Shoulder Bursitis

There are a number of shoulder bursa located around the 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  
(5) supraacromial bursa

Inflammation of any of these shoulder bursa may cause shoulder and arm 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 and inflammation of these is known as scapulothoracic bursitis.  

When a shoulder 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.

Shoulder bursitis is typically caused by:

• Repetitive Friction: Repeated overhead movements such as racket sports, painting a ceiling, throwing and swimming can cause repeated micro-trauma to the bursa.  This is the most common cause of shoulder bursitis
  
  
• 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
  
  
• Underlying Condition: Medical conditions such as rheumatoid arthritis, gout or a bacterial infection can cause bursitis shoulder
  
  
• 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, poor posture, muscle imbalance or inflammation of other surrounding structures.  

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 shoulder impingement, supraspinatus tendonitis, biceps tendonitis and rotator cuff tears.  

1. Shoulder Pain

In most cases of shoulder bursitis, 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.

Pain from bursitis of the shoulder 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 with bursitis, making things like sleeping on your side very uncomfortable - people with shoulder bursitis often report that their sleep is frequently interrupted.

If there is inflammation of the supraspinatus tendon, known as supraspinatus tendonitis, as well as the bursa, 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.

• Regular Ice Treatment: 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
  
  
• 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
  
  
• 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.

• Steroid 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. You can see both the patient and the ultrasound view, and you can actually see the bursa inflate as the fluid is injected.
  
  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
  
  
• 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
  
  
• Bursectomy 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