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Shoulder Bursitis

Shoulder Bursitis

Shoulder bursitis is a common injury that involves pain of in the shoulder and arm. Pain is due to a swollen and inflamed shoulder bursa. Your bursa is a fluid-filled sac that helps to reduce friction in your shoulder spaces. You have several bursae within your shoulder. Your subacromial bursa is the most commonly inflamed of the shoulder bursa. Pain due to shoulder bursitis is related to shoulder impingement of your bursa between your rotator cuff tendons and bone (acromion).

The subdeltoid bursa is a less commonly inflamed shoulder bursa.

What Does Bursitis in the Shoulder Feel Like?

Shoulder bursitis commonly presents with the following symptoms:

  • Gradual onset of your shoulder symptoms over weeks or months.
  • Pain on the outside of your shoulder.
  • Pain may spread down your arm towards the elbow or wrist.
  • Pain made worse when lying on your affected shoulder.
  • Pain made worse when using your arm above your head.
  • Painful arc of movement – shoulder pain felt between 60 – 90° of the arm moving up and outwards.
  • When your arm is by your side there is minimal pain and above 90° relief of pain.
  • Shoulder pain with activities such as washing hair, reaching up to a high shelf in the cupboard.

How Is Shoulder Bursitis Diagnosed?

Your health clinician is able to differentiate shoulder bursitis from other injuries, including a rotator cuff injury using manual tests. However, shoulder bursitis is commonly accompanied by  rotator cuff tears or rotator cuff tendinopathy. This is due to the movement impairments that accompany rotator cuff tears and tendinopathies resulting in irritation and impingement of the bursa and eventually bursitis.

Ultrasound scan’s or MRI’s may also be useful to confirm the diagnosis of subacromial bursitis.

What Causes Shoulder Bursitis?

Shoulder Bursitis can be caused by overuse of the shoulder joint and muscles or by a single more significant trauma such as a fall or collision.

In overuse type injuries, bursitis is often associated with impingement and tendinosis of one or more of the rotator cuff tendons.

The subacromial bursa in the most common shoulder bursa affected by bursitis. The subacromial bursa lies between the coracoacromial ligament and the supraspinatus muscle and helps to reduce friction in this small space under the acromion.

When your arm is at your side the bursa protrudes laterally and is not normally impinged unless it is severely inflamed.

When you elevate your arm further out to the side the bursa rolls beneath the bone increasing the impingement.

When you continue to elevate your arm above shoulder height, the bursa rolls clear of the impingement zone and pain eases. Further impingement may return at the top of the arc of motion, when your arm is adjacent to your ear.

How Can You Prevent Shoulder Bursitis?

Eliminating the causes of primary and secondary impingement is the key to preventing shoulder bursitis and rotator cuff problems. Factors such as posture, muscle length, shoulder stability, and rotator cuff strength need to be addressed and can be optimised with specific exercises as prescribed by your physiotherapist or other health care profession.

How Do You Treat Bursitis of the Shoulder?

Shoulder bursitis is seen fairly regularly in Physiotherapy clinics. Unfortunately it is an injury that often recurs if the patient returns to sport or work too quickly without completing a thorough rehabilitation programme.

The rotator cuff is an important group of control and stability muscles that maintain “centralisation” of the shoulder joint. This prevents injuries such as bursitis,  impingement, subluxations and dislocations.

The rotator cuff works to provide subtle glides and slides off the ball joint on the socket to allow full shoulder movement. The shoulder blade (scapular) also plays a vital role in shoulder motion, control and stability acting as the main dynamically stable base plate that attaches the arm to the chest wall.

Treatment of Shoulder Bursitis should include a period of controlled rest during which inflammation is reduced. Once pain has subsided sufficiently rehabilitation can begin. A comprehensive rehabilitation programme is required in order to ensure that shoulder range, control and stability is fully restored.

Phase 1: Pain and Inflammation Reduction

During this phase the aim will be to avoid positions and activities that squeeze and irritate the bursa. It may be necessary to wear a sling or have your shoulder taped. You should avoid sleeping on the affected shoulder and this will result in compression of the bursa which will in turn increase the inflammation.

Applying ice for 20 minutes every few hours will help to reduce inflammation of the bursa and reduce the patients pain.

Anti-inflammatory medications (NSAIDs or natural options such as arnica) may help to reduce inflammation. However, the bursa is a self-contained entity with minimal blood flow, and accordingly there is some evidence that NSAIDs are less effective in controlling bursitis than other inflammatory conditions.

 Phase 2: Regain Full Range Of Motion

It may take several weeks for the inflammation of the bursa to significantly decrease. During this time range of motion can be gradually improved. Massage, manual therapy, medical acupuncture or dry needling are all techniques that have been shown to successfully improve range of motion of the shoulder in cases of shoulder bursitis.

It is common for the shoulder capsule to have become protectively tight, the posterior joint capsule is most commonly affected. This tightness should be addressed initially with passive stretching and finally active motions.

Phase 3: Regain Control & Stability

Once full range can be achieved control and stability needs to be addressed. As set out earlier the rotator cuff muscles are the muscles that primarily control and stabilise the shoulder. A comprehensive strengthening rehabilitation must be completed to mitigate the chance of a recurrence of shoulder bursitis.

Phase 4: Restore Speed, Power, Proprioception & Agility

During this phase rehabilitation will focus on specific activities that are necessary in the patients lifestyle or sport. The focus is usually on a combination of speed, power, proprioception and agility.

Phase 5: Return To Sport

Rehabilitation will be progressed over time and it may be necessary to continue to incorporate some specific rehabilitation exercises in their warm up or warm down whilst returning to sport (and potentially indefinitely).

Chronic & Calcific Shoulder Bursitis

If left untreated shoulder bursitis can become chronic. At this stage, successful treatment is difficult to achieve and a cycle of  rotator cuff injury and impingement of the shoulder joint is often established.

Chronic shoulder bursitis may respond well to a corticosteroid injection. A corticosteroid will reduce inflammation. Physiotherapy normally commences about one week after the injection to address the biomechanical, muscles and joint issues that have caused bursitis. If biomechanical issues are not corrected it is likely that the bursitis will return.

There are a number of advantages and disadvantages with corticosteroid injection and this option should be discussed with your doctor. Diabetes and other general health issues can limit its safe use. The best results have been shown to occur when the injection is performed under ultrasound guidance.

Calcific bursitis (bone growth within the bursa) may occur over time. In such circumstances surgical excision of the bursa may be required.