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Shoulder Clinic

Shoulder Injuries & Conditions

The shoulder region is put to work the moment we are born and serves us well for a lifetime. Yet over time, injury or degeneration can occur which may create the need for surgical attention.
AC Joint Arthrosis
Arthritis commonly affects the acromioclavicular joint.

AC Joint pain may not be localised to the AC joint. Pain is worse when lifting the arm overhead and there is often a tender bony lump over the top of the shoulder where the AC joint lies if it is arthritic.
Most AC joint pains will settle with rest and simple pain tablets likePanadol and Ibuprofen. If it doesn’t, a cortisone injection can be placed into the AC joint under ultrasound guidance.

If the symptoms from the AC joint don’t settle, then a resection procedure may be suggested. This procedure is done as an arthroscopic (keyhole) operation. The procedure excises the AC joint so that it can no longer cause pain.

Surgery creates a larger joint space by removing a segment of bone at the end of the clavicle(collarbone). Resection of a painful AC joint is very effective in relieving pain. The resected AC joint is replaced by fibrous scar tissue that takes the place of the worn-out arthritic joint. Compared to a worn-out painful AC joint, the resected AC joint is a significant improvement.
Anterior Instability
Traumatic Anterior Dislocation is most seen in young males; however, it can affect anyone that suffers a high-energy traumatic injury to the shoulder.
Typically, the shoulder dislocates forwardly due to an injury. The shoulder will often need to be put back into the joint under an anaesthetic at a hospital emergency department.

After the dislocation, a sling is usually recommended for the first few days until the pain settles, and physiotherapy helps with recovery; however, physiotherapy treatment doesn’t make a significant difference in the likelihood of dislocation reoccurrence.
The main problem that people have after the shoulder dislocates is that they are at a high risk of re-dislocation or instability episodes. The likelihood of re-dislocation is determined by two factors – age and activity levels.

The younger the patient is when dislocation to the shoulder occurs, the more likely it is to re-dislocate. Similarly, the more active a patient is, the more likely the shoulder is to re-dislocate.
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We know that if you are under 19 years old and if you remain active after dislocating your shoulder, then your chance of re-dislocating your shoulder is 90%.  If you are under 15 years old the re-dislocation risk appears to be 100%.  As you get older the risk decreases so that if you are 40 years old your risk of re-dislocation decreases to about 33%.
Treatment
Treatment is essentially surgical. A good physiotherapy rehabilitation programme helps, however, there is no evidence that rehabilitation reduces the risk of re-dislocation substantially.

Surgery involves repairing the structures that have been torn when the shoulder dislocated.

In 95% of anterior dislocations, the cartilage at the front of the shoulder (the labrum) tears, allowing the dislocation to occur. Rotator cuff tendons tear rarely. in some cases, the capsule of the shoulder joint tears away from the humerus which is called a HAGL lesion.

An MRI will normally be able to show which structures have torn.
Calcific Tendonitis
Calcific Tendonitis is a relatively common shoulder condition. It has a peak onset of 40 years of age, and it affects women more commonly than men. The rotator cuff is made up of a group of muscles and tendons, and it is the supraspinatus tendon that is often the most affected.
Theories on Causes
It seems that the presence of calcium in the rotator cuff tendons is relatively common. Some studies have suggested that between 2 to 20% of people may have calcium present in their rotator cuff tendons without symptoms.

The shoulder becomes symptomatic when an inflammatory reaction occurs about the calcium within the rotator cuff tendon. It is the inflammatory reaction rather than the presence of calcium that causes the symptoms.

There are two theories as to how calcium is deposited in the tendon. One theory suggests that degenerate areas of the tendon act as a focus for the calcium to form within the tendon. The other theory claims that calcium is deposited within areas of tendons with low blood flow and a degree of hypoxia.

The argument against the degenerate tendon theory is that calcium is more commonly seen in more normal-looking tendons rather than tendons with significant tears.
Stages
Several stages of calcific tendonitis are described. There appears to be some initial change in the fibrocartilage cells within the tendon that allows calcium to be deposited within the tendon.

This pre-calcific stage is followed by a calcific formative stage in which chalky calcium deposits form. This stage tends to be a chronic, painless stage.

This is different to the resorptive stage, in which the body mounts an inflammatory reaction to the calcium. Macrophages from the bloodstream react to the calcium and start to reabsorb the calcium deposit. The calcium lump becomes soft and toothpaste-like due to the enzymes released by the macrophages. This stage is usually acutely painful.
Symptoms
Patients with calcium in their rotator cuff tendons may be entirely asymptomatic. They may present with mild to moderate chronic pain and discomfort in their shoulder or they may develop acute severe pain in the shoulder related to the inflammatory reaction against the calcium deposit as the body tries to re-absorb it.

Pain is typically felt down the side of the upper arm, and the shoulder tends to ache at night-time. Pain is often felt as the arm is lifted overhead with the swollen area of the tendon catching on the under-surface of the acromion and impinging.
Diagnosis
X-Rays show the deposited calcium very well. However, several views are needed to be certain. X-Rays need to be taken with the arm in internal, external and neutral rotation.

Ultrasound is particularly sensitive to calcium and will invariably demonstrate it.

An MRI examination is not very good at demonstrating calcium deposits because the calcium is dark on the scans, as well as the tendon in which the calcium is sitting. So, it is often hard to distinguish the calcium lump within the tendon because both appear dark on the MRI scans.
Treatment
Non-Operative
Steroid injections to the subacromial space and physiotherapy are often very helpful in relieving the symptoms. However, to prevent the symptoms from recurring it is usually necessary to remove the calcium from the rotator cuff tendon.

The calcium can be removed by needle aspiration. A large bore needle is inserted into the calcium deposit under ultrasound guidance by a radiologist and if the deposit is soft, it is often possible to aspirate it. A steroid injection is given at the same time into the subacromial space.

Needle aspiration tends to be successful in about 50% of cases. However, the results depend most on whether the lump of calcium is hard or soft.

This technique is not particularly successful if the calcific deposit is hard and chalky. The calcium is more likely to be hard and chalky if the symptoms have been present for a long period and are of mild to moderate severity.

Calcium deposits are more likely to be soft and toothpaste-like in nature if the symptoms have been present for a short period such as days to weeks and if they have started suddenly and are more severe.

There is no way to be certain before needling or surgery whether the deposit is hard or soft. Minor discomfort and soreness can be expected in the shoulder following a needle aspiration.
Surgery
The calcium can also be removed surgically. This is done arthroscopically with keyhole surgery. The region of the tendon with the calcium inside it can usually be identified by the visualisation of an inflamed area of the tendon.

The location can be confirmed by probing the tendon with a needle until calcium is seen in the tip of the needle. Once the calcium is located, a small longitudinal incision is made in the tendon and the calcium is removed with an arthroscopic shaver and curette. An acromioplasty is often performed as well.

Recovery

Recovery following surgery is straightforward, and most people take about 6 weeks to recover following surgery although symptoms may persist until 12 weeks post-operative.

Patients spend a night in the hospital following surgery, which is performed under a general anaesthetic. A pain pump will be inserted at the time of surgery and will stay in for 48 hours following the procedure to assist with the post-operative pain. The pain pump contains a local anaesthetic which is infused into the operative site by the cannula. Generally, the patient will remove the catheter on day two following the operation.
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As with any operation, there is always the possibility of a complication occurring.

- There is a small risk related to the general anaesthetic.

- There is a small risk of an infection developing.

- Frozen shoulder occurs in a small percentage of patients and is precipitated by the operation.
Recovery
Recovery following surgery is straightforward, and most people take about 6 weeks to recover following surgery although symptoms may persist until 12 weeks post-operative.

Patients spend a night in the hospital following surgery, which is performed under a general anaesthetic. A pain pump will be inserted at the time of surgery and will stay in for 48 hours following the procedure to assist with the post-operative pain. The pain pump contains a local anaesthetic which is infused into the operative site by the cannula. Generally, the patient will remove the catheter on day two following the operation.
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As with any operation, there is always the possibility of a complication occurring.

- There is a small risk related to the general anaesthetic.

- There is a small risk of an infection developing.

- Frozen shoulder occurs in a small percentage of patients and is precipitated by the operation.
Frozen Shoulder
Frozen shoulder is also called adhesive capsulitis. It typically affects patients between the ages of 40 to 60 years old. It occurs in approximately 2% of the population; however, it is more common in patients with other medical conditions such as diabetes, thyroid disease and cardiac problems.
Diabetes has the most common association. In patients with diabetes, the incidence of frozen shoulder is high with 10-20% of this group suffering from frozen shoulder at some stage. Frozen shoulder appears to be a unique condition because it doesn’t appear to affect joints other than the shoulder and it seems to invariably resolve.
Causes
The cause of frozen shoulder and how it develops is unknown. Inflammation appears to play a significant role. In most patient’s frozen shoulder occurs spontaneously without any discernible cause. In other patients, there are precipitating factors including mild to severe trauma to the shoulder, and it can also occur after prolonged immobilisation. It can occur following an operation either on the shoulder or another part of the body such as cardiac surgery.
Symptoms
People with frozen shoulder experience two main symptoms, pain and stiffness.
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Pain is a prominent symptom of a frozen shoulder and tends to be a dull aching pain that is due to inflammation in the capsule lining the shoulder joint. The pain is most often felt in the outer aspect of the shoulder and the upper part of the arm. The pain tends to be worse at night time and tends to keep the person awake.

Stiffness is also a prominent symptom and typically develops some months following the initial onset of pain. The restricted range of motion can be quite severe and incapacitating. The pain is due to inflammation in the capsule lining the shoulder joint.
Classically frozen shoulder is described as developing in three stages.
The first stage is the painful or freezing phase, this stage is characterised by the gradual onset of pain. As the pain worsens, the shoulder starts to lose its range of motion. The capsule lining the shoulder joint is highly inflamed during this phase. The capsule gradually becomes thickened and fibrous in response to the inflammation that has been affecting it. If we arthroscope the affected shoulder at this stage, the capsule of the joint will be seen to be red and inflamed.

The second stage is the stiffening or frozen phase. During this stage, the pain in the shoulder gradually subsides, however, the shoulder remains stiff and restricted in its range of motion. The capsule lining the shoulder joint has become substantially thickened by the inflammation that has been affecting it. The capsule is no longer a thin flexible membrane. Rather, it is now thickened, fibrous and non-pliable. The inflammation has now largely subsided. If the shoulder joint is arthroscopically scoped during this phase, the capsule lining the shoulder will be much less inflamed than during the first stage and the capsule will be seen to be thick and fibrous. The capsule is often 5 or 6 mm thick compared to a more normal thickness of a millimetre or so.

The third stage is the thawing phase. During this stage, the range of motion in the shoulder gradually increases and the discomfort continues to subside. The range of motion returns to the shoulder as the capsule of the shoulder joint remodels and returns from its thickened fibrous state to a more normal soft pliable membrane. A frozen shoulder often takes 18 to 24 months to resolve, however it can take considerably longer in some patients.

Frozen shoulder typically takes longer to resolve in people who have diabetes.
Treatment
An X-Ray of the shoulder is usually performed to rule out arthritis as a cause of the shoulder stiffness. A scan of the shoulder either an ultrasound or MRI scan will often be undertaken to confirm that the rotator cuff tendons are intact. There is no single investigation that can competently diagnose a frozen shoulder. A frozen shoulder is normally diagnosed based on history and examination. However, an MRI scan may demonstrate thickening of the capsule of the shoulder joint and this finding may help to confirm the frozen shoulder diagnosis.
Frozen shoulder is a condition that normally resolves of its own accord. The underlying cause is unknown and consequently, there is no treatment available for the actual cause. Treatment is aimed at alleviating the symptoms of a frozen shoulder, these symptoms being pain and stiffness.
A steroid injection placed into the shoulder joint is often very helpful in relieving the aching pain felt in the shoulder. The steroid injection works by decreasing the inflammation present in the shoulder joint capsule. Often a single injection can have a long-lasting effect; although the pain may be precipitated
if there is a further injury or aggravation to the shoulder. The injection will not normally make any difference to the stiffness in the affected shoulder.

When considering treatment for the reduced range of motion and stiffness that occurs it must be kept in mind that a frozen shoulder resolves of its own accord even without treatment. The stiffness may be markedly improved with surgery.

Surgery will normally involve an arthroscopic release of the shoulder joint capsule. At the time of surgery, I will normally perform a manipulation of the shoulder before undertaking the arthroscopic release to determine the range of motion before release. Surgery aims to restore a normal range of motion to the shoulder. In a severely frozen shoulder, the capsule is thickened and contracted to such a degree that the ball of the shoulder joint (the humeral head) is held tightly in the socket (the glenoid) unable to move. In an arthroscopic release for a frozen shoulder, an incision is made in the capsule of the shoulder joint to release one side of the joint from the other. I perform a complete 360° release of the capsule. The original teaching with frozen shoulder release surgery 10 to 15 years ago was to only release part of the capsule.

I find that the clinical result achieved with a complete 360° release is far superior. I have followed every patient I have performed a complete release as part of a prospective clinical study and in over 80 patients I have not seen a complication.

Typically 70-80% of the range of motion in the shoulder joint is regained immediately post-surgery with the remaining range of motion returning as the frozen shoulder condition burns itself out over time. Following surgery, the physiotherapist will see the patient on the same day in the afternoon, and the following morning before the patient is discharged. It is very reassuring to patients to see their range of motion dramatically restored a few hours after they wake up from the anaesthetic.

Physiotherapy post-operatively is utilised to maintain the range of motion in the shoulder. Physiotherapy is normally intensive in most patients to maintain range of motion following the surgical release.

While the range of motion in the shoulder is normally substantially improved, it is not always completely restored following surgery.
Rotator Cuff Tears
Rotator cuff tears may be partial or full-thickness tears. They may occur as part of a degenerative process where the tendon progressively becomes weaker and wears out or they may be precipitated by impingement. Rotator cuff tears may also occur in relation to acute injuries such as a fall onto the shoulder or other injuries.
Symptoms
Symptoms of rotator cuff tears are like those of tendinitis, and they are frequently associated with symptoms of bursitis and impingement. Frequently pain will be felt down the outer aspect of your arm. The shoulder invariably aches at night time and often you will have trouble sleeping because of the pain that you experience.

Patients will get impingement symptoms which occur when you lift your arm away from your body. This typically occurs when the arm is approximately 90 degrees away from the body. Impingement pain is a sharp catching pain. The arm will usually feel weak and if the tear is large then you may have trouble lifting the arm up. Patients may develop wasting of the muscles around the shoulder.
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In a small percentage of patients, long-standing untreated rotator cuff tears can progress to arthritis in the shoulder and require joint replacement surgery.
Treatment
Treatment will depend on the type of tear and the tendon that is affected. The most affected is the supraspinatus tendon, however, tears of the infraspinatus and subscapularis tendons also occur frequently.
Tears in the rotator cuff are usually treated non-operatively with steroid injections and physiotherapy to control symptoms.However, for full-thickness tears, surgical treatment is often undertaken.
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Partial-thickness tears tend to be treated non-operatively prior to any surgery being considered. Surgery for a minor partial-thickness tear will often involve a simple debridement of the tear. Debridement involves trimming the frayed edges of the tear back to healthy tissue in order to allow it to heal itself. If the tear is substantial and large surgery will typically involve the repair of the tendon back to the bone.
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Acute full-thickness tears in patients who are still working or playing sports and wish to continue to do so will often need to be repaired surgically before successfully returning to work or recreational pastimes.

Surgery for a full-thickness tear involves reattaching the tendon back to the bone and will normally be performed in conjunction with an acromioplasty. 
Understanding
Terminologies
Full Thickness Tear (FTT)
‍This term relates to the vertical depth of the tear at its insertion. The term implies that the tendon is completely detached from the insertion to the humerus. The significance of this is that a full thickness tear is unlikely to be able to heal back to its insertion because the tendon and bone are not in contact with each other. While conservative management may lead to symptomatic relief, it is unlikely that the tear will heal.

For example, if applied to the common anterior supraspinatus tendon tear, the term full thickness means that if the tear is viewed inferiorly with the arthroscope, then it will be possible to view out through this tear into the subacromial space (the bursa).

Partial Thickness Tear (PTT)
The significance of the term partial thickness tear refers to a tear that is not at full depth. The partial thickness tear can be articular surface; bursal surface; or intrasubstance.

For example, if viewing an articular surface tear from the joint with an arthroscope the abnormal tendon will be seen however it will not be possible to see out into the subacromial space because there is still some of the thickness of the tendon attached. Because partial thickness tears are still attached to the insertion, it has classically been thought that healing is possible. The healing potential of partial thickness tears may not be as great as has long been thought. The approach to treatment of partial thickness tears is different to that of full thickness tears.

A rule of thumb used by many surgeons is that if the partial thickness tear represents less than 50% of the depth of the tendon then a simple debridement procedure is appropriate. The supposition is that debridement removes devitalised tissue and encourages healing by exposing vascularised tissue whilst avoiding the requirement for prolonged immobilisation to protect a repair. If the tear is greater than 50%, then many surgeons will tend to repair the tear. The options for repair include repairing the partial tear in situ or to complete the tear to a full thickness tear and then repair it.

Complete Tear
This term is usually used to signify a full thickness tear in which the whole length of the insertion of the rotator cuff tendon has been detached. For example, if the term is applied to the supraspinatus tendon, it signifies that the tendon has detached from the greater tuberosity from its anterior insertion, just posterior to the bicipital groove to its posterior insertion just anterior to the beginning of the infraspinatus tendon insertion.
Shoulder Arthritis
The glenohumeral joint (GHJ) is the joint between the head of the upper arm bone and the shoulder blade.  It is frequently affected by arthritis.
There are different types of arthritis that affect the shoulder. Osteoarthritis is the most common form of shoulder arthritis, however in some patients, rheumatoid arthritis or other inflammatory arthritis may be the cause of symptoms.
Causes
Osteoarthritis is a condition that arises from the cartilage surfaces rubbing together in such a way that causes the cartilage to deteriorate. This deterioration happens over time and may initiate from a previous shoulder injury, overuse or for no reason other than age.

Deterioration of the joint following an injury may be due to one of the bones or tendons healing in an incorrect position. Even the slightest difference in position may cause the joint to move in a different way, causing the cartilage surfaces to rub and gradually wear down.

Rheumatoid arthritis is an inflammatory condition that affects the lining of the joints and over time this can destroy the cartilage.
Symptoms
The main symptom of arthritis is pain. Depending on which joint is affected, pain may be felt in either the front or back of the shoulder. Stiffness may also be experienced along with a grating or grinding sensation with movement.

In some cases, inflammation may occur from loose bodies in the joint. These loose bodies may be cartilage that has broken away from the joint surface due to deterioration.

Symptoms tend to worsen as the condition progresses.
Treatment
Non-Surgical
Non-Surgical treatment involves activity modification, rest, physiotherapy, and simple analgesics. Activity modification, means avoiding physical activities that aggravate the shoulder, remains the cornerstone of treatment.

Physiotherapy is used to help strengthen the shoulder muscles and improve shoulder function. Regular panadol is often effective in relieving pain. Many people find the slow release preparations of panadol particularly helpful.

Anti-inflammatory medications are used intermittently. Cortisone injections into the shoulder joint may help to reduce inflammation and pain. However, the effect of the steroid injection is usually only temporary, rarely lasting more than a few months. Platelet Rich Plasma (PRP) injections are found to be helpful by some people. Synvisc injections, which is Hyaluronan and is produced from chicken combs, have not been found to be as effective in the shoulder compared to the knee.
Surgical
If non-surgical treatment fails to control the symptoms surgical options may be discussed. There are different surgical options depending on the severity of arthritis in the joint.

The surgical treatment offered for severe arthritis in the glenohumeral joint often takes the form of a shoulder replacement. This surgery replaces the entire joint with a prosthesis. In some cases, a hemiarthroplasty (half joint replacement) may be suitable instead of an entire shoulder replacement. This procedure involves only the head of the upper arm bone being replaced.

Recovery time following a shoulder replacement is usually 3 to 6 months. Patients are frequently need to wear sling for 6 weeks following the surgery. Physiotherapy helps guide the recovery following surgery.

There are risks involved in all surgeries and these risks will be discussed in consultation prior to any surgical treatment.
Shoulder Impingement
Impingement occurs when the supraspinatus tendon or the region where the supraspinatus tendon is attached to the humerus, contacts the under surface of the acromion and the coraco-acromial ligament.
Symptoms
In patients with impingement, pain occurs as the arm is lifted up away from the side of the body. It typically occurs at approximately 90 degrees abduction and commonly occurs as a painful catch.
Causes
Impingement can occur for a variety of reasons. Injury to the rotator cuff such as a tear or strain injury can cause the supraspinatus tendon to swell in which case it can be more prone to catching on the under surface of the acromion.

A spur may be another cause for impingement and can develop on the under surface of the acromion as part of the normal aging process. This spur can then dig into the superior surface of your rotator cuff.

Arthritis of the AC joint may also cause or contribute to impingement due to spurs forming on the under surface of the acromioclavicular joint.

Impingement can also occur with bursitis.
Treatment
The initial treatment for patients with impingement will usually involve steroid injections to the subacromial space (which lies immediately under the acromion) along with physiotherapy. The aim of physiotherapy is to strengthen the remainder of the rotator cuff that is not involved and also to teach patients how you to depress the humeral head as the arm is lifted up to avoid the pinching phenomenon on the under surface of the acromion and the coraco-acromial ligament.

If treatment with physiotherapy and steroid injections is unsuccessful then surgery will usually be considered if the shoulder has impingement. Surgery in most cases will involve arthroscopic (key hole) surgery. This involves shaving off the under surface of the acromion and release of the coraco-acromial ligament. This provides more space for the rotator cuff tendons to fit under the acromion, hence allowing the lifting of shoulders up without catching. The subacromial bursa is also excised.

Post-operative recovery following an arthroscopic acromioplasty is normally straight forward. It is also a fairly rapid recovery. Surgery is not particularly long, often taking 15 minutes. There is no requirement for patients to wear a sling and discharge from hospital normally occurs the day following surgery.

Recovery should occur within the first 6 weeks following surgery. Occasionally, it can take up to 3 months following the operation for full recovery to occur.
Shoulder Instability
There are two major categories of shoulder instability; Traumatic & Multidirectional.  The commonest instability pattern is Traumatic Anterior Dislocation.  
It is seen in patients who suffer an injury to their shoulder and dislocate out the front of the shoulder.  These patients are often young males engaged in high impact sports.  If they are young and remain active they will almost always re-dislocate their shoulders and usually they are troubled with recurrent dislocations.  Modern treatment involves surgery to stabilise the shoulder and will usually be recommended after the very first dislocation.

Multidirectional instability is usually seen in people who are naturally very flexible. These people have what orthopaedic surgeons call ligamentous laxity, a condition in which the collagen is more stretchy than normal. The shoulder may dislocate out the back or the front and has often done so since the first dislocation.
Shoulder Tendonitis
Tendonitis means inflammation of the tendon. The rotator cuff tendons are particularly prone to tendonitis and of the rotator cuff tendons, the one that is most commonly involved is the supraspinatus tendon.
Symptoms
Symptoms of tendonitis in the shoulder include aching pain down the outer aspect of the arm. Using the arm away from the body can be particularly uncomfortable and can cause deep aching pain. Symptoms of impingement are often prevalent, where the shoulder catches as the arm is lifted away from the body and there is a degree of bursitis in the shoulder.
Causes
Tendonitis can be caused by an injury to the rotator cuff tendons. This can occur from a repetitive injury or it can occur from an injury such as a fall onto the shoulder. Sentence needs revising.

Tendonitis can also occur in relation to calcium build up within the tendon. Calcium build up within the rotator cuff tendons is surprisingly common and, in many cases, doesn’t cause any problems at all. However, in some patients they develop an inflammatory reaction to the calcium, which results in calcific tendinitis. An excision of calcium may be performed to help alleviate symptoms.
Treatment
Treatment for tendonitis can be difficult. Patients with tendonitis as part of bursitis and impingement can often be satisfactorily treated with steroid injection or physiotherapy. If this is unsuccessful in relieving the symptoms, then an arthroscopic acromioplasty and bursectomy may be considered.

Patients with pure tendinitis, which is fortunately uncommon, can be quite difficult to treat. These patients often have a chronic overuse injury to the shoulder and tend to keep re-injuring it, often with fairly seemingly minor events.
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If patients do not respond to prolonged periods of rest and physiotherapy, steroid injections can be helpful. Platelet Rich Plasma (PRP) injections may give relief. Arthroscopic surgery to decompress the rotator cuff can also be helpful, however patients with predominant tendonitis may not respond adequately to surgical treatment.
Subacromial Bursitis
The subacromial bursa is a structure that lies between the upper surface of the rotator cuff and the under surface of the acromion. The bursa in fact, is a potential space that lies between two surfaces that move. It is normally formed by two smooth surfaces with a thin film of fluid between them, and it allows for movement to occur by providing gliding surfaces that can move over each other.
Bursas can become inflamed and this is called bursitis. There are many bursas around all of the joints and some of the bursas are particularly problematic. One of these includes the bursa that lies underneath the acromion, called the subacromial bursa. This is the bursa that causes many of the problems in the shoulder.
Symptoms
Inflammation of the bursa can cause aching pain down the lateral aspect of the arm and usually patients with bursitis will have symptoms of impingement.
Causes
There are quite a few problems that can lead to bursitis.

Patients can have minor injuries which precipitate the inflammation of the bursa. It can be associated with injuries to the rotator cuff, including tears and tendinitis and can be associated with calcium build-up in the rotator cuff.

Inflammation related to this calcium build-up is called calcific tendinitis.
Treatment
Bursitis is usually well treated with steroid injections into the bursa. These steroid injections are true anti-inflammatories and can dramatically improve the inflammation within the bursa.
If you suffer from bursitis, good physiotherapy and cortisone injections have at least a 50% chance of resolving the bursitis for you.
If the steroid injections are unsuccessful and physiotherapy is unable to help, then surgery may need to be considered. Surgery will take the form of removing the bursa (bursectomy) and usually an acromioplasty.

An acromioplasty involves arthroscopic (key hole) surgery to remove the under surface of the acromion to create more space to accommodate the rotator cuff. This surgery then allows the shoulder to lift up without the rotator cuff catching on the under surface of the acromion.

Recovery following an arthroscopic acromioplasty and bursectomy is usually fairly rapid and normally occurs within the first 6 weeks following surgery. There is no requirement for patients to wear a sling post-operatively and physiotherapy exercise normally begins within the first few days following the procedure.