Local steroid injection will certainly reduce the inflammatory swelling to allow the rotator cuff to slip under the coracoacromial arch, but it will do little for scarring. (1) Pure inflammatory change leading to localized edema, -which if left unresolved for too long, will lead to (2) fibrosis. It may be thought that impingement has two pathologic results. In both these situations, it is known that the injection has been correctly sited and that further injection may well be helpful. Partial resolution of symptoms may be taken to mean (1) complete resolution of symptoms but only for a short time 'with complete return of symptoms, or (2) improvement in symptoms, but not complete resolution. No effect at all, in 'which case the diagnosis was 'wrong or the injection was incorrectly placed.Complete resolution of symptoms permanently, in which case, nothing further need be done apart from general advice to the patient to prevent further occurrence.There may be three possible results from therapeutic injection of the subacromial bursa: In stage 3, changes may be too severe to gain any benefit from injection alone. In stage 1, the symptoms almost certainly will settle with rest alone, and hence the dangers of injection can be avoided. Injection is most useful in stage 2 impingement (see Ch. A reasonable approach is no more than one injection every 3 weeks, with a maximum of three injections during any course of treatment. Opinion varies as to the amount and frequency that it is safe to inject this site. Therapeutic If the diagnosis of impingement of the rotator cuff has been made, then part of conservative therapy may well include injection of steroid into the subacromial bursa. If the pain is abolished, then this answers the question "Is the pain arising in the subacromial region?" I have found the impingement test described by Neer to be clinically the most useful in which the bursa is filled with 10 cc of local anesthetic.
Some prefer to identify the site of impingement but within the rotator cuff by injecting the tender spot locally actually into the tendon itself with local anesthetic. If the central painful arc (60 to 120 degrees) is abolished by this maneuver, then this indicates pain arising from the rotator cuff area and impinging under the coracoacromial arch. Neer2 described a similar injection test in which the subacromial painful arc of motion was abolished by injection of the subacromial bursa with 10 cc of xylocaine.
However, -when the shoulder is elevated in the high arc between 120 and 180 degrees, the clavicle must undergo an obligatory rotation in the coronal plane and cause rotation at the acromioclavicular joint hence, any pain arising here will be maximum during this range of rotation. Kessel and Watson,1 with elegant inj ection studies of radiopaque dye placed differentially into the tendons of the rotator cuff, have shown radiographically that the central arc of pain is associated with impingement of the cuff. Pain arising from a higher arc of abduction between 120 and 180 degrees indicates pain arising from the acromioclavicular j oint (Fig. The painful arc syndrome is not a diagnosis but is a clinical sign a painful arc of motion between 60 and 120 degrees of abduction indicates that the pain may well be arising from the subacromial region. Approximately 40 percent of patients attending a shoulder clinic with the primary diagnosis of pain will have pain arising from the subacromial area (Fig. Impingement Injection of the subacromial bursa is of the greatest importance in identifying the source of shoulder pain. Injection of the Subacromial Bursa Indications
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