Rob Mast

Steroid Injection for shoulder bursitis

What is shoulder bursitis? 

Bursae (plural) are potential fluid-filled sacs that are part of the skeletal system. They cushion the space between bones and connective tissue, allowing tendons, muscle and bone to move together. 

In the shoulder, the subacromial bursae cushion the area between the rotator cuff tendons and the acromion (the highest point of the shoulder blade or scapula). Bursae allow the tendons and bones to glide without friction when you move and lift your arms. 

Injuries or overuse of the shoulder can cause swelling of the bursae. Often the term subacromial bursitis is used to refer to bursitis that affects the shoulder. 

Symptoms:

You may have bursitis if a part of your body, particularly areas close to a joint or directly over a bone, is red or swollen, hot and sore, painful – usually with a dull, aching pain . The area is sensitive and painful if you try to press on or move it, If the bursa is just under your skin, you may also be able to see its outline, because of the swelling inside it. 

Are there different types of bursitis? 

Chronic: 

Injuries or repetitive activities can lead to irritation of the subacromial bursa causing shoulder bursitis. Significant structural injuries such as damaged tendons or irregular or damaged bone may also contribute to irritation of the subacromial bursa leading to recurrent/chronic bursitis. 

Acute: 

This is usually a bursitis of a sudden onset often due to a trauma 

Septic: 

In very unusual and rare cases bursa can become infected which can be related to a skin piercing injury. Usually, the shoulder feels hot and swollen as well as red the pain can be severe 

Common locations of bursitis: 

The most common locations for bursitis are in the shoulder, elbow and hip. However, it can also occur in the knee, heel and the base of the big toe. Bursitis often occurs near            joints that perform frequent repetitive motion.   

Causes: 

Bursitis is caused by inflammation of small fluid pads that overlie areas of strain and stress such as tendons and bones. The normal situation the small pads actually help to make normal movements run very smooth and without any pain and discomfort. However when they become inflamed sometimes due to increased irritation and local stress on the body part they can swell up and become very painful and causing significant impact on normal function. 

How would you know if you have a bursitis?

When as mentioned above you have inflammation of the bursa the bursa might be swollen and painful. This can have a significant impact on the movement of the body part. Pain from the bursitis is usually a dull ache. It can be significantly red and swollen as well. 

Some inflammatory conditions such as rheumatoid arthritis can cause bursitis and another inflammatory conditions such as gout can cause crystals in or around the joints that can cause bursitis as well. 

Often the area where there is strain on tendons such as around the knee the shoulder or the hip can result in bursitis. The underlying source here is usually a tendon which might need treatment which can improve the bursitis. 

What treatment can be helpful?  

If the pain is quite acute than ice packs on the affected area can be very helpful. Cushioning of the affected area can be helpful. This can be her a foam pad for example or a specific support with padding. 

Physiotherapy can be helpful in particular to address the underlying issues causing the bursitis. Specific exercises and conditioning can help to improve tendon function and reduce bursitis as a result.  

Medication can in some cases be helpful. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful to reduce the most acute pain 

What to do if the symptoms do not improve? 

If you have a temperature then do see your GP. If the skin overlying the bursa has been broken then also see your GP. 

If symptoms do not improve but do not have the features as mentioned above (signs of infection) then assessment by a practitioner with specialist musculoskeletal assessment skills would help to diagnose the problem. Examination of the body part should identify the exact problem. A further ultrasound scan would confirm the findings. Sometimes aspiration of the fluid is necessary usually with steroid injection to bring down the local inflammation. 

A One-Stop clinic to both diagnose and treat bursitis: 

The fastest and most effective way to manage this problem if the above management strategies have not been effective would be to be seen in a one-stop clinic. 

The Sonoscope diagnostic ultrasound and ultrasound guided injection clinic offers an expert assessment of the body part involved. Diagnostic ultrasound then follows to confirm the diagnosis and following that and after discussion and if appropriate potentially a steroid injection and/or aspiration can be carried out. This would all be done within the one session without the need for any wait and without the need for any extra expenses. 

Diagnostic ultrasound and ultrasound guided injections  

When clinical examination reveals that this is a bursitis then ultrasound can help to confirm it and ultrasound will also allow an appropriately skilled specialist to directly target the bursitis with very specific an accurate needle placement to administer the steroid pinpoint accurate in the correct structure. 

What is the benefit of an ultrasound guided injection? 

The traditional way in which steroid injections are administered is through landmark guidance, which means using known landmarks to guide needle insertion. To increase accuracy injections are increasingly administered under ultrasound guidance. 

Improved accuracy can reduce the chance of inadvertent needle placement in a neurovascular structure such as an artery or a nerve. This can help to avoid any potential complications. Also increased accuracy of ultrasound guided vs landmark guided injection can improve the outcome of the injection which has been demonstrated in several studies which has been reported by Daniels et al (2018) in their review of the evidence. 

The evidence suggest that ultrasound guidance has better outcomes for the: glenohumeral joint, subacromial bursa and biceps tendon. This was also found by several studies involving the hip and knee. There is evidence that for some conditions more accurate needle placement leads to faster benefit and better pain relief (Sibbitt, 2012). 

References:

Daniels, E.W., Cole, D., Jacobs, B. and Phillips, S.F., 2018. Existing evidence on ultrasound-guided injections in sports medicine. Orthopaedic journal of sports medicine, 6(2), p.2325967118756576. 

Sibbitt WL Jr, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol. 2012;41:66-72 

Relieving joint pain caused by arthritis is the most common reason people are coming to our clinic to have an ultrasound-guided injection. Unfortunately, arthritis and its variants of osteoarthritis and rheumatoid arthritis will eventually affect everyone.

What is arthritis?

The term arthritis literally means inflammation or swelling of the joints. According to the Arthritis Foundation, arthritis is a general term that is used to describe over 100 conditions that affect over 8.5M people in the U.K. These conditions have similar symptoms of pain, swelling, and stiffness of the joints and surrounding areas. The two most commonly diagnosed types of arthritis are osteoarthritis and rheumatoid arthritis.

What is Osteoarthritis?

Osteoarthritis, the most common form of arthritis, is degenerative arthritis. Osteoarthritis commonly affects portions of the wrists, ankles, fingers, and toes, as well as the knees, hips, neck, and lower spine.

The arthritic pain described by osteoarthritis patients includes morning stiffness and stiffness following the inactivity of the affected joint. This stiffness rarely lasts for more than 30 minutes. As osteoarthritis progresses, patients report arthritic pain with movement of the joint and resolution of pain upon resting the joint. In advanced disease, patients report pain at rest and pain that awakens them from sleep.

What is rheumatoid Arthritis?

Rheumatoid arthritis, the second most common form of arthritis, is the chronic swelling and inflammation of the joints. The hallmark rheumatoid arthritis symptom is pannus-a swelling and overgrowth of rough tissue (called granular tissue) over the smooth connective tissue that surrounds the area around and between the bones and joints. Although some cases of rheumatoid arthritis are mild, this type of arthritis is often chronic and progressive and leads to deformities and disability.

What are the risk factors and causes of arthritis?

Although researchers have been searching for the cause of arthritis for decades, the cause of arthritis remains unknown. There are three promising theories about the cause of arthritis. These include:

• Genetic or hereditary factors
• Immune system abnormalities or autoimmune disease
• A persistent or triggering infection.

Because more women have arthritis than men, some scientists believe there is a hormonal component to the disease as well.

Other arthritis risk factors are:

• Age: With the exception of juvenile rheumatoid arthritis, arthritis symptoms often begin after age 40.
• Gender: Women are at higher risk of arthritis. Of the 21 million Americans with osteoarthritis, 16 million of them are women. Other forms of arthritis, including rheumatoid arthritis, lupus and fibromyalgia, occur more often in women than in men. Men have a higher risk of gout (another common arthritis), and they experience osteoarthritis in greater numbers after age 55.
• Weight: As few as 10 extra pounds can translate into a higher risk for arthritis, especially in weight-bearing joints like the knees. This increased weight places more pressure on joints and causes the cushioning layer between bones in a joint (cartilage) to break down.
• Past injuries: A severe joint injury, such as a knee injury that damages cartilage, can add to the overall risk of arthritis.
• Ethnicity: Ethnic background affects the risk of arthritis. For example, 25% of Caucasians carry the genetic marker for rheumatoid arthritis compared to 10% of African Americans.

What are the symptoms of arthritis?

Because there are 100 conditions* that fall under the term arthritis, it would be difficult to list the symptoms of all of them. However, many of the conditions share similar symptoms. Rheumatoid arthritis symptom list:

• Gradual onset
• Weakness, fatigue, and loss of appetite (anorexia)
• Joint swelling, tenderness, and loss of motion, especially in the wrists, ankles, and fingers
• Dislocations and joint contractures
• Chronic inflammation of tendons
• Possible tendon rupture
• Rheumatoid nodules over bony areas such as the elbow and wrist.
• Enlarged spleen
• Pericarditis (inflammation of the heart wall), and vasculitis (inflammation of the blood vessels)

Osteoarthritis symptom list:

• • Stiffness, pain, and a noisy grating of the joints (crepitus)
  • Joint tenderness, swelling
  • Decreased range of motion
  • Crepitus with motion
  • Bony overgrowths
  • Pain with movement
  • Finger joint involvement leads to the development of nodular swellings.

How is arthritis diagnosed or evaluated?

It is important to see a doctor to be diagnosed properly. Because there are so many types of arthritis, it may take some time to get the correct arthritis diagnosis. Successful diagnosis depends on patient history, symptoms, blood tests, physical examination, and X-rays or radiographic studies. There are no definitive laboratory tests for osteo or degenerative arthritis. Blood work for osteoarthritis is usually normal or inconclusive. A blood test for rheumatoid factor, an autoantibody found in the blood of people with rheumatoid arthritis, can help with a diagnosis of rheumatoid arthritis. X-rays can help with an arthritis diagnosis. An X-ray of an arthritic joint will show joint space narrowing, new and abnormal bone formation, and abnormal, dense tissue growth.

Because many types of arthritis develop slowly, a doctor may suspect one kind of arthritis before other symptoms make the diagnosis clear. Patients should develop a rapport with their doctors and keep a diary of arthritis symptoms to help with diagnosis.

What are the treatments and drugs to treat arthritis?

The goals of arthritis treatment are simple:

• Relief arthritis pain
• Minimize joint stiffness
• Reduce inflammation
• Preserve muscle and joint function
• Maintain a normal lifestyle
• Minimize side effects of arthritis medication.

A basic common sense approach achieves these goals for a majority of patients. Although this approach is not an arthritis cure, it helps patients maintain their quality of life. This arthritis treatment approach consists of

• adequate rest
• anti-inflammatory therapy
• physical therapy to maintain joint function
• drug therapy to slow the progression of the disease (in some patients).

One of the most important aspects of arthritis relief is the control of inflammation and pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) help control these symptoms. There are several types of these arthritis medicines. Some of these medicines are safer to use than others.

NSAIDs include salicylates, traditional NSAIDs and COX-2 inhibitors. Aspirin is a salicylate. Traditional NSAIDs are medicines like over-the-counter Motrin, Advil, and other ibuprofen-containing brands and Aleve and other naproxen/naproxen sodium-containing brands. Other drugs in this NSAID class include ketoprofen, flurbiprofen, oxaprozin, nabumetone, tolmetin, indomethacin, sulindac, piroxicam, diclofenac, diflunisal, and etodolac. Aspirin and NSAIDs can cause GI upset, bleeding and ulcers in some patients.

COX-2 inhibitors are newer agents which bind only to COX-2 receptors. COX-2 inhibitors are less likely to cause GI symptoms than traditional NSAIDs. However, COX-2 inhibitors may not be safe choices for all patients. Recently, Vioxx, a popular COX-2 inhibitor, was removed from the market due to increased risks of stroke and heart attack with long-term use. Another COX-2 inhibitor, Bextra, may cause similar side effects. Celebrex, a third COX-2 inhibitor, may be a safer alternative.

It is important to remember that these drugs do not modify the progression of the disease but simply help with pain and inflammation, which can significantly improve the patient’s quality of life.

Other types of arthritis medication are disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine, gold, penicillamine, the immunosuppressive agent methotrexate, and azathioprine. These drugs can help slow the progress of the disease. Because these drugs have severe side effects for some patients, it is important that the patient be followed closely by their physician.

Steroid injections

Sonoscope offers injections of a long-acting steroid that may be given directly into a particularly painful joint, especially the knee or thumb. The injection often starts to work within a day or so and may improve pain for several weeks or months. Steroid injections are mainly used for very painful osteoarthritis or for sudden, severe pain caused by crystals in the joint.

How is cortisone injection administered?

Cortisone injections are most commonly given into joints to provide pain relief. They can also be given into tendons near the joint (tender points). The cortisone is injected directly into the painful joint with a needle and syringe. Ultrasound may be used to guide the needle into the correct position.

You will usually have the injection while you’re awake, although you may be given a sedative first if you’re anxious. The skin over the injection site is numbed with a local anaesthetic before the cortisone is injected.

Cortisone injections usually take a few seconds to administer. You will usually be able to go home soon after having the injection.

Conclusion

No one arthritis medicine’s best for all patients. Each patient responds differently to each medication. Some doctors prescribe an alternative arthritis remedy such as acupuncture to help control pain. In a recent study, acupuncture worked better than arthritis medication for the control of the pain and swelling of osteoarthritis of the knee.

Regular exercise and appointments with a physical therapist can help preserve a range of motion for arthritis patients and delay disability.

Other aspects of arthritis treatment can include simple interventions such as the local application of heat or ice, periods of rest at selected times during the day, exercise to maintain joint motion and muscle power, and reduction of weight on painful joints by the use of canes or crutches. Patients also need patient education and emotional support. Surgical procedures may be necessary in patients with severe hip or knee involvement or spinal nerve compression.

Sources:

Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomized controlled trial. British Medical Journal. 18 November 2004; 329: 1216-9.

Arnett, FC. Rheumatoid Arthritis. IN: Cecil Textbook of Medicine, 21st ed. Philadelphia, PA: W. B. Saunders Company; 2000: 1492 – 1499.

Arthritis Foundation. What is Arthritis? Available at: http://www.arthritis.org/resources/gettingstarted/what_is_arthritis.asp.
Accessed November 18, 2004.

Arthritis Foundation. Arthritis. What Are The Risks? This content was formerly available at arthritisfoundation.org (link no longer active). For updated information, please see: https://www.arthritis.org/search/results?query=risks

Bathon, JM and Ling, SM. Osteoarthritis. IN: Rakel, MD. Textbook of Family Practice, 6th ed. Philadelphia, PA: W. B. Saunders Company; 2002: 1044-1048.

Mercier, LR. Arthritis, Rheumatoid. IN: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2005 ed. St. Louis, MO: Mosby, Inc; 2005: 89.

Mercier, LR. Osteoarthritis. IN: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2005 ed. St. Louis, MO: Mosby, Inc; 2005: 578.

Stedman, TL. Stedman’s medical dictionary. 26th ed. Baltimore, MD: Williams & Wilkins; 1995: 149.