Subscapular Bursa Research Articles

Pathological formation of subcoracoid bursa effusion on magnetic resonance imaging studies

BackgroundThe subcoracoid space includes the subcoracoid bursa (SCB) and subscapular bursa (SSB). We aimed to clarify the relationship between the presence or amount of SCB effusion and other structures around the SCB on magnetic resonance imaging (MRI) and to discuss the pathological formation of SCB effusion. MethodsMedical records and MR images of patients who had undergone MRI examinations for shoulder pain were retrospectively reviewed. The presence or absence of SCB, SSB, and subacromial-subdeltoid bursa (SASDB) effusion was evaluated. If SCB effusion was present, the largest diameter of the effusion was measured on sagittal images to represent the amount of SCB effusion. The presence or absence of communication between the SCB and SASDB or SSB effusion were also evaluated on sagittal and axial MRI. ResultsEighty shoulders in 70 patients were analyzed. The mean age was 70.4 ± 10.4 (range, 50-87) years. Thirty-three of the 80 shoulders (41.3%) showed SCB effusion on MRI. The clinical diagnoses of these 33 shoulders were rotator cuff tear (RCT), n = 23; frozen shoulder, n = 6; subacromial impingement, n = 3; and calcific tendinopathy, n = 1. Multivariate logistic regression analysis showed that RCT (P = 0.015) and SSB effusion (P = 0.036) were significantly associated with the presence of SCB effusion, but SASDB effusion was not. In shoulders with RCT, the SCB communicated with the SASDB in 65.2%, and with the SSB in 4.3%. In other shoulders, the SCB communicated with the SASDB in 60.0%, and with the SSB in 40.0%. The rate of SCB-SSB communication was significantly higher in shoulders without RCT than in shoulders with RCT (P = 0.021). The largest diameter of SCB effusion was normally distributed in 33 shoulders (4.7–34.8 mm), and mean 19.6 ± 7.4 mm. The largest diameter of SCB effusion was 21.9 ± 6.3 mm in 23 shoulders with RCT, and 13.5 ± 6.8 mm in 10 other shoulders (P < 0.05). Multiple regression analysis showed that RCT (P = 0.002) and SSB effusion (P = 0.029) were significantly associated with the largest diameter of SCB effusion, but SASDB effusion was not. ConclusionSCB effusion can be recognized and extended by inflow from SASDB effusion in RCT. Without RCT, SCB effusion may occasionally be visible due to inflow from SSB effusion.

Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder

Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.

Subscapular Bursa: Anatomy and Magnetic Resonance Appearance.

Subscapular Bursa: Anatomy and Magnetic Resonance Appearance.

Unusual Cause of Periscapular Pain

HISTORY: 38 yo female recreational athlete presents with left posterior shoulder pain which has gradual worsened over the past 4 months. Denies any previous trauma, injury to the area. It 8/10 sharp quality pain localized to posterior scapula with radiation to the neck. Denies any numbness, tingling, weakness, instability or crepitus. Symptoms are worse with activity. She tried PT and has modified her activities. On 1/29/2016 she underwent an ultrasound guided injection into the subscapular bursa. On 4/29/2016 she reports symptoms had resolved. On 7/29/2016 she reported her symptoms returned with a feeling of crunching under the shoulder blade. Underwent a second injection into the subscapular buritis, MRI was obtained and she restarted physical therapy home exercise program. PHYSICAL EXAMINATION: GEN: Alert, oriented x 3 EYES: emoi RESP: normal respiratory effort SKIN: intact no signs of infection NEURO: sensation to light touch intact. CN 2-12 intact. MSK: Neck: full rom to flexion, extension, lateral rotation. Negative spurlings. Shoulder: Mild periscapular tenderness, crepitus with active abduction. ROM 180 degrees of abduction, forward flexion. 5/5 strength with empty can testing, internal external rotation, negative obriens, Hawkins, neers testing. Myofascial soreness on posterior medial boarder of the scapula. Negative scapular liftoff with scapular stress, pain with scapular compression and active abducation. DIFFERENTIAL DIAGNOSIS: Subscapular Bursitis Cervical Paraspinal Muscle Strain Cervical Radiculopathy Glenohumeral Joint Arthritis Labral Tear Neoplasm Multidirectional Instability Parascapular Strain RTC Tendonitis TESTS AND RESULTS: Musculoskeletal Ultrasound left periscapular region showing no subscapular bursal fluid collection. MRI: medial border of right upper scapula, within intermuscular planes between trapezius, erector spinae, serratus anterior muscles there is a 2.9 x 1.3 x 1.1 cm mass. Lobulated cluster of grapes morphology with interspersed fast and central low T2 signal dots. No surrounding soft tissue edema. 3 cm soft tissue mass consistent with a vascular lesion such as soft tissue hemangioma. FINAL WORKING DIAGNOSIS: 3 cm soft tissue hemangioma TREATMENT AND OUTCOMES Consult Vascular Surgery Continue activities as tolerated

Involvement of the subscapular bursa as a cause of throwing pain

Involvement of the subscapular bursa as a cause of throwing pain

Involvement of the Subscapular Bursa as a Cause of Throwing Pain

Little attention has been paid to a role of the subscapular bursa keeping smooth movement of the shoulder. We hypothesized that irritation in the subscapular bursa causes throwing pain and investigated in which position pain would occur in a clinical scenario and effectiveness of distension arthrography for pain relief in baseball players. One hundred and ten baseball players with shoulder pain were enrolled in this study. All underwent examination of whether pain was provoked with arm rotation at different angles of abduction before and after arthrography. Factors including skill level, playing position, symptom duration, and concurrent injury of the rotator cuff tendon were investigated to affect the results. All patients experienced pain with external rotation at 135° of abduction before arthrography, and the pain was reduced after arthrography in 92 players (84%). Thirty-three patients could continue their playing level 6 months after treatment, while 59 players experienced pain recurrence. Eighteen patients (16%) could not return to their playing level without treatment efficacy. Symptom duration was the only additional factor that affected the results. Irritation in the subscapular bursa plays a role in the development of disabled throwing shoulders. Distension arthrography is an effective procedure for pain relief.

Contrast Dispersion Pattern and Efficacy of Corticosteroid at the Glenohumeral Joint in Adhesive Capsulitis

Background: Corticosteroid injection has a wide range of success in adhesive capsulitis but the reason for this has not yet been explained. We hypothesized that this difference might be due to the distribution of the corticosteroids injected into the joint cavity because particulate steroid deposits in the capsule and will not be moved over time by shoulder motion. Objectives: The purpose of this study is to determine whether the therapeutic efficacy of particulate corticosteroid injection into the glenohumeral joint differs according to the dispersion pattern. Study Design: Prospective evaluation. Setting: Outpatient clinics at a tertiary university hospital Methods: Seventy-two patients diagnosed as having adhesive capsulitis received a corticosteroid injection at the glenohumeral joint. The posterior capsule and the subscapular bursa were selected as dispersion sites and the dispersion of contrast dye was expressed as a ratio (%). Two weeks and 3 months after the injection clinical improvement (“not improved,” “slightly improved,” “much improved”), numeric rating scale (NRS), and passive range of motions (PROM) were evaluated. The dispersion of the contrast dye was compared according to the clinical improvements by an analysis of variance test. Pearson correlation test was done to find the relationship between PROM and the dispersion and between change of NRS and the dispersion. Results: The distribution in the subscapular area was 30.0% in the “much improved” group, 22.0% in the “slightly improved” group, and 37.1% in the “no improvement” group which was not significantly different (P = 0.179). Correlations between changes of NRS and the dye distribution were not statistically significant (P = 0.429 at 2 weeks and P = 0.629 at 3 months). The change of passive external rotation 3 months after the injection was significantly correlated with the dye distribution (P = 0.035). Limitations: Because of diverse pathologic findings in adhesive capsulitis, further studies will be needed to address the effect of the dye distribution on the pain improvement according to pathologic findings revealed by magnetic resonance imaging (MRI). Conclusion: External rotation of the shoulder in adhesive capsulitis has greater improvement as the corticosteroid solutions injected into the glenohumeral joint are increasingly dispersed to the subscapularis area. However, this does not affect the pain improvement after the injection. Key words: Adhesive capsulitis, dispersion, contrast dye, subscapularis, glenohumeral joint, corticosteroid, range of motion, numeric rating scale

脳卒中後の肩手症候群2症例における臨床所見と肩のMRI

In two cases of poststroke shoulder-hand syndrome, the patients complained of hemi-paretic shoulder pain. Both cases showed characteristic findings on magnetic resonance imaging (MRI) of the paretic shoulder. Case 1 underwent MRI before the syndrome occurred, while Case 2 underwent MRI after the syndrome occurred. In both cases, chemical saturation T2-weighted images revealed high intensity signals mainly anterior to the scapula, but also surrounding the articular capsule of the shoulder joint. Also, the subscapular muscle and subscapular bursa appeared damaged, and bloody fluid extended into the connective tissue. In Case 2, chemical saturation T2-weighted images revealed high intensity signals in the axillary fat. The paretic hands of both patients showed conscious and objective allodynia, edema, and decreased range of finger flexion and carpal extension. Observed symptoms were consistent with a diagnosis of complex regional pain syndrome (CRPS). Adherence of the posterior brachial plexus to the subscapular muscle may result in positional relationship changes and tears to the cords when the paretic shoulder is moved. The resultant small fiber neuropathy may result in edema by conduction block. Furthermore, aseptic synovitis from neurogenic inflammation may also occur. In Case 1, the arthritis of the shoulder appeared before the neuropathy. This indicates that damage to the subscapular bursa rather than neuropathy may be the underlying cause of the arthritis.

Synovial Chondromatosis of the Sub- Scapular Bursa

A 42-year-old housewife was admitted to our clinic because of shoulder pain. At X-ray and CT, multiple calcifications and ossifications were seen in the subscapular bursa and glenohumeral joint. MRI findings were consistent with synovial chondromatosis. Surgical treatment was planned but the patient refused. Thus conservative treatment was initiated for pain relief. The shoulder joint is a rare localization in this disorder. Although our patient’s symptoms resolved with conservative treatment, we think that it would be better to perform surgical treatment because of the increased size and number of loose bodies and minimal or moderate chondral damage.

Um caso de sinovite vilonodular do ombro em adolescente: diagnóstico por imagem e anatomopatológico

Chronic monoarthritis demand an investigation of inflammatory diseases, such as rheumatoid arthritis (RA), infectious diseases like tuberculosis; and other diseases that cause synovitis and joint effusion, such as pigmented villonodular synovitis (PVNS), synovial hemangioma, synovial osteochondromatosis and arborescence lipoma. We report the case of a young patient with chronic right shoulder monoarthritis, who's magnetic resonance imaging (MRI) showed synovitis. Arthroscopy was performed and the biopsy revealed PVNS. CASE REPORT: J C M, 15 years-old, female, Caucasian, student. She was sent to a Rheumatologist along with a diagnosis of juvenile idiopathic arthritis (JIA). The patient presented, for one year, a mild pain of insidious onset in her right shoulder, with relief of the symptoms in two days under nonsteroidal anti-inflammatory therapy (NSAIDs). During this year, the patient presented five or six episodes of pain with the same characteristics. No other signs and symptoms were related. The following tests showed normal or negative results:complete blood count, ESR, C-reactive protein, rheumatoid factor and urinalysis. The antinuclear antibody (ANA) was 1/80 speckled pattern. The MRI of the shoulder showed glenohumeral synovitis with joint effusion and soft tissue swelling in the subscapular bursa, which could correspond to pannus. As the medical history and physical examination were not compatible to JIA, a second MRI was performed, which showed an increase of the synovitis. The patient was submitted to an arthroscopy with biopsy and the histopathological examination showed PVNS. A complete synovectomy was performed and a new MRI, nine months later, showed no synovitis. PVNS of the shoulder is uncommon, and synovectomy was curative in this case.

Adhesive capsulitis of the shoulder: the rate of manipulation following distension arthrogram

To determine the rate of manipulation under anaesthesia (MUA) following distension arthrogram for adhesive capsulitis of the shoulder. Thirty-nine patients (42 shoulders) between 1998 and 2004 were treated with distension arthrogram for adhesive capsulitis diagnosed by the clinical picture of progressive pain and stiffness. Capsular disruption into the subscapular bursa was demonstrated in 40 of the 42 shoulders (95%). Thirty-seven of 42 (88%) shoulders were painfree following distension arthrogram. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram for stiffness although 10 of these (67%) were painfree. Prior to distension arthrogram, the range of external rotation (ER) was no different between those that had MUA and those that did not (P = 0.36). The improvement in ER was 33% (P = 0.28) in those that had MUA and 50% (P = 0.001) in those that did not. The only complication was a vasovagal episode during the procedure. Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the majority of adhesive capsulitis and decrease the rate of MUA of the shoulder.

Arthroscopic Management of the Painful Snapping Scapula

The aim of this study was to evaluate the results of the arthroscopic management of the snapping scapula syndrome. Case series. Thirteen patients underwent surgery for painful scapular snapping that had not responded to adequate conservative treatment. They had no evidence of anatomic abnormalities on plain radiographs. All patients underwent bursectomy and resection of bands of fibrous tissue at the superomedial angle. Bone was resected from the superomedial angle only if it appeared to be prominent during arthroscopy. This occurred in 3 cases. The patients' outcomes were assessed subjectively by their ability to return to work and their return to leisure, as well as the Constant score. At the time of follow-up, 9 patients (69%) reported an improvement in their symptoms. Their median Constant score was 87 (range, 95 to 58). Four patients felt that their symptoms were unchanged or worse. Their median Constant score was 55 (range, 66 to 32). Of 9 employed patients, 8 returned to their previous careers. This group included 2 patients with physically demanding jobs. Of 9 patients who played sports regularly, 6 returned to their presymptomatic level of sporting activity. There were no complications. Subscapular bursectomy is a safe procedure with a low rate of morbidity. In the absence of a definable anatomic abnormality, arthroscopic bursectomy for the painful snapping scapula can result in satisfactory outcomes in approximately 70% of patients. More clearly defined indications for and contraindications against surgery are required to avoid poor results. Complete resolution of the snapping in the subscapular bursa is not necessary to obtain a satisfactory result. Level IV, case series, no control group.

The subscapular and subcoracoid bursae: descriptive and functional anatomy

The subscapularis and subcoracoid bursae, as well as the subscapularis muscle, were studied in 42 fresh cadaveric shoulders. Fibrous bands were found in the medial part of the muscle; they were intercalated with the distal tendon-like bands. The superior distal fibrous band was always found to be thicker than the others. Strong fibrous attachments of the subscapularis muscle were found along the lateral border of the scapula as well as along the medial third of the bony crests in the subscapular fossa. Between the crests, the muscle bundles were directly attached to the bone. In the lateral part of the scapula, the subscapularis muscle had only weak connective links with the bone. The subscapularis bursa was found in all cases as a pouch strongly attached to the scapular neck and the adjacent part of the joint capsule. The top of the bursa was linked to the coracoid process by a fibrous attachment called the suspensory ligament. The subcoracoid bursa had only weak connective links with the coracoid process. In 28% of cases, the subscapularis and subcoracoid bursae merged into a unique wide bursa. The subscapular bursa had two types of links with the muscle: (1) weak connective links with the superficial muscle bundles and (2) at least 2 fibrous arcs joining the lateral tendon-like bands, the bursa, and bony crests of the subscapularis fossa. These arcs allow the bursa to follow the course of the muscle exactly. During movements of the glenohumeral joint, the subscapularis muscle sustains huge changes of orientation, particularly the upper part of the muscle that coils around the coracoid process. The strong superior fibrous band enables the muscle to maintain contact with the coracoid process. It is the function of the subscapularis and subcoracoid bursae to manage the friction of the superficial fibers against the scapular neck, the humeral head, and the coracoid process.

Some peculiarities of the rotator cuff muscles

The authors studied the origin, course and insertion as well as some peculiarities of RC muscles on 25 cadaverous fixed limbs. They discovered that RC muscles exchange muscle bundles and are secured by synovial sheaths. They described the articular muscles in all of the observed muscles, including the deltoid muscle, which significantly stretch the capsule of the glenohumeral joint. They expressed the opinion that the subscapular bursa enhances motions in the shoulder joint. Due to the possibilities of arthroscopic diagnostic and treatment methods, they are convinced that more attention must directed to this issue from both the morphological and functional perspective.

Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distension and rupture

Sixteen patients with adhesive capsulitis of the shoulder were treated in an open trial of capsular distension with intraarticular injection of 30mL of fluid containing 8mL of 1% lidocaine, 2mL of corticosteroid, and 20mL of radiocontrast material. A capsular tear during arthrography occurred in all cases. Rupture usually occurred at the subscapular bursa or the subacromial bursa. Rupture at the distal bicipital sheath occurred in two patients and was not associated with pain relief. Thirteen patients experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months. Disruption of the constricted capsule by hydraulic distension seems to be the mechanism for achieving symptomatic relief in adhesive capsulitis.

Effects of Immobilization on the Capsule of the Canine Glenohumeral Joint

The effects of immobilization on the function of the glenohumeral joint and its capsule were investigated in eight beagle dogs. One foreleg of each animal was immobilized in a spica cast, and the dogs were euthanized after 4, 8, 12, and 16 weeks of immobilization in groups of two. The contralateral limb and the forelegs of two normal beagles were used as controls. At the time of euthanasia, the range of motion, intraarticular filling volume during passive movements of the joint, and intraarticular filling volume to rupture the capsule were measured. The synovium, including the capsule and the subscapular bursa, were examined histologically. In the immobilized limb, there was progressive restriction in the range of motion with increases in intraarticular pressure, and the filling volume that was required to cause a rupture of the capsule diminished. Morphologically, the capsule and the subscapular bursa showed focal adhesions. Thus, it appeared that immobilization of these canine forelimbs produced changes in the glenohumeral joint that resembled those of frozen shoulder in humans.

Effects of Joint Distention in Shoulder Diseases

From 1982 to 1992 arthrography was performed in 3707 patients with painful shoulders to determine the role of the subscapular bursal obliteration in the pathogenesis of painful, stiff shoulders and to evaluate the effects of distention on the subscapular bursa. Three hundred thirty-nine patients were excluded from the study because of incomplete data, leaving 3368. There were 2391 male and 977 female patients; their average age was 39.2 years (range, 8-86 years). Obliteration was noted in 1156 patients (34.3%), and filling of the bursa was seen in 2212 patients (67.7%). Function was regained in 178 patients (5%) by fluid distention alone, and in 308 (8%) patients by additional forced motion. Thus, 486 shoulders (14%) underwent distention and mobilization successfully. The most effective motion was forced abduction and internal rotation. Four hundred fifteen subjects were evaluated clinically; immediate pain relief after distention and/or bursting of the subscapular bursa was noted in all. There was also a remarkable improvement in the range of motion in all subjects who underwent distention alone, or in combination with forced mobilization.

Distention Arthrography in the Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis involving the glenohumeral joint (frozen shoulder) is an insidious and painful condition that results in gradual loss of joint motion. Recovery is frequently prolonged despite multiple therapeutic maneuvers. The authors investigate the mechanism of action and the long-term clinical result of distention arthrography for the treatment of patients with frozen shoulder. Sixteen patients with adhesive capsulitis of the shoulder were treated with therapeutic capsular distention by using intra-articular injection of a 30-mL mixture of lidocaine, corticosteroid, and contrast media immediately following diagnostic arthrography. Capsular disruption was demonstrated in all cases. Thirteen patients (80%) experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months or more. Disruption occurred at the subscapular bursa in eight patients, the subacromial bursa in six, and the distal bicipital tendon sheath in two. These latter two patients had no pain relief. Arthrographic distention of the constricted capsule appears to be an excellent therapeutic intervention for achieving rapid symptomatic relief from adhesive capsulitis.

肩甲下滑液包に発生した滑液包性骨軟骨腫症の１例

Bursal osteochondromatosis (B. O. C) is a rare disorder of synovial tissue commonly seen around the knee joint, such as in poplitea bursa or suprapatellar bursa. It is considered that B. O. C. is a condition of metaplasia and focal formation of cartilage in the synovial membrane. A first case of B. O. C in the subscapular bursa is reported.A 22-year-old female was pointed out the calcified bodies in her right shoulder region by accidental radiogram. On arthrogram, several round free bodies were recognized in the subscapular bursa, however, glenohumeral joint appeared nomal.Through axillary approach, eleven osteochondral bodies encapsulated by the subscapular bursa were excised.The synovial membrane of the bursa showed scarring stage without osteochondroma formation, and the osteochondral free bodies showed central ossification, corresponding to stage III of synovial osteochondromatosis reported by Milgram.

The Arthrographic Findings of the Painful Shoulder in Middle and High Aged People

We have examined X-P and arthrograms of 32 cases, or 35 joints of the painful shoulder patients over forty years old. They did not have any history of injury, tumor, infection or systemic diseases.X-P findings appeared much more in the 2nd shoulder joint than in the 1st shoulder joint.If AHI is less than 7mm, we have to suspect the rupture of rotator cuff.We found any arthrographic findings in all cases, 89% in inferior pouch and subscapular bursa, 40% in rotator cuff, and 70% in biceps groove.The reduction of inferior pouch and subscapular bursa increases with aging and suffering period, and it makes the limitation of ROM. The rupture of rotator cuff increases with aging, and especially it exists in 64% of the patients over 60 years old. We could not find any relation between the clinical findings and the arthrographic findings of bicipital groove.