Shoulder bursitis – diagnosis and management

9th November 2024, NIA Diagnostic Imaging

What is shoulder bursitis?

Shoulder bursitis is one of the most common causes of shoulder pain and is referred as an inflammatory disorder affecting the subacromial-subdeltoid bursa (Faruqi & Rizvi, 2023). The subacromial-subdeltoid bursa is a fluid-filled sac lined with synovium which separates the supraspinatus tendon from the acromion, coracoacromial ligament and deltoid and helps ease movement between the rotator cuff and other structures of the shoulder joint (MacMahon & Yablon, 2017).

What are the causes of shoulder bursitis?

Shoulder bursitis often results from repetitive overhead activities that place strain on the shoulder, leading to impingement as well as by minor injuries such as falls (Faruqi & Rizvi, 2023). However, the underlying causes of shoulder bursitis are often complex and multifactorial, involving factors such as altered biomechanics, age-related degeneration, and in some cases, systemic inflammatory conditions (Lo et al., 2022). While overuse is a predominant contributor, other factors like poor posture, previous shoulder injuries, or even genetic predispositions may also play a role in its development (Lo et al., 2022).

Ultrasound imaging for shoulder bursitis

The subacromial-subdeltoid bursa is normally seen sonographically as a thin (2mm in thickness), anechoic fluid-filled structure with a hyperechoic peribursal fat border (MacMahon & Yablon, 2017). If there is increased fluid (hypoechoic or complex appearance), thickening of the bursal walls, or a change in the normal structure, this suggests bursitis or other shoulder pathologies. Bursal impingement is assessed with dynamic scanning of the patient’s shoulder during abduction and adduction (MacMahon & Yablon, 2017). Free gliding movement of the supraspinatus beneath the acromion should be demonstrated (Jacobson, 2018). Signs of bursal impingement can include pain on abduction, bunching and pooling of bursal fluid and pain (Jacobson, 2018).

Treatment

Treatment for shoulder bursitis aims to reduce inflammation, relieve pain, and restore normal function of the shoulder (Fawcett et al., 2018). The approach typically depends on the severity of the condition and whether it is associated with other shoulder problems, such as rotator cuff tendinopathy or impingement syndrome (Fawcett et al., 2018).

Corticosteroid injections are often recommended as an effective non-surgical treatment to alleviate symptoms of bursitis (Hseih et al., 2023). During the injection, a fine needle is carefully inserted into the affected bursa under ultrasound guidance. Once in position, a combination of local anaesthetic and cortisone is injected directly into the area, which helps to reduce inflammation and swelling over time and potentially provide longer-term pain relief (Hseih et al., 2023).

This method enhances the accuracy of the injection, reduces the risk of complications, and minimises discomfort for the patient by ensuring that the medication is delivered precisely to the site of inflammation (McGill et al., 2022). By targeting the source of the pain with precision, ultrasound-guided corticosteroid injections can significantly improve outcomes for individuals with bursitis, helping them regain mobility and function more quickly (McGill et al., 2022).

NIA Diagnostic Imaging performs these injections on a regular basis and has helped hundreds of patients to regain their mobility and return back to normal every day activities. Furthermore, NIA Diagnostic Imaging bulk-bills all musculoskeletal ultrasound as well as all cortisone injections.

(McGill et al., 2022, p. 969)

References

Faruqi, T. & Rizvi, T. J. (2023). Subacromial bursitis. StatPearls Publishing. Retrieved 20^th October 2023, from https://www.ncbi.nlm.nih.gov/books/NBK541096/#:~:text=Subacromial%20bursitis%20is%20an%20inflammatory,the%20etiology%20can%20be%20multifactorial

Fawcett, R., Grainger, A., Robinson, P., Jafari, M., & Rowbotham. (2018). Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: A study of short- and long-term outcomes. Clinical Radiology, 73(8). doi:10.1016/j.crad.2018.03.016

Hseih, L.-F., Kuo, Y.-C., Hunag, Y.-H., Liu, Y.-F., & Hsieh, T.-L. (2023). Comparison of corticosteroid injection, physiotherapy and combine treatment for patients with chronic subacromial bursitis-A randomised controlled trial. Clinical Rehabilitation, 37(9). doi: 10.1177/02692155231166220

Jacobson, J. A. (2018). Fundamentals of musculoskeletal ultrasound. (3^rd ed.). Elsevier

Lo, C. N., van Griensven, H., & Lewis, J. (2022). Rotator cuff related shoulder pain: An update of potential pathoaetiological factors. New Zealand Journal of Physiotherapy, 50(2), 82-93. doi:10.15619/NZJP/50.2.05

McGill, K. C., Patel, R., Chen, D., & Okwelogu, N. (2023). Ultrasound-guided bursal injections. Skeletal Radiology, 52, 967-978. doi: 10.1007/s00256-022-04153-y

McMahon, C. & Yablon, C. (2017). The Shoulder. In C. M. Rumack & D. Levine (Eds.), Diagnostic ultrasound (5th ed., pp. 877-897). Elsevier.

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”