if you add weights attached to the waist.

If you do the above exercises occasionally, I'm fairly certain no harm or damage is done. But if done regularly, with high load and especially if you have a pre-existing shoulder dysfunction, they can definitely make your shoulder worse.

Don't get me wrong, the above mentioned exercises are not bad exercises to do at the gym. It's just that some of us do not have the perfect joint placement for certain exercises, due to imbalances and underlying movement restrictions, that makes those exercises damaging.

Shoulder Still Painful After Subacromial Decompression Surgery

Recently, we had a patient referred to our clinic for his shoulder pain (shoulder impingement). He had pain just lifting his arm/shoulder sideways. After talking to him, he mentioned that he already had surgery a few years ago to remove part of his acromion to increase the subacromial space. 

R shoulder impingement

This surgery (usually called subacromial decompression) is done to free up more space for the supraspinatus muscle and subacromial bursa so there is less chance of an impingement.

If part of the acromion (see picture above) was already shaved off and removed, how can the patient still be getting shoulder pain from shoulder impingement?

Actually, I was not surprised at all. Two recent systematic reviews/ meta-analyses and a Cochrane systematic review (referenced below) concluded with high certainty that for patients who painful shoulder impingement, subacromial decompression surgery does not help. Pain wise, function or health-related quality of life is not better compared with placebo surgery or physiotherapy.

In the United States alone, there are more than 500,000 procedures of subacromial compression done for subacromial pain, or in conjunction with a rotator cuff repair every year. 

In another recently published study, authors from Finland did a 5 year follow up on patients to compare arthroscopic subacromial decompression versus diagnostic arthroscopy, a placebo surgical intervention, and exercise therapy. They found that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy at 5 years follow up.

Looking at all the current evidence, if you have subacromial shoulder pain or shoulder impingement, then it is safe to say that going under the surgeon's knife may not help after all. The study by Paavola et al (2020) suggested exercise therapy was just as effective.

What did we do? Treating his neck and nerve root irritation got rid of his shoulder pain.

References

Hao Q, Devji T, Zeraatkar D et al (2019). Minimal Important Differences For Improvement In Shoulder ConditionPatient-reported Outcomes: A Systematic Review To Inform a BMJ Rapid Recommendation. BMJ Open DOI: 10.1136/bmjopen-2018-028777.

Karjalainen TV, Jain NB, Page CM et al (2019). Subacromial Decompression Surgery For Rotator Cuff Disease. Cochrane Database Syst Rev. 1:CD005619. DOI: 10.1002/14651858.CD005619.pub

Lahdeoja T, Karjalainen TV, Jokihaara J et al (2020). Subacromial Decompression Surgery For Adults With Shoulder Pain: A Systematic Review With Meta-analysis. BJSM. 54: 665-73. DOI: 10.1136/bjsports-2018-10048.

Paavola M, Kanto K, Ranstam J et al (2020). Subacomial Decompression Versus Diagnostic Arthroscopy For Shoulder Impingement: A 5-year Follow-up Of A Randomised, Placebo Surgery Controlled Clinical Trial. BJSM 55(2): 99-107. DOI: 10.1136/bjsports-2020-102216.

Are Shoulder Stabilization Exercises Useful?

Your physiotherapist or trainer may have taught you the following exercise(s) to help with shoulder pain. You may have been asked to bring your elbows back while squeezing your shoulder blades together behind you. You were told that you should feel the muscles between your shoulder blades activate and your chest stretching or opening up. This is also to help position your scapula(e) for an improved posture.

R shoulder

I must confess that I, too, have been guilty of teaching this in the past. Fortunately, that's a long time ago! I used to to instruct patients to do scapula (or shoulder blade) stabilization exercises when they come in to our clinic complaining of shoulder impingement. This is also known as subacromial pain syndrome. Sub acromial means all structures below the acromion that can cause problems. Please see picture above and below.

What are some common scapular stabilization exercises? Anything that emphasizes retraction (drawing back)  and depression (bringing lower) of the scapular. Like what I described in the first paragraph of the article.

Well, not all cases of subacromial pain patients will benefit from doing the above exercise. Not according to a recently published randomized controlled study (Hotta et al, 2020).

The objective of that study was to determine if adding scapular stabilization exercises especially retraction and depression of the scapular will help patients with subacromial pain. 60 subjects were randomly divided into two groups. One group did strengthening exercises for muscles around the scapular while the other did the strengthening as well as stabilization exercises for 8 weeks (3x daily).

Results at the end of their study after 8 weeks and even 8 weeks after showed no differences between the 2 groups. The researchers concluded that adding scapular stabilization exercises that emphasized scapular retraction and depression to a general strengthening exercise for muscles around the scapular did not add any benefits to pain, muscle strength or range of motion.

Now after 21 years of treating patients with shoulder pain, my approach has changed dramatically. I now look at a person's shoulder together with the ribcage, neck, spine, hips, feet. I look at how a patient's body is sitting in space and how it moves through space. All while assessing the balance of the structures around their joints. I see which structures need to be worked on by me and which the patient would need to tone and strengthen on their own with specific instructions.  

Reference 

Hotta GH, De Asiss Couto AG et al (2020). Effects Of Adding Scapular Stabilization Exercises To A Periscapular Strengthening Exercise Program In Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial. Muscu Sci Pract 49: 102171. DOI: 10.1016/j.msksp.2020.102171.

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck

I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement

Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.

Reference

Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Patient With "Shoulder Tendinitis" Not Better After Medication

Can you guess what's wrong with my patient's shoulder?

Just by looking at the picture above, can you guess which shoulder was giving my patient problems? I also showed the picture to some of my staff and asked them "what can you see from this picture?"

Alright, for those who can't tell, here are some more clues. My patient came in with some neck pain and a very uncomfortable shoulder. He had seen his family doctor who told him he had tendinitis in his shoulder and gave him some NSAIDS (non steroidal anti inflammatory drugs).

However he did not get much better with the medication. He still had some neck discomfort and couldn't raise his arm above shoulder height. Lying on his affected side made his shoulder worse and he could only sleep supine.

At first I too thought the shoulder pain was referred from his neck. He mentioned that there was slight tingling sensation in his fingers occasionally too (which was why I thought the problem was coming from his neck). However I changed my mind after seeing he had trouble even lifting his arm sideways above shoulder height.

I told him that he probably had a tear in his L Supraspinatus muscle. If you look at the picture above carefully, you will see a hollowing above his left shoulder blade. There is also wasting in the muscle (or muscle atrophy) around the part where his neck on the left connects to his shoulder.

I was told later after an ultrasound scan that he had a full thickness tear in his left Supraspinatus muscle with retraction of the tendon! The doctor referred him for an MRI and said he may need surgery to repair the retracted tendon.

By the way, scientists have assessed biopsies from both people and animals with supposed tendinitis and found very few signs of inflammation in the tendons.

NSAIDs are commonly prescribed to reduce pain and inflammation of tendinitis. So if there is no inflammation, the medication is not going to help.

So the word tendinitis with the suffix "itis" means inflammation is misnamed since the condition has little or no inflammation. Researchers prefer the term "tendinopathy" meaning damaged or degenerating tendon.


Reference

Warden SJ (2009). Prophylactic Misuse And Recommended Use Of Non-steroidal Anti-inflammatory Drugs By Athletes. BJSM. 43(8): 548-549. DOI: 10.1136/bjsm.2008.056697.