Shoulder Bursitis

Shoulder bursitis is a common cause of shoulder pain. It develops when one of the bursa, a small fluid-filled sac, becomes irritated and inflamed.  There are a number of different bursa (pleural bursae) around the shoulder that may be affected, but the most common is subacromial bursitis. Pain tends to develop gradually over time and may limit movements where you lift your arm above your head or behind your neck or back.

When treated promptly and effectively, symptoms will usually resolve within a few weeks, but left untreated, symptoms gradually get worse and secondary problems can develop.  Here, we will look at the common causes, symptoms and treatment options for shoulder bursitis.

What are Bursae?

Shoulder bursa: (1) subacromial bursa and (6) subdeltoid bursa (which tend to be connected), (2) subscapular bursa, (3) subcoracoid bursa, (4) coracoclavicular bursa and (5) supraacromial bursa.

A bursa is a smooth sac that contains synovial cells that produce lubricating fluid.  There are over 150 bursa located throughout your body which sit between muscles, tendons and/or bones.  They provide cushioning and a smooth surface allowing the tissues to glide freely and fully as you move without any friction.  

There are a number of bursae located around the shoulder joint as shown in the diagram including the (1) subacromial bursa and (6) subdeltoid bursa (which tend to be connected), (2) subscapular bursa, (3) subcoracoid bursa, (4) coracoclavicular bursa and (5) supraacromial bursa. Inflammation of any of these may cause pain.  

The most common type of shoulder bursitis is subacromial bursitis which is often linked with shoulder impingement syndrome.  There are other bursa located around the shoulder blade which we will look at separately.  

Causes of Shoulder Bursitis

When the bursa gets irritated or injured, it responds by producing more synovial fluid in an attempt to protect itself and the surrounding tissues which leads to inflammation.  This may be caused by:

Repetitive overhead activities are a common cause of shoulder bursitis

1)  Repetitive Friction

Repeated overhead movements such as painting a ceiling, throwing, racquet sports and swimming can cause repeated micro-trauma to the bursa.  This is the most common cause of shoulder bursitis.

2)  Injury

A sudden injury such as a fall onto the shoulder, or landing on an outstretched hand can lead to bleeding and inflammation of the bursa.

3)  Underlying Condition

Medical conditions such as rheumatoid arthritis, gout or a bacterial infection can cause bursitis shoulder.

4)  Surrounding Structures

If the space surrounding the bursa is reduced, such as the subacromial space, more pressure is placed on the bursa and it gradually becomes inflamed.  This can happen as a result of arthritis (small lumps of bone known as osteophytes protrude into the space surrounding the bursa), poor posture (such as forward rounded shoulder position, common with people who work on computers all day), muscle imbalance or inflammation of other surrounding structures.  

Any decrease in the subacromial space places increased pressure on the bursa which can lead to subacromial bursitis.  It is often accompanied by shoulder impingement.

Whilst inflammation can develop in any of the bursae around the shoulder, the most common is subacromial bursitis. The subacromial bursa provides cushioning between the rotator cuff tendons and the acromion, the front part of the shoulder blade that forms a sort of bridge over the tendons, in what is known as the subacromial space. Anytime you move your arm up the rotator cuff tendons are gliding through this space so anything which narrows the space leads to irritation in the bursa and the tendons themselves.  

Bursitis shoulder is rarely found in isolation but tends to co-exist with other shoulder problems such as impingement or tendon tears – visit the shoulder impingement and rotator cuff tear sections to find out more.  

Shoulder Bursitis Symptoms

Shoulder bursitis often produces a muddled picture of symptoms so it can be hard to diagnose, especially in the early stages.  You should always see your doctor or physical therapist for a full assessment.  Symptoms may vary from person to person but usually include:

1)  Pain

Shoulder bursitis can cause a painful arc. This is when pain gradually increases as the arm lifts up but once it has reached a certain point further movement gets less painful

In most cases, pain develops gradually over time due to repeated friction over the bursa.  It tends to be a low level aching pain that gets worse with activities where your arm is raised over your head.  The pain is usually fairly localised over the problem area but over time, the pain may radiate down the arm, but usually not past the elbow.  If shoulder bursitis was caused by a one-off injury, the pain will more likely be instant and more severe.

It can be extremely painful when any pressure goes through the shoulder, making things like sleeping on your side very uncomfortable - people with shoulder bursitis often report that their sleep is frequently interrupted.

If associated with shoulder impingement, you may have a painful arc, where as you lift the arm up it starts to get painful, but once you have reached a certain height, the pain diminishes.  This is due to how the pressure changes through the bursa as you move the arm – you can find out more in the shoulder impingement section.

2)  Stiffness 

Shoulder movements may become limited, particularly reaching over head or behind your back/neck as the condition progresses.  This tends to develop secondary to pain - it hurts to move the arm so you use it less.  This is fine in the short term, as you need to protect the bursa from further damage, but if it continues long term, the soft tissues aren't getting moved and stretched as they should so they start to tighten which further limits movement and creates and more pain.  Physical Therapy is one of the best ways to avoid this from happening, or treat it if it has.

3)  Weakness

In time, if the pain is causing you to favour the arm, the shoulder muscles may lose some strength.  This can cause further problems as the weakness leads to subtle changes to the way the shoulder and shoulder blade move which can lead to further irritation. Strengthening exercises from a physical therapist helps to prevent and correct this.

4) Signs of Infection

Septic bursitis, where there is an infection in the bursa, usually bacterial, will result in you feeling unwell with a high temperature, and the shoulder is often red and warm.  If you suspect you have an infection, you must see your doctor immediately as the infection will need to be treated with antibiotics.

Sometimes when bursa become inflamed, particularly with elbow or knee bursitis, it gets to a point where there is noticeable swelling, like a small squashy orange, but this is uncommon in shoulder bursitis.

Shoulder Bursitis Treatment

Shoulder bursitis treatment aims to reduce pain and inflammation, prevent and correct any weakness and decreased movement at the shoulder, prevent secondary problems developing such as shoulder impingement, and get you back to your usual activities.  There are a number of different shoulder bursitis treatment options:

1)  Rest 

It is important to avoid activities which aggravate your shoulder bursitis, such as overhead movements to give the bursa a chance to heal.  If you keep pushing on into the pain, the friction over the bursa continues and the inflammation doesn’t get a chance to settle down and will gradually get worse.

Applying ice can help to reduce shoulder bursitis pain and inflammation.  You can either use a simple ice pack or a specially designed shoulder strap if you want to be able to move around

2)  Ice

Applying ice (wrapped in a towel), or a specially designed shoulder ice pack regularly to the shoulder can help to reduce pain and inflammation in the bursa. It should be used for 10-15 minutes at a time, with at least two hours between applications.  

You can find out more about safe and effective ice treatment on our sister site.

3)  NSAID’s

Your doctor may prescribe non-steroidal anti-inflammatory medication such as ibuprofen or Advil to help to reduce the pain and the swelling .

4)  Aspiration

In some cases, your doctor may decide to drain fluid off the bursa to help reduce the swelling, especially if they are worried about infection.  They will send the fluid off for testing to see if there is an infection which would require antibiotics.  Aspiration is usually combined with a corticosteroid injection.

CC BY 2.0, via Wikimedia Commons

5)  Injections

Injections are one of the best ways to treat shoulder bursitis. A mix of local anaesthetic and corticosteroid solution are injected into the bursa to reduce pain and inflammation.

Ideally the injection should be done under ultrasound guidance to ensure delivery to the correct area as shown in the video here.  At the end of the video you can see the ultrasound image of the solution entering the bursa during the injection.  It is important to take it easy for the first few days following an injection and avoid heavy lifting.  You can find out more about injections on our sister site.

6)  Physical Therapy

This is a vital part of shoulder bursitis treatment, both to treat the condition and to prevent it from recurring.  A physical therapist will work on rehab programme with you to address any areas of weakness, stiffness, instability and tightness as well as any postural problems to ensure you regain full movement and strength in the arm, and good stability around the shoulder blade all of which help to prevent the problem from recurring.  Visit the rotator cuff exercises section for suitable exercises.  Some therapists may use ultrasound to help reduce inflammation and facilitate healing but the evidence is mixed.

7)  Surgery

It is very rare that shoulder bursitis requires surgery but if all other treatment options fail, the bursa can be surgically removed through keyhole surgery.

Recovery & Prevention

People usually make a full recovery from shoulder bursitis but it may take a few weeks or months depending on the severity and any associated conditions. Strengthening exercises, shoulder stability exercises focusing on the shoulder blade, and postural re-education are some of the best ways to reduce the friction going through the bursa thus preventing the condition from recurring. Visit the rotator cuff exercises section to find out more.  

Shoulder bursitis is often accompanied by other problems such as rotator cuff tears and shoulder impingement syndrome.  You can find out more about each of this by using the links.

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