Bursitis

[Erin Priestly]

Hi Stephen,

I have recently watched your shoulder and hip webinars and live scanning tutorials on the Bird Ultrasound website and I was wondering if I could ask you a few questions about bursitis.
What is your opinion on what bursal thickness is considered to be bursitis when looking at subacromial bursitis and greater trochanteric bursitis?

I also wondered what your thoughts are on bursitis sometimes being present but it not necessarily explaining the main cause of the patient’s symptoms?

In my limited scanning experience, I have noticed a few times that a patient who has been referred for a hip ultrasound +/- cortisone injection querying greater trochanteric bursitis has presented with lower lumbar region pain as their main complaint + referred pain into their buttock (which could be suggestive of a lower back issue).
On ultrasound assessment they have had some fluid in or mild thickness of their greater trochanteric bursa and they have not been tender over their greater trochanter bursa.

Would you consider the ultrasound finding of bursitis in these sorts of scenarios to perhaps be an incidental finding or secondary to another issue and therefore not clinically be very significant in the decision for the patient having a GTB cortisone injection or not?

Kind regards,
Erin

[Stephen Bird]

Hi Erin,

You raise some great points.

I agree that “bursitis” is over-diagnosed and often used as a reason for symptoms incorrectly.

In answer to your first question about the thickness of a bursa before I get excited about it. I don’t have a number. This may disappoint you, but I am really not a numbers person, even in obstetrics I prefer to take a global perspective rather than fixate on the biometry.

The first thing to understand is that bursitis is not a stand alone entity. It exists in a spectrum of disease. If you watch the MSK principles webinar on the website I do cover some of this in the early part of that presentation.
In the MSK system as we use our bodies we get degenerative changes in the tendons and the enthesis attachments to the skeleton. When we develop degeneration in these areas as a response to overuse it sets up an inflammatory response in what is known as the synovial entheseal complex (SEC). Now this all sounds a bit fancy but it is simple really. All tendons have a SEC and they are comprised of a combination of either (bursas, fat pads, syvovial sheaths or peritenons) . For example the Achilles has a peritenon, subtendinous bursa, subcutaneous bursa and Kagers fat pad. Supraspinatus has the subacromial -subdeltoid bursa. Tibialis posterior has a synovial sheath. Gluteus medius has the trochanteric bursa and the sub-tendinous bursa.
So when a tendon gets degenerative changes in the collagen or at the enthesis this triggers an inflammatory response in the SEC.
So with trochanteric bursitis there is always a degenerative process underway in the tendon (tendinosis) or an enthesopathic process under way and this triggers the trochanteric bursitis.
The point in treating the trochanteric bursa with a steroid injection is NOT to make the patient better. The injection will relieve the pain by temporarily reducing the inflammation in the SEC and while the patient has some relative comfort they must be doing physiotherapy to regenerate the degenerative tendinosis in the gluteal tendons or they will end up right back where they started. We are just part of management package if the patient is being well managed and this is not always the case.

I think the only time you see bursitis in the setting of a perfect tendon is in rheumatoid patients where the synovium in the bursa simply gets cranky as part of the synovium proliferative process.

Propper assessment of any tendon requires assessment of the enthesis, tendon, musculotendinous junction, muscle belly and the associated SEC. The you have done a complete job. This is how I approach all tendons.

As for when I call the diagnosis of bursitis I am not really interested in an absolute measurement. I look at the tendon and enthesis for changes. Palpate with the transducer to see if it tender and ask about the clinical presentation. Bursitis often causes nocturnal pain and sleep disturbances as well as being point tender on palpation. If the patient has these symptoms I will guide an injection even if the bursa looks normal. I know we live in an imaging world, but I think we need to treat the patient and not the imaging, so if the symptoms are typical we should inject as a diagnostic trial even if the scan is fairly normal. Comparison with the other side can be helpful but again I am guided mainly by the clinical presentation.

I hope this helps Erin,

Please continue the conversation with me,

Happy scanning,

Steve.

[Erin Priestly]

Thanks for your reply Steve.

Your explanation makes a lot of sense.
I have always considered bursitis to be secondary to something else rather than the main problem itself and your advice to correlate a bursitis thickening or bunching finding with other ultrasound findings and the patient’s clinical presentation/history sounds like the best thing to do.

Thanks for your help.
Erin

[Ashleigh Shilling]

Hi Erin and Steve.

Erin, I’m glad you brought this topic up as it’s something I initially struggled with. I think I am a “numbers” person so I have had to teach myself to approach bursitis clinically rather than from an imaging perspective.

Steve, do you find adhesive capsulitis similar? Should we be placing more emphasis on the clinical symptoms?
I have only been scanning shoulders for 6 months or so, so I haven’t come across many “frozen shoulder” cases yet. The limited scanning I have done to assess adhesive capsulitis has been from an axillary approach and comparing to the contralateral side.

Thanks,
Ashleigh

[Stephen Bird]

Hi Ashleigh,

Yes, I am not at all a numbers person and I think that is an advantage.

A global perspective works best I think.

With adhesive cap I look at a number of things clinically and sonographically.

Clinically I test them for external rotation range compared to the other side.
Then I stand behind them and dig a finger into the medial border of the scapula and then abduct their arm as far as they can. If the scapula stays stationary until they reach between 60 and 90 degrees of abduction the humeral head has good rotation range and they don’t have adhesive cap. If the scapula starts to swing laterally early in the abduction this is due to a loss of humeral rotation capability at the GH joint and this is a good clue for adhesive cap. It is called the scapulo-humeral rhythm. You need a set of normal plain radiographs as advanced GH joint OA or a bony mass / old fracture remodelling etc can cause the lack of rotation. But if the plain x-rays are fairly normal it is a great test.
Then I like to see a bit of fluid in the long head of biceps sheath as this communicates with the GH joint and the fluid is squeezed out of the GH joint when the capsule contracts and into the LHBT sheath.
Then I look for flow in the rotator cuff interval with whatever your most sensitive Doppler tool is on your machine. The arm must be relaxed in the lap (not modified Crass) and NO transducer pressure, relaxed patient, high gain , low PRF (scale).

Then look at the posterior capsule for thickness and assess during internal and external rotation. Compare capsule thickness and range of movement with the other side.
Then I lay them down, arms up as far as they can and scan the inferior glenohumeral ligament (axillary GH joint capsule) and compare to the other side to see if it thick.

If you do all of this I reckon you get it right nearly all the time.

Happy scanning,

Steve

[Ashleigh Shilling]

Hi Steve,

Thanks for your detailed response! I hadn’t considered the scapulo-humeral rhythm as part of assessment of adhesive cap. Really looking forward to the upcoming workshops in a few weeks.

Thanks,

Ashleigh

[Stephen Bird]

Hi Ashleigh,

I think part of doing a good ultrasound is to convey some clinical presentation details to the reporting Doctor. I am not pretending to ge a Doctor myself as I am a sonographer so I don’t do formal tests like empty can etc but I am happy to make simple observations like the scapula-humeral rhythm and limited external rotation etc.
I think this type of observation is important like area of bruising / skin redness etc.
See you soon,

I am looking forward to it,

Steve

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