|Year : 2013 | Volume
| Issue : 2 | Page : 98-102
A difficult case of subacromial bursitis in diabetes treated by steroid injection and physiotherapy combined with yoga
Vijay Pratap Singh1, Bidita Khandelwal2, Namgyal T Sherpa3
1 Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
3 Department of Medicine, STNM Hospital, Gangtok, Sikkim, India
|Date of Web Publication||4-Oct-2013|
Vijay Pratap Singh
College of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
Subacromial injections of steroid when given accurately to the subacromial space followed by appropriate physiotherapy and yoga resulted in significantly reduced pain and increased functional outcomes in subacromial bursitis in a type II diabetes patient. Steroidal injections wherever indicated and if injected correctly into the subacromial space under proper sterile condition leads to enhanced healing, reduced pain, improved range of motion, and increased functional ability and return to work. In situations of doubt, ultrasonography (USG) or magnetic resonance imaging (MRI) can provide better insight to its pathology and site which in turn helps the clinician to take correct decisions about injection therapy, drug, and approach to be used. Inaccurately administered injections may delay the healing process and burden the patient further to undergo surgical intervention. It is better to use physiotherapy exercises and yoga asanas as adjuvant to enhance recovery and functions after injection therapy.
Keywords: Physiotherapy, steroid injection therapy, subacromial bursitis, yoga asanas
|How to cite this article:|
Singh VP, Khandelwal B, Sherpa NT. A difficult case of subacromial bursitis in diabetes treated by steroid injection and physiotherapy combined with yoga. Indian J Pain 2013;27:98-102
|How to cite this URL:|
Singh VP, Khandelwal B, Sherpa NT. A difficult case of subacromial bursitis in diabetes treated by steroid injection and physiotherapy combined with yoga. Indian J Pain [serial online] 2013 [cited 2019 Mar 26];27:98-102. Available from: http://www.indianjpain.org/text.asp?2013/27/2/98/119345
| Introduction|| |
Shoulder pain is a common problem encountered in diabetics. Shoulder pain has been found to be one of the disabling causes which cause absenteeism from work. Subacromial bursitis is one of the common diagnoses in shoulder pain.  Anatomically, the subacromial bursa separates the deltoid muscle from the underlying rotator cuff. Often, there is a history of overuse or trauma followed by pain and limited activity. Friction among the adjacent structures or impingement of rotator cuff may lead to inflammation and bursitis.
Inflammation of the subacromial bursa is a kind of injury which causes inflammation of the bursa due to some kind of pathologic effusion. This inflamed bursa gets trapped and compressed between the humeral head and the acromion because of the associated movement in shoulder flexion, internal rotation, and abduction. Such impingement on an already tense structure may precipitate or aggravate the pain. This pain can be relieved when a position is adapted in such a way that the structures are held apart, for example, in external rotation. 
Physiotherapy modalities and manual techniques are the preferred choices of management in such musculoskeletal disorders. Sometimes, these techniques fail to show their efficacy due to different pathophysiologic mechanisms in cases like diabetes.  Corticosteroid injection using a subacromial anterior or posterior approach has shown wonderful results for this problem.  Adequate volume of injection (5 to 10 cc lidocaine with corticosteroid) can be useful in achieving good results.  The primary objective of management in subacromial bursitis is management of pain and improvement of function. This particular case study presents the efficacy of subacromial steroid injection in conjunction with physiotherapy treatment along with yoga in the management of subacromial bursitis in a diabetic patient.
| Case Report|| |
The patient was a 42-year-old person with a history of five years of diabetes II. He was left handed. During history taking, on asking the site of pain, the patient pointed directly beneath the acromion process. On asking what movements, if any, exacerbated his pain, the patient complained of pain exacerbated by overhead movements. The quality of pain was dull and of an aching kind. The site of pain was reported as aching pain around the shoulder and down the same arm but not below the elbow, as shown in [Figure 1]. The patient had complaints of pain since three months for which he had taken a nonsteroid anti-inflammatory drug (NSAID, aceclofenac 100 mg twice daily) for two weeks. This time, the physician had referred him to a physiotherapist after prescribing the same NSAID. Intensity of pain on the visual analogue scale (VAS) was 8/10 on the first day of assessment. The pain was precipitated by overhead movements. Rest and the NSAID relieved the pain. The pain was hampering activities of daily living of the patient, especially jobs requiring overhead movement and lifting heavy objects on the left side. There had been associated symptoms like reduced movement of the left shoulder and irritability on rotation. Pain in this episode had suddenly increased to unbearable limits and the patient had come for physiotherapy after referral from the physician.
|Figure 1: Body chart shows site of pain in red color on anterior and posterior sides|
Click here to view
He was married and had two children of six and eight years. He worked on almost all days except weekends and was the only breadwinner of the family.
Physical examination was performed after history taking. The pattern of examination was adapted from the literature.  First, inspection for any obvious signs of muscle atrophy or asymmetry was done. Palpation of the acromioclavicular (AC) joint for any asymmetry or defect was done. Next, palpation along the biceps tendon was done as it runs in the bicipital groove (tenderness over a tendon may reflect tendonitis).
Next, palpation of the subacromial bursa (located beneath the acromion) was done. This is a common site of inflammation and impingement of the supraspinatus tendon. It was palpated by extending and rotating the arm internally. The patient complained of excruciating pain during this maneuver. This exposes the bursa from under the acromion.
Assessment of the range of motion of the patient was done by seeing functional movements, and ranges were then recorded by the goniometric method. Internal rotation and adduction was functionally tested by having the patient reach across the chest and touch the opposite shoulder, which was pain-free. Next, he was asked to reach behind the neck and touch the opposite scapula. This is the Apley Scratch test, and it was used to assess for external rotation and abduction which was painful. Next, the arms of the patient were adducted across the chest passively. This maneuver stresses the AC joint and was used to assess for AC joint injury or arthritis. A few special tests were performed to confirm the disorder. Ranges are shown in [Table 1].
A combination of Hawkins-Kennedy test, painful arc test, and infraspinatus strength test suggested a significant likelihood of some degree of subacromial impingement. A combination of a positive drop arm, painful arc, and infraspinatus strength test are suggestive of having a full-thickness rotator cuff tear.  Palpation of the bursa in extension and internal rotation caused sudden excruciating pain which was more indicative of subacromial bursitis. However, an ultrasonographic scan was done to confirm the diagnosis due to the reasons explained. Although diagnosis made through clinical examination and history are cost effective, there are situations which warrant the use of ultrasonography (USG) or magnetic resonance imaging (MRI) to make an accurate diagnosis and to decide over adequate management. The previous study had reported a high incidence of fluid being present in the subacromial bursitis. There was excess fluid along with thickness and inflammation which was the source of the shoulder pain. In such a situation, with the help of USG, the clinician can confidently diagnose the source of the problem by differentiating from other shoulder pathologies like rotator cuff tear.  An X-ray of the shoulder was done and there was no obvious abnormality with no calcific deposition.
After assessment, treatment was begun with ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and exercises with the expectation that symptoms may subside and the need for steroid injections could be negated. TENS was considered for pain relief and the NSAID (aceclofenac 100 mg bid) was also prescribed by the physician for a week only. Continuous ultrasound was applied with 1.5 W/cm 2 for eight minutes over the left subacromial bursa. TENS was given by placing electrodes over the shoulder and lower arm. Graded exercises were given in the form of isometrics and active range-of-motion exercises.
Pain relief and improvement in range of motion were the primary goals of therapy. There was a gradual improvement in the range by the end of the 10th day by 10°. The pain was reduced gradually by 40% (5 out of 10) by the end of the 10th day on the VAS.
A peculiar phenomenon was noted after 10 days, when the patient started complaining of more pain and therefore reduction in range was seen as well. Physiologically, we noted that this change could be due to the termination of NSAIDs in the regimen. It was not advisable to continue NSAIDs after a week of observing gastrointestinal complaints of the patient. Physiologically, there were chances of increased swelling and effusion in the subacromial space which was already evident by the USG scan taken during diagnosis.
The physician was reconsulted and the option of steroid injection therapy was discussed as a viable option for longer and sustained relief. The single-needle technique with posterior approach was adopted. The risks, benefits, and alternatives were discussed with the patient and informed consent was obtained for ethical reasons. A needle was inserted inferior to the posterolateral edge of the acromion. The needle was directed medially and slightly anterior. This places the needle tip beneath the acromion. Aspiration of the syringe before injecting was done to ensure that the needle tip was not placed intravascularly, and the injection was then released. The site was dressed with a sterile adhesive bandage. The patient was asked to apply ice to the area immediately following the injection and to avoid strenuous activity with the involved shoulder for the remainder of the day. The same injection was repeated after a gap of 10 days for two further sessions. Physiotherapy was not given on that day and the patient was advised to resume physiotherapy from the next day. This time, we adopted a physiotherapy regimen combined with yoga asanas. The asana protocol is detailed in [Table 2].
| Results|| |
Pain and range of motion were assessed and recorded to eye progression as shown in [Table 1]. A week after all three injection therapy sessions and continued exercise program with yoga asanas, the pain had reduced to 1/10 on the VAS. There was <5° restriction in abduction and external rotation, and the patient was able to perform activities of daily living with minimal limitation of the left shoulder. Moreover, a subjective evaluation revealed improved satisfaction of the patient with the treatment, motivation to engage in daily exercise, as well as overall well-being due to the yoga asanas.
A home program was advised with general range-of-motion exercises of the shoulder and yoga asanas, and treatment was discontinued. The patient was asked to contact in case of recurrence and a final follow-up session was advised after four weeks of discontinuation of daily physiotherapy sessions. This progress was well maintained even after four weeks of the home program only. He had normal range of the shoulder joint and was pain-free. His social and job activities were not restricted as informed on his last follow-up while the patient continued doing yoga asanas.
| Discussion|| |
Subacromial bursitis and shoulder pain due to adhesive capsulitis are not uncommon in diabetes. There are various inflammatory factors reported by researchers in different literatures. Handa et al., reported vascular endothelial growth factors 121 and 165 in the subacromial bursa as potential reasons for pain and shoulder joint contracture in type II diabetes.  Ko et al., reported interleukins (ILs), specifically increased IL-1β expression, and myofibroblast recruitment as reasons for shoulder pain and stiffness after subacromial bursitis in diabetes.  Gotoh et al., emphasized the role of substance P as a factor for pain and stiffness in the subacromial bursa in diabetes. 
Steroid injection therapy can reduce inflammation and augment healing which cannot be achieved by NSAID or physiotherapy alone.  Corticosteroid injection reduces the inflammatory process caused by subacromial bursitis by optimizing vascular permeability and capillary dilatation. It reduces the release of vasoactive kinins, the major source of pain, by restricting the accumulation of polymorphonuclear leukocytes and macrophages. They also inhibit the release of destructive enzymes which augment the inflammatory process of soft tissues by invariably destroying normal cells in the vicinity. Steroidal injections also inhibit the release of arachidonic acid from phospholipids, which in turn reduces the formation of prostaglandins, which is a major contributor to the inflammatory process. 
Some studies reported that exercises may improve shoulder pain compared to placebo in people with rotator cuff disease in both the short and longer term but this benefit was not maintained after 12 weeks; however, pain becomes a limiting factor for improvement of range and strengthening exercises. Mobilization of the shoulder joint with combined treatment modalities used as per requirement like moist packs, active range-of-motion exercises, stretching, soft tissue mobilization, patient education, and so on may help acute shoulder pain in the short term but its efficacy has not been proved in the long run. 
Ginsberg and Famaey reported that topical and oral NSAIDs may improve acute shoulder pain to some extent but only for up to four weeks compared to placebo. This is mainly due to the pain relief mechanism.  However, serious adverse effects of NSAIDs have been reported which include gastrointestinal complications. A systematic review reported that therapeutic ultrasound may provide short-term pain relief in conditions of calcific tendonitis during acute shoulder pain; evidence is limited for other forms of subacromial bursitis. 
Our study shows similar congruence with a systematic review which found that yoga intervention is moderately feasible and is likely to be equal to or superior to exercise or the usual care for reducing pain and use of pain medication.  Another systematic review particularly analyzed the efficacy of yoga in musculoskeletal conditions (MSCs) and suggested that yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcomes associated with a range of MSCs. Future analysis of outcomes which take into account the amount of yoga received by participants may provide insight into any putative duration or dosage effects of yoga interventions for MSCs. 
It is difficult to say whether yoga alone could have improved this condition, as yoga asanas were not tried before steroid injection therapy. However, a future study is warranted comparing yoga with injection therapy or physiotherapy.
| Conclusion|| |
The authors found that subacromial injections of steroid when administered accurately to the subacromial space along with physiotherapy and yoga asanas result in significantly reduced pain and increased functional outcomes.
Future research must be directed to blinded controlled trials with various forms of steroidal drugs and frequency and strength to be used. These drugs/injections must be weighed with promising yoga asanas alone or combined with physiotherapy. There should be adequate sample size and outcomes should be directed to approaches and their efficacy, duration to recover pain, and a regain of functional as well as normal social activities including quality of life. A research measuring the effect of evidence-based interventions must compare their role over biomarkers like interleukins, substance P, and so on.
| References|| |
|1.||Murphy R, Carr A. Shoulder Pain. Am Fam Physician 2011;83:137-8. |
|2.||Szomor ZL, Wang MX, Kruller A, Murrell GA, Farmer KM, Kirkham BW, et al. Differential expression of cytokines and nitric oxide synthase isoforms in human rotator cuff bursae. Ann Rheum Dis 2001;60:431-2. |
|3.||Ginn KA, Herbert RD, Khouw W, Lee R. A randomized controlled clinical trial of a treatment for shoulder pain. Phys Ther 1997;77:802-11. |
|4.||Miches WF, Rodriquez RA, Amy E. Joint and soft tissue injections of the upper extremity. Phys Med Rehab Clin North Am 1995;6:823-40. |
|5.||Gruson KI, Ruchelsman DE, Zuckerman JD. Subacromial corticosteroid injections. J Shoulder Elbow Surg 2008;17:118-30S. |
|6.||Magee DJ. Orthopaedic Physical Assessment, 3 rd ed. New York: W.B Saunders; 1997. |
|7.||Park HB, Yokoto A, Gill HS, Rassi GE, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg 2004;87:1446-55. |
|8.||Awerbuch M. The clinical utility of ultrasonography for rotator cuff disease, shoulder impingement syndrome and subacromial bursitis. Med J Aust 2008;188:50-3. |
|9.||Handa A, Gotoh M, Hamada K, Yanagisawa K, Yamazaki H, Nakamura M, et al. Vascular endothelial growth factor 121 and 165 in the subacromial bursa are involved in shoulder joint contracture in type II diabetics with rotator cuff disease. J Orthop Res 2003;21:1138-44. |
|10.||Ko JY, Wang FS, Huang HY, Wang CJ, Tseng SL, Hsu C. Increased IL-1beta expression and myofibroblast recruitment in subacromial bursa is associated with rotator cuff lesions with shoulder stiffness. J Orthop Res 2008;26:1090-7. |
|11.||Gotoh M, Hamada K, Yamakawa H, Inoue A, Fukuda H. Increased substance P in subacromial bursa and shoulder pain in rotator cuff diseases. J Orthop Res 1998;16:618-21. |
|12.||Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003;1:CD004016. |
|13.||Cole BJ, Schumacher HR Jr. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg 2005;13:37-46. |
|14.||Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis 2003;62:394-9. |
|15.||Ginsberg F, Famaey JP. Double blind randomised crossover study of the percutaneous efficacy and tolerability of a topical indomethacin spray versus placebo in the treatment of tendinitis. J Int Med Res 1991;19:131-6. |
|16.||Ebenbichler GR, Erdogmus CB, Resch KL, Funovics MA, Kainberger F, Barisani G, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999;340:1533-8. |
|17.||McCaffrey R, Park J. The benefits of yoga for musculoskeletal disorders: A systematic review of the literature. J Yoga Phys Ther 2012;2:122. |
|18.||Ward L, Stebbings S, Cherkin D, Baxter GD. Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: A systematic review and meta-analysis. Musculoskeletal Care 2013. |
[Table 1], [Table 2]