What is Shoulder Bursitis?
Shoulder bursitis is an inflamed shoulder bursa. Your bursa is a synovial fluid-filled sac that helps to reduce tendon-bone and tendon-tendon friction in your shoulder spaces. You have several bursae within your shoulder. Your subacromial bursa is the most commonly inflamed of the shoulder bursa.
There are five main bursae around the shoulder. They include:
- subacromial-subdeltoid (SASD) bursa
- subscapular recess
- subcoracoid bursa
- coracoclavicular bursa
- supra-acromial bursa
Subacromial bursitis is a common cause of shoulder pain that is usually related to shoulder impingement of your bursa between your rotator cuff tendons and bone (acromion). Your subdeltoid bursa is a less commonly inflamed shoulder bursa.
Shoulder Bursitis Symptoms
Shoulder bursitis commonly presents with the following symptoms:
- Pain on the outside of your shoulder.
- Pain may spread down your arm towards the elbow or wrist.
- The pain made worse when lying on your affected shoulder.
- The 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 to Diagnose Shoulder Bursitis
An ultrasound scan is often the most helpful investigation to confirm subacromial bursitis. MRI scan may also be useful.
What Causes Shoulder Bursitis?
Repeated minor trauma such as overuse of the shoulder joint and muscles or a single more significant injury such as a fall, commonly causes shoulder bursitis.
When your arm is at your side, the subacromial bursa protrudes laterally. It does not invade unless it is grossly 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 the impingement zone, and your pain eases. However, further impingement may return at the extreme of the range 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.
For more specific advice, please consult your physiotherapist.
What is Calcific Shoulder Bursitis?
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.
About one-week post-injection, physiotherapy normally recommences. Address the biomechanical, muscles and joint issues that have caused bursitis.
There are some advantages and disadvantages to corticosteroid injection. Please discuss the pros and cons with your doctor. Diabetes and other general health issues can limit its safe use. The best results occur when the needle is ultrasound-guided.
Shoulder Bursitis Treatment
Shoulder bursitis is one of the most common problems that we see as physiotherapists, and it is, unfortunately, an injury that often recurs if you return to sport or work too quickly – especially if a thorough an incomplete rehabilitation program.
Your rotator cuff is an essential 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 centralisation prevents injuries such as bursitis, impingement, subluxations and dislocations.
We also know that your rotator cuff provides subtle glides and slides off the ball joint on the socket to allow full shoulder movement. Plus, your shoulder blade (scapula) 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 the shoulder blade)? The rest of your attachments are muscular, which highlights the importance of retraining and strengthening of your shoulder muscles.
Shoulder Bursitis Exercises
In the early phase, you’ll most likely be unable to lift your arm or sleep comfortably fully. Pain relief is usually a very high priority for patients who are suffering from acute shoulder bursitis.
Researchers have concluded that there are mostly seven stages that need to be covered to effectively relieve your bursitis pain in the short-term and then prevent your bursitis from returning in the future. These are:
Phase 1 – Early Injury Protection: Pain Relief & Anti-inflammatory Tips
Your first aim is to avoid activities and positions that squeeze or irritate your bursa. Your physiotherapist will provide you with some active rest suggestions to help you prevent pain-provoking postures and movements. In most cases, this means that you should stop doing the action or activity that provoked the shoulder pain in the first place and avoid doing anything that causes suffering within your shoulder.
You may need to wear a sling or have your shoulder “sling” taping 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, natural and effective modality to reduce your pain and swelling. Apply ice for 20 to 30 minutes each 2 to 4 hours during the initial phase. Or, apply when you notice that your shoulder is warm or hot.
Anti-inflammatory medications (if tolerated) and natural substances, e.g. arnica, may help reduce your pain and swelling. However, due to the bursa being a self-contained entity with minimal blood flow, there is a theory that NSAIDs are less effective than in other inflammatory conditions.
Most patients can tolerate paracetamol as pain-reducing medication. Please check with your doctor or pharmacist.
What about Cortisone Injections?
Corticosteroid injections combined with a local anaesthetic (Hydrocortisone + Local anaesthetic = HCLA) may relieve pain and promote healing. The best results occur with the injection performed under ultrasound guidance. The local anaesthetic can provide short-term pain relief. Over the next week or so, the cortisone starts to improve your medium-term pain.
Researchers generally find that there is excellent short-term pain relief from HCLA injection corticosteroids, but there are some potential long-term side effects, which may be less desirable. Unfortunately, as with most drugs, there are side effects and corticosteroids should be cautiously, especially with diabetics. Whether you are a suitable candidate for a corticosteroid injection should be discussed with your doctor. Diabetes and other general health issues can limit its safe use.
Some patients report good initial relief before a recurrence of symptoms. This reaggravation is due to a resumption of your poor movement patterns/weakness that caused bursitis in the first instance. In these cases, the long-term solution is to have your shoulder and movement patterns thoroughly assessed by your physiotherapist to commence some corrective rehabilitation.
Phase 2: Regain Full Range of Motion
If you protect your injured rotator cuff structures appropriately, the injured tissues will heal. Inflamed structures, e.g. (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 essential to create an environment that allows you to return to regular use quickly and prevent a recurrence.
Your physiotherapist will utilise a range of pain-relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this painful range-restricted phase. The good news is that researchers have concluded that physiotherapist-assisted treatment will improve your range of motion quicker and, in the long-term, improve your functional outcome.
In some cases, you may also have developed short or long-term protective tightness of your shoulder joint capsule (usually posterior) and some compensatory muscles. These structures need stretching to allow normal movement. Your physiotherapist can assess your limitations and prescribe the appropriate treatment.
Signs that you 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), e.g. your physiotherapist. As you improve, you will be able to do this under your muscle power.
Phase 3: Restore Scapular Control
Your shoulder blade (scapula) is the base of your shoulder and arm movements.
Normal shoulder blade-shoulder movement – known as scapulohumeral 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 scapulohumeral rhythm.
Researchers have identified poor scapulohumeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an essential component of your rehabilitation.
Plus, they have identified scapular stabilisation exercises as a critical ingredient for successful rehabilitation.
Your physiotherapist will be able to guide you through the appropriate exercises for your shoulder blade.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will ease your pain, improve your shoulder movement and stop pain or injury returning.
Your neck and upper back (thoracic spine) are significant in the rehabilitation of shoulder pain and injury. Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can affect a nerve’s electrical energy supplying your muscles, causing weakness and altered movement patterns. Painful spinal structures, caused by poor posture or injury, don’t provide your shoulder or scapular muscles with the required solid pain-free base.
For specific advice, whether your neck or upper back is related to your shoulder pain, please consult your physiotherapist for individualised assessment and treatment as required.
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 primary healing before we load the architectures with anti-gravity and resistance exercises.
Researchers have discovered the importance of strengthening the rotator cuff muscles in a successful rehabilitation program. These exercises need progression in both load and position to accommodate for any damaged rotator cuff tendons 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 sport has caused your shoulder injury, it is usually during high-speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions.
To prevent a recurrence as you return to sport, your physiotherapist will guide you through exercises to address these essential components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a customised speed, agility, proprioception and power program will prepare 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 thorough rehabilitation program has minimised your chance of future injury.
There is no specific time frame for when to progress from each stage to the next. Many factors will determine your injury rehabilitation status 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 crucial to carefully monitor your progression since 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.
Common Shoulder Pain & Injury Conditions
- Rotator Cuff Syndrome
- Shoulder Tendinopathy
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Tear
- Bicep Tendinopathy
- Shoulder Impingement
- Swimmer's Shoulder
- Shoulder Dislocation (Instability)
- Subacromial Decompression
- Shoulder Arthroscopy
- Rotator Cuff Repair
- SLAP Repair
- Biceps Tenodesis
- Biceps Tenotomy
- Total Shoulder Replacement
Researchers have discovered that managing your shoulder injury with physiotherapy is usually successful. Typically, you have two options: non-operative or a surgical approach. Your condition will dictate which option is best for you at this time. Non-operative care is conservative rehabilitation.
If shoulder surgery is required, then your physiotherapist may undertake:
- Pre-operative rehabilitation - to either try a non-operative treatment approach or to condition and prepare your body for a surgical procedure.
- Post-operative physiotherapy - to safely and methodically regain your normal range of movement, strength, speed and function.
PhysioWorks physiotherapists have a special interest and an excellent working relationship with leading shoulder surgeons. Our physiotherapy team provide you with both conservative and post-operative shoulder rehabilitation options. We aim for you attaining the best possible outcome for your shoulder injury.