Impingement syndrome, subacromial bursitis
1) Avoid overhead activities.
2) A single injection of corticosteroid and local anaesthetic into the subacromial space. The position of insertion of the needle is 1 cm medial and 1 cm inferior to the postero-lateral corner of the acromion. The needle should be directed upwards towards the anterior edge of the acromion. Redirect the needle downwards if it hits the bone or upwards if it hits tendon. The solution for injection should include a corticosteroid (eg 1 ml of Depo-Medrol 40 mg/ml) and 5-10 ml of local anaesthetic (eg 1% lidocaine).
3) Once the pain has settled down, usually at 3-4 weeks, institute a rehabilitation exercise regime focussing on external rotation power and endurance.
4) If non-operative measures fail, then referral for arthroscopic acromioplasty. Our experience is that the first injection of corticosteroid is the most helpful, and that the response from subsequent injections reduces by 50% on each further injection. I would not recommend more than three injections of corticosteroid to a given area.