Shoulder Impingement Syndrome / Subacromial Pain Syndrome — বাংলা নোট
Medical caution: নিচের dose adult সাধারণ guideline-ভিত্তিক। Pregnancy, CKD, liver disease, peptic ulcer, uncontrolled HTN, IHD/stroke history, anticoagulant use, diabetes থাকলে drug choice বদলাবে। একসাথে একাধিক NSAID দেবেন না।
1) Definition — সংজ্ঞা
Shoulder impingement syndrome হলো shoulder elevation/abduction করার সময় subacromial space–এর ভিতরে থাকা structure—বিশেষ করে supraspinatus tendon, subacromial-subdeltoid bursa, rotator cuff tendon—irritation/compression হয়ে pain, painful arc ও functional limitation তৈরি করা।
বর্তমানে বেশি accepted term হলো Subacromial Pain Syndrome — SAPS, কারণ সব ক্ষেত্রে শুধু mechanical “impingement” না; tendon degeneration, bursitis, scapular dyskinesis, overload—সব মিলেও pain হয়। 2026 Dutch guideline SAPS-কে non-traumatic, non-rheumatologic shoulder pain হিসেবে বর্ণনা করেছে যা arm elevation-এ বেশি painful হয় এবং supraspinatus tendinosis, calcific tendinitis, degenerative supraspinatus tear অন্তর্ভুক্ত করতে পারে।
2) Causes / Etiology — কারণসমূহ
A. Intrinsic tendon-related কারণ
- Rotator cuff tendinopathy
- Repetitive overhead activity, ageing, microtrauma → supraspinatus tendon degenerative change।
- Tendon weak হলে arm lift করার সময় tendon irritate হয়।
- Partial-thickness rotator cuff tear
- Long-standing tendinopathy বা trauma থেকে হতে পারে।
- Pain + weakness বেশি থাকে।
- Calcific tendinitis
- Rotator cuff tendon-এ calcium deposit।
- Acute severe pain হতে পারে; X-ray/USG-তে দেখা যায়।
- Subacromial bursitis
- Bursa inflamed হলে abduction ও overhead movement-এ pain হয়।
B. Extrinsic / mechanical কারণ
- Subacromial space narrowing
- Acromial spur, hooked acromion, AC joint osteophyte থাকলে tendon compression বাড়ে।
- Scapular dyskinesis
- Scapula ঠিকমতো rotate না করলে humeral head superior migrate করে pain বাড়ায়।
- Poor posture
- Rounded shoulder, thoracic kyphosis → subacromial clearance কমে।
- Muscle imbalance
- Weak rotator cuff + weak lower trapezius/serratus anterior → abnormal shoulder mechanics।
C. Risk factors
- Repetitive overhead work: painter, electrician, garments/industrial worker, athlete
- Age >40 years
- Diabetes mellitus, hypothyroidism — tendinopathy/frozen shoulder risk বাড়ে
- Previous shoulder trauma
- Poor ergonomics
- Sudden heavy lifting
- Smoking and low physical conditioning
3) Symptoms — লক্ষণসমূহ
- Lateral shoulder pain
- সাধারণত deltoid area-তে pain হয়।
- রোগী বলে: “হাত উঠালে কাঁধের পাশে ব্যথা।”
- Painful arc
- Arm abduct করলে সাধারণত 60°–120° range-এ pain বেশি।
- Overhead activity pain
- মাথার উপর কিছু তোলা, কাপড় শুকানো, shelf থেকে জিনিস নামানোতে ব্যথা।
- Night pain
- আক্রান্ত shoulder-এর উপর শুতে গেলে pain বাড়ে।
- ঘুম ভেঙে যেতে পারে।
- Pain on internal rotation
- Shirt পরা, back pocket-এ হাত দেওয়া, bra hook লাগানো—painful হতে পারে।
- Weakness
- True weakness থাকলে rotator cuff tear suspect করতে হবে।
- Pain inhibition থেকেও apparent weakness হতে পারে।
- Restriction of function
- Dressing, grooming, driving, lifting, work performance কমে যায়।
- No obvious systemic sign
- Fever, hot swollen joint, weight loss থাকলে impingement না ধরে infection/inflammatory/malignancy rule out করতে হবে।
4) Clinically Diagnosis — Clinical diagnosis specific
Diagnosis single test দিয়ে করা উচিত না; test cluster দরকার। 2014 guideline বলেছে SAPS diagnosis clinical tests-এর combination দিয়ে করতে হবে, আর imaging সাধারণত 6 weeks-এর পরে useful। 2026 guideline-ও physical diagnostic test cluster এবং suspected supraspinatus tear হলে ultrasound recommend করে।
A. History points
- Non-traumatic or minor-overuse shoulder pain
- Lateral upper arm pain
- Pain with overhead movement
- Night pain
- Painful arc
- Work/sport overhead load history
- Red flags নেই কিনা: trauma, fever, swelling, chest pain, neurological deficit, malignancy history
B. Examination tests
1. Painful arc test
- Patient arm actively abduct করে।
- 60°–120° pain = subacromial source suggestive।
2. Hawkins-Kennedy test
- Shoulder 90° flexion, elbow 90°, তারপর internal rotation।
- Pain হলে positive।
3. Neer impingement sign
- Scapula stabilize করে arm passive forward flexion।
- Pain হলে positive।
4. Jobe / Empty can test
- Arm 90° abduction + 30° forward flexion, thumb down, resisted elevation।
- Pain/weakness হলে supraspinatus involvement।
5. Resisted external rotation / Infraspinatus test
- Elbow side-এ রেখে external rotation against resistance।
- Pain/weakness হলে rotator cuff involvement।
6. Drop arm test
- Arm abducted position থেকে slowly নামাতে বলে।
- Drop করে দিলে বা severe weakness হলে full-thickness rotator cuff tear suspect।
7. Subacromial local anesthetic test — optional
- Subacromial lidocaine injection দিলে pain markedly কমলে subacromial source support করে।
- এটি specialist/experienced clinician দ্বারা aseptic technique-এ করা উচিত।
5) Investigations — কোন investigation specific
A. No routine investigation initially
- Mild/moderate, non-traumatic, typical SAPS হলে প্রথম 4–6 সপ্তাহ conservative treatment করা যায়।
B. X-ray shoulder
Indication:
- Trauma history
- Age >50 with persistent pain
- Calcific tendinitis suspicion
- AC joint OA / glenohumeral OA suspicion
- Red flag
- Surgery planning
Views:
- True AP view
- Axillary view
- Scapular-Y / outlet view
- AP internal/external rotation if calcific deposit suspect
Findings:
- Calcific deposit
- Acromial spur
- AC joint OA
- Glenohumeral OA
- Fracture/dislocation exclusion
C. Ultrasound shoulder
First-line imaging for rotator cuff and bursa when symptoms persist >6 weeks or tear suspected. 2026 guideline specifically says suspected partial/full supraspinatus rupture হলে ultrasonography করা উচিত; MRI consider if US unavailable or inconclusive.
Detects:
- Supraspinatus tendinopathy
- Partial/full thickness tear
- Subacromial-subdeltoid bursitis
- Calcific tendinitis
- Dynamic impingement
D. MRI shoulder
Indication:
- USG inconclusive
- Suspected significant rotator cuff tear
- Failed 3–6 months conservative treatment
- Pre-operative planning
- Labral pathology suspicion
E. Blood tests — routine নয়
Only if atypical/red flag:
- CBC, ESR, CRP — infection/inflammatory disease suspect
- Uric acid — gout suspicion
- HbA1c/fasting glucose — diabetes, injection planning
- TSH — recurrent tendinopathy/frozen shoulder risk
6) Differential Diagnosis
- Rotator cuff tear
- Adhesive capsulitis / frozen shoulder
- AC joint osteoarthritis
- Glenohumeral osteoarthritis
- Biceps tendinopathy
- Calcific tendinitis
- Cervical radiculopathy
- Septic arthritis
- Inflammatory arthritis
- Referred pain: cardiac ischemia, diaphragmatic irritation, gallbladder disease
7) Complications of Disease — রোগের জটিলতা
- Chronic shoulder pain
- Proper rehab না করলে pain মাসের পর মাস থাকতে পারে।
- Functional disability
- Dressing, grooming, lifting, driving, sleeping—সবকিছুতে limitation হয়।
- Rotator cuff tear progression
- Long-standing tendinopathy থেকে partial tear/full tear হতে পারে, especially older patient।
- Frozen shoulder
- Pain-এর কারণে shoulder কম নড়ালে capsular stiffness হয়ে adhesive capsulitis হতে পারে।
- Muscle weakness and disuse atrophy
- Pain avoidance → rotator cuff/scapular stabilizer weak হয়ে problem আরো বাড়ে।
- Sleep disturbance
- Night pain chronic fatigue ও reduced productivity তৈরি করে।
- Work/sport limitation
- Overhead workers/athletes কর্মক্ষমতা হারাতে পারেন।
8) Treatment / Management — Guideline-based
A. First-line non-pharmacological management
- Patient education
- Painful overhead repeated work temporarily কমানো।
- সম্পূর্ণ rest না; graded activity।
- Activity modification
- Overhead lifting, heavy pushing/pulling, sudden jerky movement avoid।
- Pain-free range-এ কাজ করা।
- Physiotherapy — main treatment
- Rotator cuff strengthening
- Scapular stabilizer strengthening
- Posterior capsule stretch
- Thoracic mobility
- Posture correction
- Eccentric loading if tendinopathy
- Home exercise 6–12 weeks
NICE CKS rotator cuff disorders management-এ analgesia, physiotherapy referral এবং subacromial corticosteroid injection consider করার কথা বলে। BESS patient information অনুযায়ী simple shoulder exercises করলে অনেক রোগীর shoulder 6–12 weeks-এ improve করতে পারে।
B. Injection
- Severe pain হলে, exercise করতে না পারলে subacromial corticosteroid + local anesthetic injection consider করা যায়। 2026 guideline এই injection-কে exercise therapy enable করার জন্য severe complaints-এ consider করতে বলেছে।
- Repeated injection avoid; BESS/BOA pathway conservative care-এ generally no more than two corticosteroid injections বলেছে।
C. Surgery
- Most SAPS non-operative management-এ improve করে।
- 3–6 months structured rehab + appropriate injection despite persistent severe disability হলে orthopedics referral।
- Full-thickness rotator cuff tear, acute traumatic tear, severe weakness, failed conservative care → surgical opinion।
- Routine subacromial decompression now strongly questioned; trials show limited added benefit in many patients. 2026 guideline references decompression evidence and operative considerations separately.
9) Pharmacological Treatment — Bangladesh prescription-relevant drug list
Important prescribing rule
একসাথে NSAID combination করবেন না:
Ibuprofen + Naproxen + Aceclofenac + Etoricoxib + Diclofenac oral একসাথে দেওয়া যাবে না। One NSAID at a time, lowest effective dose, shortest duration.
1. Paracetamol
Generic name: Paracetamol / Acetaminophen
Therapeutic category: Analgesic, antipyretic
Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
Purpose: Mild–moderate shoulder pain control; inflammation কমায় না, pain threshold বাড়ায়। Napa 500 mg MedEx-এ mild to moderate pain/fever-এর miscellaneous analgesic হিসেবে উল্লেখ আছে এবং NSAID নয় বলা হয়েছে।
Adult dose:
- 500–1000 mg orally every 6–8 hours PRN
- Max: 3 g/day safer; selected healthy adults up to 4 g/day
- Liver disease/alcohol use: avoid or max 2 g/day after physician assessment
Duration: 3–7 days PRN; persistent pain হলে reassess।
Bangladesh available brand examples:
- Napa 500 mg tablet — Paracetamol
- Ace 500 mg tablet — Paracetamol
- Renova 500 mg tablet — Paracetamol
- Napa Extend 665 mg tablet — Paracetamol ER
- Renova XR 665 mg tablet — Paracetamol ER
MedEx shows Napa 500 mg, Ace 500 mg and Renova/Renova XR available forms.
Side effects:
- Usually safe in correct dose
- Nausea, allergy, rash rare
- Overdose → severe hepatotoxicity
Interaction:
- Alcohol, enzyme inducer anticonvulsants, rifampicin → liver toxicity risk
- Warfarin with long-term high dose → INR rise possible
- Same generic containing cold/flu medicine একসাথে খেলে accidental overdose হতে পারে
2. Ibuprofen
Generic name: Ibuprofen
Therapeutic category: Anti-inflammatory analgesic
Pharmacological class: NSAID; non-selective COX inhibitor
Purpose: Pain + inflammatory flare; bursitis/tendinopathy-related pain কমাতে short course।
MedEx Ibuprofen 400 mg-এর indication হিসেবে mild–moderate pain with inflammation, backache, rheumatic pain, muscular pain উল্লেখ করেছে; pharmacology হিসেবে COX inhibition → prostaglandin synthesis কমানো বলা হয়েছে।
Adult dose:
- 400 mg orally 2–3 times daily after food
- MedEx: 200–400 mg every 6 hours PRN; max 1200 mg/day for OTC-type use; rheumatic disease dose higher but shoulder impingement-এ usually short low dose যথেষ্ট।
Duration: 3–5 days; maximum 7 days without review।
Bangladesh available brand examples:
- Flamex 400 mg tablet — Ibuprofen
- G-Ibuprofen 400 mg tablet — Ibuprofen
MedEx lists G-Ibuprofen 400 mg and Flamex 400 mg.
Side effects:
- Gastritis, dyspepsia, nausea
- GI bleeding/ulcer
- Renal impairment
- Fluid retention, BP rise
- Bronchospasm in NSAID-sensitive asthma
- Rash
Interaction:
- Warfarin/DOAC/antiplatelet/SSRI → bleeding risk
- ACE inhibitor/ARB + diuretic → AKI risk
- Methotrexate, lithium toxicity risk
- Other NSAIDs/steroid → GI bleeding risk
MedEx also warns about aspirin, other NSAIDs, methotrexate, ACE inhibitors, diuretics, lithium, warfarin, corticosteroids, cyclosporine/tacrolimus, quinolones.
3. Naproxen / Naproxen Sodium
Generic name: Naproxen / Naproxen Sodium
Therapeutic category: Anti-inflammatory analgesic
Pharmacological class: NSAID; non-selective COX-1/COX-2 inhibitor
Purpose: Longer-acting NSAID; shoulder tendinitis/bursitis pain-এ useful when sustained anti-inflammatory effect needed।
MedEx Naproxen 500 mg-এর indication হিসেবে tendonitis, bursitis এবং pain উল্লেখ করেছে; dose section-এ acute musculoskeletal disorders-এর জন্য 500 mg initially then 250 mg every 6–8 hours if needed বলা আছে।
Adult dose:
- 500 mg initially, then 250 mg every 8–12 hours PRN
- Alternative: 500 mg twice daily after food
- Max: 1000 mg/day
Duration: 5–10 days; high GI/CV/renal risk হলে avoid বা very short course।
Bangladesh available brand examples:
- Naprox 500 mg tablet — Naproxen Sodium
- Naprosyn 500 mg tablet — Naproxen Sodium
- Napro-A 500 mg tablet — Naproxen Sodium
- Napryn 500 mg tablet — Naproxen Sodium
MedEx lists Naprox 500 mg and multiple Naproxen brands including Naprosyn, Napro-A, Napryn.
Side effects:
- Heartburn, abdominal pain, nausea, diarrhea, dyspepsia
- Headache, dizziness, drowsiness
- Edema, palpitation
- GI bleeding/ulcer, renal injury
MedEx lists GI symptoms, CNS symptoms, edema/palpitation and other effects.
Interaction:
- Warfarin → GI bleeding risk
- SSRI → GI bleeding risk
- ACE inhibitors/diuretics → reduced BP effect + renal risk
- Methotrexate toxicity
- Aspirin/other NSAIDs → adverse effects increase
MedEx lists these interactions.
4. Aceclofenac
Generic name: Aceclofenac
Therapeutic category: Anti-inflammatory analgesic
Pharmacological class: NSAID; COX inhibitor
Purpose: Bangladesh prescription-এ musculoskeletal pain/inflammation-এ commonly used; shoulder impingement pain flare-এ short course।
MedEx Aceclofenac 100 mg indication হিসেবে pain and inflammation relief উল্লেখ করে; adult dose 100 mg twice daily।
Adult dose:
- 100 mg orally twice daily after meal
Duration: 5–7 days; risk থাকলে shorter।
Bangladesh available brand examples:
- Analgen 100 mg tablet — Aceclofenac
- Flexivan 100 mg tablet — Aceclofenac
- Acebid 100 mg tablet — Aceclofenac
- Acelock 100 mg tablet — Aceclofenac
- AC PR 100 mg tablet — Aceclofenac
MedEx lists Analgen/Flexivan and multiple Aceclofenac brands.
Side effects:
- Dyspepsia, nausea, abdominal discomfort
- Dizziness
- GI ulcer/bleeding
- Renal impairment
- BP rise/fluid retention
- Rash
Interaction:
- Lithium/digoxin level increase
- Diuretics effect reduce
- Anticoagulant effect enhance
- Methotrexate level increase
MedEx lists these interactions and peptic ulcer/GI bleeding, hepatic/cardiac/renal impairment caution.
5. Etoricoxib
Generic name: Etoricoxib
Therapeutic category: Anti-inflammatory analgesic
Pharmacological class: Selective COX-2 inhibitor NSAID
Purpose: Pain + inflammation relief, comparatively less gastric irritation than non-selective NSAIDs, but CV risk বেশি important। Use only when appropriate।
MedEx describes Etoricoxib as potent COX-2 specific inhibitor and advises shortest duration/lowest effective dose because CV risk increases with dose and duration.
Adult dose for shoulder pain practice:
- 60 mg once daily after food
- Severe pain: 90 mg once daily may be used short-term
- Avoid prolonged use
Duration: 3–5 days; maximum 7 days without review।
Bangladesh available brand examples:
- Tory 60/90/120 mg tablet — Etoricoxib
- Etorix 60/90/120 mg tablet — Etoricoxib
- Etoshine 60/90/120 mg tablet — Etoricoxib
- Etovan 60/90/120 mg tablet — Etoricoxib
- Cox-E 60/90/120 mg tablet — Etoricoxib
MedEx lists Tory, Etorix, Etoshine, Etovan and multiple Etoricoxib brands.
Side effects:
- Palpitation, fatigue
- Dizziness
- BP rise, edema
- GI upset, ulcer risk lower but not zero
- CV risk: MI/stroke risk in high-risk patient
- Liver enzyme abnormality, rash
Contraindication/caution:
- Uncontrolled hypertension
- Ischemic heart disease, stroke, peripheral arterial disease
- Heart failure
- Active peptic ulcer/GI bleeding
- Severe renal/liver disease
MedEx lists these contraindications and cautions.
Interaction:
- Warfarin/oral anticoagulant → PT/INR rise
- ACE inhibitor/ARB/diuretic → antihypertensive effect কমে, renal risk
- Cyclosporine/tacrolimus → nephrotoxicity
- Lithium level rise
MedEx lists these interactions.
6. Diclofenac topical gel
Generic name: Diclofenac Sodium topical
Therapeutic category: Topical anti-inflammatory analgesic
Pharmacological class: NSAID; prostaglandin synthesis inhibitor
Purpose: Local shoulder pain relief with less systemic GI/renal risk than oral NSAID; mild/moderate localized pain-এ useful।
MedEx Diclofenac gel dose হিসেবে 2–4 g affected area-তে 3–4 times daily apply করার কথা বলে।
Adult dose:
- Apply 2–4 g thin layer over painful shoulder area 3–4 times daily
- Wash hand after use
- Broken skin/open wound-এ দেবেন না
Duration: 7–14 days; persistent pain হলে review।
Bangladesh available brand examples:
- Diclofen 1% w/w gel — Diclofenac Sodium
- Volifen 1% spray / 1% gel form — Diclofenac Sodium
- Volinac 1%/2% gel — Diclofenac Sodium + Methyl salicylate + Linseed oil + Menthol
MedEx lists Diclofen 1% gel and Volinac 1% gel.
Side effects:
- Local burning, rash, itching
- Photosensitivity rare
- Large area/long use করলে systemic NSAID risk possible
Interaction:
- Oral NSAID/anticoagulant ব্যবহার করলে caution
- Methotrexate/cyclosporine/warfarin users-এ long extensive use avoid
7. Esomeprazole — NSAID gastric protection
Generic name: Esomeprazole
Therapeutic category: Anti-ulcerant, gastric protection
Pharmacological class: Proton pump inhibitor — PPI
Purpose: NSAID-induced gastritis/ulcer risk কমানো; especially age >60, ulcer history, steroid/anticoagulant/antiplatelet use, dyspepsia।
MedEx Esomeprazole MUPS indication-এ NSAID-associated gastric ulcer healing/risk reduction উল্লেখ করেছে; dose 20 mg once daily।
Adult dose:
- 20 mg once daily 30–60 min before breakfast
- High-risk or symptomatic: 20–40 mg once daily
Duration: NSAID course চলাকালীন; usually 5–14 days. Ulcer/GERD হলে 4–8 weeks physician-directed।
Bangladesh available brand examples:
- Esomep 20/40 mg tablet/capsule — Esomeprazole
- Esonix M 20/40 mg MUPS tablet — Esomeprazole
- Nexum 20/40 mg — Esomeprazole
- Maxpro 20/40 mg — Esomeprazole
- Nexpro MUPS 20/40 mg — Esomeprazole
MedEx lists these Esomeprazole brands/forms.
Side effects:
- Headache, nausea, abdominal pain
- Diarrhea/constipation, flatulence
- Long-term: hypomagnesemia, B12 deficiency, fracture risk, kidney issue rare
Interaction:
- Diazepam level may rise
- Gastric pH-dependent drug absorption affected: ketoconazole, iron salts, digoxin
- Warfarin/phenytoin usually monitor if high risk
MedEx lists CYP2C19-related and pH-dependent absorption interactions.
8. Naproxen + Esomeprazole fixed-dose combination
Generic name: Naproxen Sodium + Esomeprazole Magnesium
Therapeutic category: NSAID with gastric protection
Pharmacological class: NSAID + PPI combination
Purpose: Inflammatory pain control + NSAID-associated gastric ulcer risk reduction in selected high-risk patients।
MedEx Napro-A Plus/Naprosyn Plus indication-এ OA/RA/ankylosing spondylitis symptoms and NSAID-associated gastric ulcer risk reduction উল্লেখ করেছে। Dose: 375/20 mg or 500/20 mg twice daily; tablet split/chew/crush করা যাবে না, meal-এর অন্তত 30 min আগে।
Adult dose:
- 375/20 mg or 500/20 mg orally twice daily
- Shoulder impingement-এ usually short course only if NSAID needed and GI risk exists
Duration: 5–10 days; longer হলে review।
Bangladesh available brand examples:
- Napro-A Plus 500 mg + 20 mg — Naproxen Sodium + Esomeprazole
- Naprosyn Plus 500 mg + 20 mg — Naproxen Sodium + Esomeprazole
- Naproflex 500 mg + 20 mg
- Napronil Plus 500 mg + 20 mg
- Napsec 500 mg + 20 mg
MedEx lists these combination brands.
Side effects:
- Dyspepsia, gastritis, diarrhea, nausea
- NSAID risks: GI bleeding, renal injury, edema, BP rise
- PPI risks with prolonged use
Interaction:
- Warfarin → bleeding risk
- ACE inhibitor/diuretic/beta blocker effect reduce
- Ketoconazole/iron/digoxin absorption affected
MedEx lists these interactions.
9. Subacromial corticosteroid injection
Option A: Triamcinolone Acetonide
Generic name: Triamcinolone Acetonide injection
Therapeutic category: Local anti-inflammatory steroid
Pharmacological class: Glucocorticoid corticosteroid
Purpose: Severe subacromial bursitis/tendinopathy pain কমিয়ে physiotherapy শুরু করতে সাহায্য করা। Routine first-line না।
MedEx Triamcinolone 40 mg/ml injection-কে synthetic glucocorticoid corticosteroid with anti-inflammatory action হিসেবে বর্ণনা করে; intra-articular/soft tissue adjunct therapy-তে acute/subacute bursitis, tenosynovitis ইত্যাদিতে উল্লেখ আছে।
Typical specialist dose:
- Triamcinolone acetonide 20–40 mg subacromial bursa
- Often mixed with Lidocaine 1–2 ml
- Strict aseptic technique
- Repeat only if clear benefit; avoid frequent repetition
Bangladesh available brand examples:
- Trialon 40 mg/ml injection — Triamcinolone Acetonide
- Cenolon 40 mg/ml injection — Triamcinolone Acetonide
- Triacin 40 mg/ml injection — Triamcinolone Acetonide
- Triamon 40 mg/ml injection — Triamcinolone Acetonide
- Trimcort 40 mg/ml injection — Triamcinolone Acetonide
MedEx lists these Triamcinolone injection brands.
Side effects:
- Post-injection flare pain 24–48 h
- Skin depigmentation, fat atrophy
- Infection rare
- Tendon weakening/rupture risk if repeated or wrong site
- Temporary hyperglycemia in diabetics
- Facial flushing, BP rise rare
Local corticosteroid injection side effects include infection, tendon rupture, hypopigmentation and soft tissue atrophy; systemic effects may include hyperglycemia and hypertension.
Interaction/caution:
- Diabetes: glucose monitoring 3–5 days
- Anticoagulant: bleeding/hematoma risk
- Active infection: contraindicated
- Avoid injecting directly into tendon
- Live vaccines/systemic steroid context: caution
Option B: Methylprednisolone Acetate
Generic name: Methylprednisolone Acetate injection
Therapeutic category: Local anti-inflammatory steroid
Pharmacological class: Glucocorticoid corticosteroid
Purpose: Alternative steroid for subacromial bursitis/tendinopathy pain; short-term pain relief to start rehab।
MedEx Depo-Medrol local effect dosing table includes large joints like shoulder 20–80 mg and tendinous/bursal structures 4–30 mg depending on condition; therapeutic class glucocorticoids।
Typical specialist dose:
- 20–40 mg subacromial bursa
- With/without lidocaine
- Reassess after 4–6 weeks
Bangladesh available brand examples:
- Depo-Medrol 40 mg/ml; 80 mg/2 ml — Methylprednisolone Acetate
- Depomed 40 mg/ml; 80 mg/2 ml — Methylprednisolone Acetate
- Methsolon 40 mg/ml — Methylprednisolone Acetate
- Medrol 40 mg/ml; 80 mg/2 ml — Methylprednisolone Acetate
MedEx lists these brands/forms.
Side effects:
- Hyperglycemia
- Local pain flare
- Skin atrophy/depigmentation
- Infection
- Tendon degeneration if repeated
- BP rise/fluid retention
MedEx lists steroid systemic effects such as hypertension, sodium retention, muscle weakness, osteoporosis, peptic ulcer, increased sweating, headache, increased intraocular pressure, allergic reactions.
Interaction:
- Warfarin effect may increase/decrease → INR monitor
- Phenytoin/rifampicin/phenobarbital → steroid clearance increase
- Ketoconazole/macrolide → steroid level increase
- Cyclosporine → seizure risk reported
MedEx lists these interactions.
10. Lidocaine — injection adjunct
Generic name: Lidocaine Hydrochloride
Therapeutic category: Local anesthetic
Pharmacological class: Amide local anesthetic; sodium channel blocker
Purpose: Subacromial injection-এর সময় immediate analgesia এবং diagnostic pain relief assessment।
MedEx Lidocaine 2% injection indication-এ local anaesthetic for infiltration blockade উল্লেখ করেছে; onset fast and duration approximately one hour।
Dose:
- Commonly 1–2 ml of 1% or 2% with steroid by trained clinician
- Maximum dose must calculate by body weight; intravascular injection avoid
Bangladesh available brand examples:
- Lidocaine 2% injection — Lidocaine Hydrochloride
- G-Lidocaine 2% injection
- Z-Lidocaine 2% injection
- Chemocain 2% injection
MedEx lists Lidocaine 2%, G-Lidocaine and Z-Lidocaine/Chemocain brands.
Side effects:
- Local numbness
- Dizziness, tinnitus, metallic taste if systemic absorption
- Seizure/arrhythmia in toxicity
- Allergy rare
Interaction/caution:
- Antiarrhythmic drugs
- Severe heart block
- Liver disease
- Avoid intravascular injection
11. Muscle relaxant — only if associated cervical/trapezius spasm
Tolperisone
Generic name: Tolperisone Hydrochloride
Therapeutic category: Skeletal muscle relaxant
Pharmacological class: Centrally acting muscle relaxant
Purpose: Shoulder impingement-এর core drug না। কিন্তু neck/trapezius spasm, protective muscle tightness থাকলে short adjunct হিসেবে কিছু physician prescribe করেন।
MedEx Tolperisone-কে centrally acting muscle relaxant হিসেবে বর্ণনা করে, elevated muscle tone/tension-এ ব্যবহারের কথা উল্লেখ করেছে।
Adult dose:
- 50 mg orally 2–3 times daily after food
- Some cases 100 mg 2–3 times daily physician-directed
Duration: 5–7 days only; sedation/dizziness হলে stop/review।
Bangladesh available brand examples:
- Tolson 50 mg — Tolperisone
- Tolus 50/100 mg — Tolperisone
- Myoson 50/100 mg — Tolperisone
- Toperin 50 mg — Tolperisone
- Myolax 50 mg — Tolperisone
- Tolmus 50 mg — Tolperisone
MedEx lists these Tolperisone brands.
Side effects:
- Dizziness, weakness
- Nausea, GI upset
- Hypotension rare
- Hypersensitivity/rash
Interaction:
- Alcohol/CNS depressants → dizziness/sedation বাড়তে পারে
- Driving/machinery caution
Tizanidine — alternative, more sedating
Generic name: Tizanidine Hydrochloride
Therapeutic category: Muscle relaxant / antispasticity agent
Pharmacological class: Centrally acting α2-adrenergic agonist
Purpose: Painful spasm থাকলে selected cases; routine shoulder impingement drug না।
MedEx Tizanidine indication-এ painful muscle spasms associated with cervical/lumbar syndromes উল্লেখ করেছে।
Adult dose:
- 2 mg at night or 2 mg 2–3 times daily if needed
- Start low due to sedation/hypotension
Duration: 3–7 days।
Bangladesh available brand examples:
- Relentus 2 mg — Tizanidine
- Tizan 2 mg — Tizanidine
- Tizadin 2 mg — Tizanidine
- Tizalex 2 mg — Tizanidine
MedEx lists these brands.
Side effects:
- Sleepiness, dizziness
- Dry mouth
- Hypotension, bradycardia
- LFT elevation
Interaction:
- Ciprofloxacin/fluvoxamine: avoid
- Alcohol/sedatives: sedation + hypotension
- Antihypertensives: BP drop
10) Bangladesh doctors commonly prescribe — practical list
For shoulder impingement/SAPS, Bangladesh clinical practice-এ commonly দেখা যায়:
- Paracetamol 500 mg
- Mild pain, safe first-line analgesic।
- Example: Napa/Ace/Renova 500 mg।
- One NSAID
- Pain + inflammation বেশি হলে।
- Example: Ibuprofen 400 mg, Naproxen 500 mg, Aceclofenac 100 mg, Etoricoxib 60/90 mg।
- Never combine multiple NSAIDs.
- PPI
- NSAID দিলে gastritis/ulcer risk থাকলে।
- Example: Esomeprazole 20 mg before breakfast।
- Topical NSAID gel
- Local pain কমাতে।
- Example: Diclofenac 1% gel / Volinac gel।
- Subacromial steroid injection
- Severe pain হলে exercise শুরু করতে।
- Example: Triamcinolone 20–40 mg or Methylprednisolone 20–40 mg + Lidocaine।
- Repeated injection avoid।
- Muscle relaxant
- Only if neck/trapezius spasm আছে।
- Example: Tolperisone 50 mg or Tizanidine 2 mg short course।
- Antibiotic
- Shoulder impingement-এ antibiotic-এর role নেই।
- Fever/hot swollen joint/septic arthritis suspicion হলে আলাদা urgent workup।
- Vitamin B complex / calcium
- Impingement cure করে না; deficiency থাকলে only supplement।
11) Prevention — কীভাবে প্রতিরোধ করবেন
- Overhead workload gradually increase
- হঠাৎ heavy overhead work শুরু করবেন না।
- Rotator cuff strengthening
- External rotation, internal rotation, scaption, isometric exercises।
- Scapular stabilization
- Serratus anterior, lower trapezius strengthening।
- Posture correction
- Rounded shoulder, forward head posture ঠিক করা।
- Workplace ergonomics
- Shoulder height-এর উপরে repeated work কমানো।
- Step stool ব্যবহার করে overhead reach কমানো।
- Warm-up before sport/work
- Throwing, gym, swimming, badminton/cricket-এর আগে warm-up।
- Avoid painful arc loading initially
- Painful range-এ repeated lifting না।
- Sleep modification
- Painful shoulder-এর উপর না শোয়া।
- Pillow support দিয়ে arm neutral position-এ রাখা।
- Metabolic control
- Diabetes, thyroid disease manage করলে tendinopathy/frozen shoulder risk কমে।
- Early rehab
- Pain শুরু হলেই complete rest না নিয়ে graded mobility + strengthening শুরু করা।
Overview / Summary
Shoulder impingement syndrome-এর better term হলো Subacromial Pain Syndrome। Main pathology হলো rotator cuff tendinopathy/bursitis/biomechanical dysfunction। Diagnosis মূলত history + test cluster: painful arc, Hawkins-Kennedy, Neer, Jobe/Empty can, resisted external rotation। Imaging প্রথমে routine নয়; >6 weeks persistent pain বা tear suspicion হলে ultrasound first, MRI if inconclusive or surgery planning। Treatment-এর cornerstone হলো physiotherapy + activity modification। Drugs pain control করে; steroid injection severe pain হলে exercise enable করতে ব্যবহৃত হয়, repeated নয়।
Actionable Plan / Steps
- Confirm clinical pattern: lateral shoulder pain, painful arc, overhead pain, night pain।
- Red flag exclude: trauma, fever, hot swollen joint, neuro deficit, chest pain।
- Initial treatment 2–6 weeks: activity modification + home/physio exercise + paracetamol/topical NSAID ± one oral NSAID।
- NSAID risk check: ulcer, CKD, HTN, IHD/stroke, anticoagulant, pregnancy। Risk থাকলে avoid or PPI cover।
- If severe pain prevents exercise: consider single subacromial steroid injection by trained clinician।
- If >6 weeks persistent or weakness: USG shoulder; MRI if USG inconclusive/tear/surgery planning।
- Refer orthopedics/PM&R: acute traumatic weakness, suspected full-thickness tear, failed 3–6 months rehab, recurrent severe disability।
Reference List — Textbook + Guideline + DOI
Textbooks
- Harrison’s Principles of Internal Medicine, 21st ed. Approach to musculoskeletal pain and regional rheumatic disorders.
- Davidson’s Principles and Practice of Medicine, 24th ed. Musculoskeletal disorders and regional pain syndromes.
- DeLee, Drez & Miller’s Orthopaedic Sports Medicine, 5th ed. Rotator cuff disease and impingement-related shoulder pain.
- Braddom’s Physical Medicine and Rehabilitation, 6th ed. Shoulder pain rehabilitation and rotator cuff disorders.
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. NSAIDs, analgesics, glucocorticoids, local anesthetics.
Guidelines / Clinical pathways
- Dutch Orthopaedic Association / Acta Orthopaedica guideline update, 2026 — SAPS diagnosis, imaging, non-surgical treatment. DOI: 10.2340/17453674.2026.45365.
- Dutch Orthopaedic Association guideline, 2014 — SAPS diagnosis and treatment. DOI: 10.3109/17453674.2014.920991.
- NICE CKS — Shoulder pain: rotator cuff disorders; analgesia, physiotherapy, corticosteroid injection consideration.
- BESS/BOA pathway — Subacromial shoulder pain conservative care and injection limitation.
Peer-reviewed articles with DOI
- Michener LA et al. Diagnostic accuracy of physical examination tests for subacromial impingement. Arch Phys Med Rehabil. 2009. DOI: 10.1016/j.apmr.2009.05.015.
- Crawshaw DP et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain. BMJ. 2010. DOI: 10.1136/bmj.c3037.
- Beard DJ et al. Arthroscopic subacromial decompression for subacromial shoulder pain — CSAW trial. Lancet. 2018. DOI: 10.1016/S0140-6736(17)32457-1.
- Kamel SI et al. Local and systemic side effects of corticosteroid injections for musculoskeletal indications. AJR. 2024. DOI: 10.2214/AJR.23.30458.
Md.Rafiqul Islam Lipu,Date:-19-06-2026 Thursday,Time:-12-22-12 Pm