Your shoulder bursa is a fluid filled sac that helps to reduce friction in joint spaces. Your sub-acromial bursa is the most commonly inflammed of the shoulder bursa.
Sub-acromial bursitis is a common cause of shoulder pain that is usually related to impingement of your bursa between your rotator cuff tendons and bone (acromion). Your sub-deltoid bursa is less commonly inflamed shoulder bursa.
The usual cause of inflammation of tendons and the bursa is impingement.
What are the Symptoms of Shoulder Bursitis?
- 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 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 high shelf in the cupboard.
How to Diagnose Shoulder Bursitis
Your physiotherapist is able to differentiate shoulder bursitis from a rotator cuff injury using manual tests. Shouder bursitis commonly co-exists with rotator cuff tears or tendonitis.
Ultrasound scan is often the most helpful test to diagnose sub-acromial bursitis. Sometimes MRI scan is required to confirm the diagnosis of bursitis of the shoulder.
What Causes Shoulder Bursitis?
Bursitis around the shoulder can be caused by a repeated minor trauma such as overuse of the shoulder joint and muscles or a single more significant trauma such as a fall.
In overuse type injuries, bursitis is often associated with impingement andtendonitis (inflammation) of the rotator cuff tendons.
| | Specifically, the sub-acromial bursalies 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 grossly inflammed.
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When you elevate your arm further out to the side the bursa rolls beneath the bone increasing the impingement. |
 | When you continue elevate your arm above shoulder height, the bursa rolls clears the impingement zone and yourpain eases. However, further impingement may return at the extreme of range when your arm is adjacent to your ear.
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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 you physiotherapist.
For more specific advice please consult your physiotherapist.
What is Calcific Shoulder Bursitis?
If treating shoulder bursitis is neglected, it can become quite chronic and be very difficult to treat resulting in a cycle of rotator cuff injury and impingementof the shoulder joint.
Calcific bursitis (bone growth within the bursa) may occur over time. If physiotherapy rehabilitation is unsuccessful, then surgical excision of the bursa may be required in these instances.
What is Chronic Shoulder Bursitis?
In chronic (persistent) shoulder bursitis, a corticosteroid injection, which is an injection of a drug to help reduce inflammation may be required.
Physiotherapy normally commences about one week after the injection to address the biomechanical, muscles and joint issues that have caused the bursitis.
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.
What is your Rotator Cuff?
What is Rotator Cuff Impingement Syndrome?
Impingement (impact on bone into rotator cuff tendon or bursa) should not occur during normal shoulder function. When it does happen, the rotator cuff tendon becomes inflamed and swollen, a condition called tendonitis. Likewise if the bursa becomes inflamed, bursitis will develop.
Both these conditions can co-exist or be present independently.
While a traumatic injury can occur eg fall, it is repeated movement of your arm into the impingement zone overhead that most frequently causes the rotator cuff to contact the outer end of the shoulder blade (acromion).
When this repeatedly occurs, the swollen rotator cuff is trapped and pinched under the acromion.
What is the Shoulder Impingement Zone?
Postures that significantly narrow the sub-acromial space are:- Your arm directly overhead.
- Your arm working at or near shoulder height.
Who Suffers Impingement Syndrome?
Impingement syndrome is more likely to occur in people who engage in physical activities that require repeated overhead arm movements, such as tennis, golf, swimming, weight lifting, or throwing a ball.
Occupations that requires repeated overhead lifting or work at or above shoulder height are also at risk of rotator cuff impingement.
What are the Symptoms of Rotator Cuff Impingement?
Commonly rotator cuff impingement has the following symptoms:- An arc of shoulder pain approximately when your arm is at shoulder height and/or when your arm is overhead.
- Shoulder pain that can extend from the top of the shoulder to the elbow.
- Pain when lying on the sore shoulder
- Shoulder pain at rest as your condition deteriorates
- Muscle weakness or pain when attempting to reach or lift
- Pain when putting your hand behind you back or head.
- Pain reaching for the seat-belt.
How is Shoulder Impingement Syndrome Diagnosed?
In most cases, a thorough clinical examination will identify a rotator cuff impingement. Your physiotherapist will ask about your shoulder pain and its behaviour plus examine your shoulder with some specific tests that identify impingement signs.
Diagnostic tests may include X-rays, MRI or ultrasound scans to look for tears in the rotator cuff or signs of bursitis.
Shoulder pain can commonly be caused by a problem with your neck joints. Your physiotherapist will examine this area to rule out this cause or include its treatment in your care plan.
What Causes Rotator Cuff Impingement & Bursitis?
Rotator cuff impingement and the bursitis it causes has primary (structural) and secondary (posture & movement related) causes.
Primary Rotator Cuff Impingement – Structural Narrowing
Some of us are born with a smaller sub-acromial space. Conditions such as osteoarthritis can also cause the growth of sub-acromial bony spurs, which further narrows the space.
Because of this structural narrowing, you are more likely to squash, impinge and irritate the soft tissues in the sub-acromial space, which results in bursitis or rotator cuff tendonitis.
Secondary Rotator Cuff Impingement – Dynamic Instability
Impingement can occur if you have a dynamically unstable shoulder. This means that there is a combination of excessive joint movement, ligament laxity and muscular weakness around the shoulder joint.
This impingement usually occurs over time due to repetitive overhead activity, trauma, previous injury, poor posture or inactivity.
In an unstable shoulder, the rotator cuff has to work harder, which can cause injury.
An overworking rotator cuff fatigues and eventually becomes inflamed and weakens due to pain inhibition or tendon tears.
When your rotator cuff fails to work normally, it is unable to prevent the head of the humerus (upper arm) from riding up into the sub-acromial space, causing the bursa or tendons to be squashed.
Failure to properly treat this instability causes the injury to recur. Poor technique or bad training habits such as training too hard is also a common cause of overuse injuries, such as bursitis or tendonitis.
Poor Shoulder Blade (Scapular) Stability
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
Poor shoulder blade stability results in tipping and rotation of your scapular, which causes your acromion (bone) to pinch down into the subacromial structures (eg bursa and tendons) causing impingement leading to swelling or tears.
Normal shoulder blade-shoulder movement - known as scapulo-humeral rhythm - is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury.
How to Normalise Your Scapulo-Humeral Rhythm
Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm. Any deficiencies will be an important component of your rehabilitation.
Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder.
How to Treat Shoulder Bursitis
Shoulder bursitis is one of the most common problems that we see at PhysioWorks and it is unfortunately an injury that often recurs if you return to sport or work too quickly – especially if a thorough rehabilitation program is not completed.
Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents injuries such as bursitis, impingement, subluxations and dislocations.
We also know that your rotator cuff provides subtle glides and slides of the ball joint on the socket to allow full shoulder movement. Plus, your shoulder blade (scapular) has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall.
Did you know that your arm only has one bony joint articulation where your collarbone (clavicle) attaches to the acromion (tip of shoulder blade)?
The rest of your attachments are muscular, which highlights the importance of retraining and strengthening of your shoulder muscles.
Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate these injuries and prevent recurrence – these are:
Phase 1 - Early Injury Protection: Pain Relief & Anti-inflammatory Tips
In the early phase you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some active rest from pain-provoking postures and movements.
This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder.
You may need to be wear a sling or have your shoulder taped to provide pain relief. In some cases it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.
As you improve, supportive taping will help to both support the injured soft tissue and reduce excessive swelling.
Your physiotherapist will utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this painful phase.
Phase 2: Regain Full Range of Motion
If you protect your injured rotator cuff structures appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage.
Symptoms related to shoulder bursitis may take several weeks to improve while we await Mother Nature to work her wonders. During this time it is important to create an environment that allows you to return to normal use quickly and prevent a recurrence.
It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, shoulder muscle stretches, and light active-assisted and active exercises.
Researchers have concluded that physiotherapist-assisted treatment will improve your range of motion quicker and, in the long-term, improve your functional outcome.
In most cases, you will also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement.
Signs that your have full soft tissue extensibility includes being able to move your shoulder through a full range of motion. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power.
Phase 3: Restore Scapular Control
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
Normal shoulder blade-shoulder movement - known as scapulo-humeral rhythm - is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury.
Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm.
Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an important component of your rehabilitation.
Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder blade.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
You may find it difficult to comprehend, but your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury.
Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can effect a nerve’s electrical energy supplying your muscles causing weakness and altered movement patterns.
Plus, painful spinal structures form poor posture or injury doesn’t provide your shoulder or scapular muscles with a solid pain-free base to act upon.
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your pain, improve your shoulder movement and stop pain or injury returning.
Phase 5: Restore Rotator Cuff Strength
It may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a structure is injured we need to provide nature with an opportunity to undertake promary healing before we load the structures with anti-gravity and resistance exercises.
Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles in a successful rehabilitation program. These exercises need to be progressed in both load and position to accommodate for which specific rotator cuff tendons are injured and whether or not you have a secondary condition such as bursitis.
Your physiotherapist will happily prescribe the most appropriate program for you.
Phase 6: Restore High Speed, Power, Proprioception & Agility
If your shoulder injury has been caused by sport it is usually during high speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions.
In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.
Phase 7: Return to Sport or Work
Depending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment.
Your PhysioWorks physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work.
Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor or employer.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury.
Summary
There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment.
You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.
It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration.
For more specific advice about your bursitis or rotator cuff injury, please contact your PhysioWorks physiotherapist.
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Common Treatments for Shoulder Bursitis
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