Subacromial bursitis is a common problem that occurs in the middle age leading onto painful shoulder. It limits performing activities involving shoulder joint movement and can affect the quality of life significantly. Bursa is the medical term for a lubrication sac. Lubrication sac (Bursa) is present in various locations of the human body where gliding movements are occurring eg. Joint. Subacromial bursa is the name of the lubrication sac that is present underneath a bone called Acromion in the shoulder blade. This bursa is present in a small space between the acromion of the shoulder blade and also the head of the arm bone called humerus. The space is usually around 1-2cm and this space also contains an important rotator cuff tendon called supraspinatus. The function of the tendon is elevating the arm. The normal function of the subacromial bursa is to produce jellylike substance to reduce friction in movement occurring between the shoulder blade bone acromion and the arm bone humerus.
If the lubrication sac underneath the acromion gets inflamed then the condition is called as subacromial bursitis. Inflammation of this bursa leads on to pain in the upper arm, difficulty in lifting the arm due to pain. Initially the pain occurs during overhead activities such as reaching top shelf. But further progression of the condition can lead on to difficulty in daily basic activities such as dressing up, combing hair etc. The pain can also be present in the night and can disturb overnight sleep.
Inflammation of this bursa is commonly seen after the age of mid 30. This is especially common in those who have lots of overhead activities in their life such as in an occupation like painting, plastering etc. It is also common in sports person performing lots of shoulder movements such as cricket, tennis and badminton. Some of them may have curved or hooked shape to their acromion bone. This inherently can reduce the available space between the acromion and the arm bone. This leads on to a tight space under the acromion and predisposes to inflammation as it gets stressed repetitively.
Inherently, when everyone lift the arm to the level of the shoulder joint, the space between the acromion and the arm bone gets narrower, If the bursa that is normally present in this space is inflamed, then the narrowing of the space pinches on the inflamed tissue. Naturally, if the inflamed tissue is pinched it will be experienced as excruciating pain in the upper arm.
A thorough physical assessment and clinical tests will guide towards diagnosis. X ray of the shoulder will be important to assess the subacromial space.
Initial treatment of this condition involves giving anti-inflammatory medicines, steroid injection into the subacromial bursal space and physiotherapy exercises. Often, this can relieve the symptoms temporarily. Occasionally the symptoms can completely improve and patients may return back to their normal life. But majority of the times, the shoulder pain comes back and becomes resistant to all these treatments. In such a situation arthroscopic surgery can be useful and can resolve the pain in more than 85% of the time.
This procedure is the treatment of choice in those suffering from subacromial bursitis. If the patient has already tried injection and physiotherapy but did not provide a long lasting relief of pain, then this surgery will improve the condition and can give long-lasting relief of symptoms. The aim is to clear out all the inflamed bursal tissue. Once the bursal excision is done, to prevent further occurrence, the small space between the acromion (part of shoulder blade bone) and the upper end of arm bone is widened. This is done by shaving about 0.5 – 1cm of the shoulder blade bone acromion. Once the space is increased the shoulder movements are passively performed and ensured that there is no more of impingement of tissues in the subacromial space.
In the past this procedure was done with a large incision in the shoulder joint. Currently it is done through two or three tiny incision of around 0.5cm around the shoulder joint. A tubular camera is first introduced into the shoulder joint to look for any other reason for pain in the shoulder joint. Then the tubular camera is introduced through these small incisions into the space beneath the acromion bone. All inflamed tissue will be excised with the help of 4.2mm wide tubular soft tissue shaver and also with the help of radiofrequency probe. The radiofrequency probe generates heat and can excise the tissue in a controlled fashion. Once the soft tissue clearance is done a special 5mm tubular burr is introduced through the same portal and the acromion bone is excised for a depth of about 0.5 to 1cm. Once the procedure is completed the small skin cuts are closed with one or two stitches.
By doing arthroscopically the space is much better visualized than by doing through a open technique. Because the incision is small and minimal tissue disruption is done during the surgery the postoperative pain is less and the recovery is quick. Usually the shaving of bone heals in about 6 weeks time and the patients will be back to normal function in around 6 weeks to 3 months. The surgery is performed as a day case procedure. Physiotherapist will see you after the surgery and teach you of the exercises that has to be performed to get the function back quickly.
The surgery is pretty safe. The success rate is in the order of 85-90%.
The complications are rare, but one should be aware that bleeding from the wound, swelling of the shoulder is part of the procedure and these will settle down in few days time. Occasionally infection can occur, and then it needs to be treated as needed. Getting shoulder movement can be an issue in about 10%; usually systematic physiotherapy will resolve the problem. Sometimes, if recalcitrant to physiotherapy manipulation under anaesthetic of the shoulder joint may be needed in order to speed up the rehabilitation.
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