Background and Etiology
A bursa is a fluid filled sac that decreases friction between two tissues. The subacromial bursa is located between the rotator cuff muscles and the acromion in the shoulder. The bursa, in addition to decreasing friction, protects the rotator cuff from injury when moving under the acromion. The bursa can become inflamed causing a shoulder bursitis.
Bursitis of the shoulder is very common due to the anatomy of the shoulder and the amount of activity and stress placed on this joint. Most of the bursitis at the shoulder occurs at the subacromial space.
The subacromial space is an area on the top of the shoulder that is formed by the arch created by the acromio-clavicular joint, coraco-acromial ligament, and acromion (outer edge of the scapula, or shoulder blade). This is called the coracoacromial arch. The bursa and primary tendons of the shoulder including the rotator cuff tendons, and the long head of the biceps tendon pass under this arch. Anything that compromises this space places the bursa and these tendons at high risk for friction, rubbing and irritation. This sets the stage for bursitis to occur. Shoulder bursitis is most common between the ages of 40-60 years old, but also occurs in younger people with overuse sport injuries.
Bursitis is often the result of repetitive injury to the bursa or surrounding tendons, especially the supraspinatous tendon. Bursitis can be the result of a shoulder impingement problem or bony spur. Other causes of bursitis include:
- Participating in activities like swimming or other activities requiring repetitive overhead motions like tennis, softball, baseball, overhead throwing activities and other sport activities that may aggravate the shoulder.
- Repetitive strain injuries (RSI) are overuse activities at work, common in people who have jobs that require performing activities of a repetitive nature like working on an assembly line.
- Sudden trauma or an accident like falling on the shoulder
- Patients with rheumatoid arthritis, gout, calcific bodies, or infection
- Postural factors like a forward head and shoulder posture that reduce the subacromial space and cause irritation of the shoulder tendons and bursa.
- Overload injuries like lifting heavy objects or weight training can cause strain and irritation
- Weakness of the rotator cuff that causes a muscular imbalance that results in shoulder impingement (or pinching) of the tendons against the corocoacromial arch. This can eventually result in a bursitis.
- Pain or burning sensation in the front of the shoulder during active or passive motion of the shoulder.
- Moderate to severe loss of shoulder motion
- Painful arc of motion between 80-120 degrees of motion
- Pain with overhead activities or when sleeping on the effected side
- Difficulty dressing and performing daily activities
- Weakness, especially as the inflammation and pain get worse
- A feeling of tightness or loss of motion due to discomfort
- Localized swelling or redness of the shoulder
- Pain and difficulty sleeping at night
If one suspects they have bursitis, initial treatment should consist of first avoiding the positions and activities that produce the pain. A course of conservative treatment, including rest, ice, physical therapy, and nonsteroidal medications to reduce inflammation is recommended. If persistent, treatment by a physician may include steroidal medication or injections, in conjunction with therapy. In more severe cases surgical intervention may be indicated to correct any mechanical causes.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Common Physical Therapy interventions in the treatment of Shoulder Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage and joint mobilization by a physical therapist to regain mobility and range of motion of the shoulder and tendon. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen rotator cuff muscles that may cause impingement and subsequent bursitis. Stretching and active exercises also help prevent the onset of adhesive capsulitis, a common complication of bursitis.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity, and improve movement techniques and mechanics (for example, throwing) of the involved upper extremity in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation at the shoulder, bursa and involved tendon.
- Home programs including strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
These are procedures that your physician may recommend and perform in addition to physical therapy.
- REST and ICE
- The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
- Steroidal injections to reduce inflammation
- Pain medication to reduce discomfort and allow the patient to perform recommended exercises
- Surgery to correct underlying pathology or the cause of the bursitis when impingement is significant or instability produces shoulder bursitis and tendonitis.
Most people recover full function following a course of conservative care that includes physical therapy, medication and/or injections. Those with more involved conditions, like impingement with bone spurs, do well with surgical decompression of the area. Outcomes where there is a torn tendon depend on the size of the tear, integrity of the tissue, age and preoperative condition of the patient. For more information, please refer to the Rotator Cuff Tear section.