Are you waking up with a sore, aching shoulder? Do you dread the thought of getting ready for the day because it means you have to lift your arm? From washing your hair to getting dressed or driving to work, lifting your arm means that your shoulder must be able to move in any and all directions. That is why shoulder bursitis is such a pain – it affects almost every aspect of your life.

A bursa is a small pocket of synovial fluid that protects tendons in your body from friction. All of your muscles are anchored to your skeleton via tendons and where there’s a tendon, you will usually find a bursa close by.

Shoulder bursitis, or subacromial bursitis, happens when the bursa at the top of your shoulder joint becomes swollen and inflamed. If something goes wrong and a bursa is injured you will quickly realise how important this small structure is when it comes to getting things done without pain.

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Let’s talk about a bursa

As a small pocket of fluid, the bursa helps with shock absorption and protects your tendons from friction. When you move, tendons glide because the muscles they are attached to lengthen and shorten. A bursa’s job is to reduce the friction caused by this gliding movement.

This is why you will find a bursa wherever a tendon attaches to bone and there are lots of different tendons around your shoulder joint. These pockets of fluid are very sensitive to changes in pressure, so any swelling or extra compression in your shoulder will cause severe pain.

There are 6 major bursae around your shoulder joint.

  • Subscapular bursa at the front of your shoulder.
  • Subdeltoid bursa on the outer part of your shoulder.
  • Subacromial bursa underneath the bone at the top of your shoulder (acromion).
  • Subcoracoid bursa also at the front part of your shoulder.
  • Infraspinatus bursa at the back or your shoulder joint.
  • Subcutaneous acromial bursa also at the top of your shoulder, but between the acromion and your skin.

The subdeltoid bursa and subacromial bursa are the usual suspects when you have shoulder bursitis.

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But what is shoulder bursitis?

Bursitis happens when the membrane, or outer layer, of the bursa becomes irritated and inflamed. Inflammation is our body’s normal response to an injury to start the healing process. Part of this inflammatory response is an increased number of synovial cells in the bursa. These cells produce synovial fluid inside the bursa to create the cushioning effect that allows tendons to glide smoothly. Under normal circumstances there are only enough cells to maintain the perfect pressure for your shoulder bursa to function.

However, an increase in synovial cells means that more fluid is formed. More fluid means more pressure, like an overfilled balloon, and this is where the characteristic swelling of a bursitis comes from. Although it may not seem like it, inflammation is actually helpful because it is the first step towards healing. Unfortunately, the resulting swelling is what makes it so painful to move your arm. But why is does movement make the pain so much worse?

When the muscles at the top of your shoulder contract to lift your arm, the tension on the tendons will increase. This extra pressure is just too much for your already inflamed and swollen bursa. You will immediately regret the movement and drop your arm to stop whatever you were trying to do. This happens every time you use the muscles that move your arm, so the bursa doesn’t have time to heal. Now you’re stuck in a vicious cycle of inflammation, swelling and pain.

I think I have shoulder bursitis – what could have caused it?

  • Trauma like falling on your shoulder will overstretch or compress the bursa, triggering the inflammatory process.
  • A flare-up of systemic conditions like arthritis or gout can result in widespread inflammation in your body, including the bursa in your shoulder.
  • Overuse or overload happens after doing something above shoulder height that you aren’t used to. The repetitive friction over the bursa is what causes subacromial bursitis. This usually happens with activities like hanging curtains, painting a ceiling, washing your car or hanging portraits. 
  • Chronic irritation or compression also happens due to overload, but over a longer period of time. In this case there might be less pressure on your bursa or you stop what you’re doing when your shoulder gets sore. The bursitis happens because your repeat the activity before your shoulder bursa has time to recover. Examples would be sleeping with your arm under your pillow, sewing, knitting, weight lifting or working on your laptop without support under your wrists.
  • Shoulder impingement is a narrowing of the space at the top of your shoulder. Your shoulder bursa is also found in this space, so any narrowing will increase pressure and might lead to shoulder bursitis.
  • Shoulder muscle injuries, like rotator cuff tendinopathy, supraspinatus tendinitis or rotator cuff strain, go hand in hand with shoulder impingement and therefore shoulder bursitis. These muscles should keep the subacromial space (at the top of your shoulder) open by controlling the small movements inside your shoulder joint. If the muscles are weak or injured, the space narrows leading to impingement and subacromial bursitis.
  • Excessive movement due to muscle weakness or shoulder instability means more friction that can result in shoulder bursitis.
  • Septic bursitis is caused by a bacterial infection of your shoulder bursa that triggers inflammation and swelling.
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Symptoms of subacromial bursitis

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Self-test for shoulder bursitis

  • Lift your arm out to the side, in the direction of your ear.
  • If you have pain when your arm reaches shoulder height you may have shoulder bursitis.
  • Lift your arm to the front to the height of your shoulder, with your palm facing up.
  • Try to push the painful arm down using your other hand while the affected arm pushes up to stop the movement.
  • If your shoulder hurts with this test you may have subacromial bursitis.
  • Lift your arms to form a wide “V” shape with your thumbs pointing down.
  • Ask someone to press your wrists down towards the floor while you try to keep your arms up.
  • If this test is painful you may have shoulder bursitis.
  • Turn your arm all the way in i.e. your thumb points to the floor.
  • Now lift your arm up towards the roof.
  • If this movement is painful your symptoms may be caused by a swollen shoulder bursa.

How bad is my subacromial bursitis?

In the early stages of shoulder bursitis your main symptom will be shoulder stiffness and a vague discomfort that comes and goes. Your soreness is more noticeable after overhead activities like washing your hair or putting away plates on shelves. The ache disappears in less than 30 minutes and you can still carry on with all your daily activities.

As your subacromial bursitis gets worse you will have definite twinge every time you lift your arm to shoulder height. Carrying a laptop bag on your shoulder will be painful and you will avoid activities where you have to keep your arm lifted for more than a few seconds. At night your sore shoulder will wake you if you turn onto it. When you reach this stage of shoulder bursitis, resting will still help to relieve your pain, but now it might take hours or a day to settle. By now you’ll start noticing that more shoulder movements and different positions are painful like tucking in your shirt behind your back or brushing your teeth. This happens because other structures like your rotator cuff muscles are starting to take a lot of strain due to the swollen and inflamed bursa.

With shoulder bursitis at its worst you will have constant pain around your whole shoulder. Even light pressure on your shoulder or lifting something like a plate of food will cause severe pain. Simple, everyday things like getting dressed or putting on a mask will feel like impossible tasks. You will struggle to find a comfortable sleeping position at night and if you turn onto the painful side you will wake up immediately with severe pain that can take hours to subside.

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Diagnosing shoulder bursitis

Our physiotherapists are experts in human anatomy and movement with the necessary experience to diagnose shoulder bursitis. We understand the intricacy of your shoulder and how every muscle, tendon and bursa should work together for you to move without pain. We also look at all other aspects that could be contributing to your shoulder pain. Getting the necessary information from you, together with a clinical assessment is the starting point.

During your physiotherapy evaluation, we will stretch and stress different structures around your shoulder to identify any stiffness or underlying injury. We also test muscle strength and length and the range of movement of your shoulder. Another important aspect is your posture and the way your neck and upper back moves when you move. This is how our physiotherapists get to the actual cause of the problem. We don’t just treat your symptoms for temporary relief, we fix the root problem.

X-rays

An x-ray of your shoulder will only show the bones that form your shoulder joint, so it will not be necessary to diagnose subacromial bursitis. However, it can show fractures, frozen shoulder or signs of arthritis of your shoulder. If your physiotherapist feels that it is necessary for you to get x-rays, you will be referred to the right place.

Diagnostic ultrasound

If necessary, diagnostic ultrasound will be the first choice to confirm a diagnosis of shoulder bursitis. Many of the soft tissue structures around your shoulder joint are quite superficial, so diagnostic ultrasound will look for signs of increased fluid (swelling) in the bursa. A follow-up ultrasound after your course of treatment can determine if the swelling has gone down.

In most cases there is no need for further imaging like diagnostic ultrasound, because your physiotherapist can get enough information from specific tests when assessing your shoulder.

MRI

An MRI is a very expensive type of scan and you can only get one via a referral from an orthopaedic surgeon. Although an MRI will show soft tissue structures, it is usually not necessary to get one if you have shoulder bursitis. However, the deeper structures of your shoulder joint will be visible on an MRI, so you will be referred to the right specialist if your physiotherapist feels that it is necessary for you to get an MRI.

Why is my subacromial bursitis not going away?

Subacromial- or shoulder bursitis is a vicious cycle. In the beginning you will only have pain after too much activity like repeated lifting or by carrying heavy objects. The pain goes away with rest and medication, so you tend to avoid using the arm for a couple of days and then forget about the problem. However, ignoring the problem doesn’t solve anything. The underlying muscle weakness and movement patterns that caused the extra pressure on your shoulder bursa will still be there. To make matters worse, the muscles will become even weaker, because your body will compensate by using different “stronger” muscles to avoid the pain. Whenever you use your arm in a lifted position the shoulder bursitis will flare up again resulting in resting, more compensation and weaker muscles.

Does this sound familiar? Rather call us for an assessment and treatment to break the cycle of your shoulder bursa pain.

What NOT to do

  • Anti-inflammatory medications are not recommended, especially in the first 48 hours as they are thought to delay healing

  • Apply heat and avoid hot baths

  • Leave it untreated, if you are uncertain of the diagnosis, rather call us and be safe

  • Force shoulder movements through pain

  • Use a sling for more than a day or two

What you should do

  • Avoid staying in painful positions

  • Make an appointment to confirm the diagnosis and determine the severity of your problem

  • Apply an ice pack to help with pain relief

  • Take a break if your shoulder gets tired

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Making the injury worse

  • Working at your computer for hours at a time

  • Push ups

  • Hanging washing

  • Washing your car

  • Repetitive throwing

  • Blow-drying your hair

  • Weight-training

  • Carrying heavy objects

A big problem we see with shoulder bursitis

  • A big problem we see with shoulder bursa pain is unnecessary imaging resulting in immediate surgery. In some cases an X-ray will show a bony growth called a Type II acromion at the top of the shoulder. This usually leads to the assumption that the bony growth is the cause of the subacromial bursitis. What will be the first recommendation with a type II acromion? Surgery. However, removing this bony growth usually doesn’t solve the problem. The underlying muscle weakness and “bad habits” that caused the bursitis will still be there.
  • Another problem we see is that people take medication until the pain settles without realising that there is an underlying problem. Every time the shoulder bursa pain flares up the muscle weakness and movement dysfunction gets worse. The result is that after every episode it takes even less activity for the pain to come back again and you will need more rest, more medication and more time to get back the full use of your arm.
  • Stopping treatment too soon is probably the most common problem we see with subacromial bursitis. At the start of treatment there can be severe pain and shoulder movements can be very limited. Then, during the course of rehabilitation, pain is replaced by stiffness and only extreme movements cause discomfort. At this stage your shoulder muscles can handle everyday activities, but as soon as you add extra load or activities which you aren’t used too, the pain comes back again. The later stages of treatment are crucial to restore muscle endurance and capacity to get rid of your shoulder bursa pain for good.
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Physiotherapy treatment for shoulder bursitis

Our physiotherapists see shoulder conditions on a daily basis, so call us for effective treatment of your shoulder bursa pain. Physiotherapy treatment aims to manage the swelling and inflammation with electrotherapy and therapeutic exercise and treat associated muscle spasm using myofascial release and dry needling. As your pain improves we will focus on restoring your range of movement using exercises and joint mobilization. Throughout the course of treatment we will add exercises to strengthen the muscles around your bursa. These strengthening exercises will be chosen specifically to improve your shoulder’s capacity to handle load. This means that we don’t just treat the swollen and inflamed bursa – we also treat the cause of your subacromial bursitis.

Phases of rehabilitation

1st Phase: Protection and initial healing

Protect

The first phase of treatment will involve decreasing tension and pressure on your painful shoulder bursa. One of the techniques we use is strapping and we will also teach which activities and positions to avoid during this stage of treatment.

Avoid anti-inflammatory medication

Avoid using anti-inflammatory medication continuously, it delays healing by delaying inflammation. If you have severe pain, try to rather use medication for pain without an anti-inflammatory component. That way your pain will be under control, you’ll be able to get enough sleep and won’t have pain that constantly bothers you. Once the pain is under control, you can decrease the use of your medication and eventually stop taking it completely.

Information

Make sure that you get information from the person treating you. It’s important to understand what you should and shouldn’t do. You can make better decisions if you are informed. Your body knows best, so avoid too many types of treatments at once.

Load

Let pain guide you to gradually return to your normal activities. Initially, it is tricky to know if it is better to rest or to move, but finding a balance between the two is the best you can do. Your physiotherapist will guide you on when to decrease or increase the load.

Phase 2: Below 30 degrees of movement (week 1)

During this phase of treatment we will focus on getting your rotator cuff muscles to activate. Your rotator cuff is both a mobilizer and stabilizer, so the muscles are responsible for movements like lifting or turning your arm and, when working together, play a major role in shoulder stability. Subacromial bursitis leads to pressure and friction on your rotator cuff tendons as they pass through the top of your shoulder. This increased pressure and chafing causes pain which ultimately inhibits these muscles. In other words the stabilizing muscles around your shoulder stop working. Activating and retraining your rotator cuff muscles forms the foundation for all movements and rehabilitation of your shoulder bursitis.

At the end of this phase you should be able to lift your arm 30 degrees to the front and side. You should also be able to lift light objects like a cup of coffee and work at your keyboard.

Phase 3: From 30 to 60 degrees of movement (week 2)

The next phase of treatment will start as soon as your shoulder can lift about 30 degrees to the front and sides. Initially your exercises will involve small movements in more supported positions like lying on your back or sides. We will use active-assisted exercises using a stick or ball to retrain shoulder movements. Our hands-on treatment during this phase will include modalities like therapeutic massage and dry needling to treat muscle spasm that can limit movement of your shoulder. Joint mobilisation and electrotherapy like laser and ultrasound may be used to improve the pain free active movement around your shoulder.

During this phase we will also add resistance exercises. Mobility (movement) must always be coupled with stability and control. Otherwise the range of movement we gain during each session will just be lost again due to muscle spasm and joint stiffness. This happens because your shoulder will improvise to give you stability if your muscles can’t control the new increased mobility.

At the end of this phase you should be able to lift your arm to 60 degrees to eat, brush your teeth or wash your other arm.

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Phase 4: From 60 to 90 degrees range of movement (week 3-4)

During this phase of rehabilitation we will teach you how to identify and move the different parts of your shoulder separately. By the time someone develops shoulder bursitis, the lines between the different joints around their shoulder has usually “blurred” quite a bit. You will probably have noticed that your shoulder blade, arm and even the side of your neck moves as a unit when you try to lift your arm. That’s why shoulder pain is often associated with a sore neck.

By the end of this phase you should be able to lift your arm to shoulder height to reach for a parking ticket, wash and brush your hair and hold your cellphone to your ear.

Phase 5: From 90 to 120 degrees of movement (weeks 5-6)

Retrain and improve upper back extension. The upper back is closely linked to shoulder mobility. Have you ever tried to lift your shoulder while sitting in a slouched position? If your upper back is hunched over, the your shoulder blade will block your shoulder before you can lift your arm all the way up. Your shoulder blade should literally get out of the way, otherwise you can’t lift your arm above shoulder height.

In this phase of rehabilitation we will continue to use therapeutic massage, joint mobilisation and exercises to improve the movement in your upper back. Strapping is also a useful tool during this phase, to remind you of the correct position of your shoulder blade and upper back.

At the end of this phase you should be able to blow dry your hair, put away plates on high shelves and

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Phase 6: From 120 degrees to full range of movement (weeks 6-8)

If you’ve been doing your home exercises and following the protocol, you should be able to lift your arm above shoulder height with ease by now. Even though most of your movement is restored, you arm will still get tired quickly and feel heavy in a raised position more than a few minutes. Especially with activities like hanging clothes on a washing line, painting or changing a lightbulb.

That’s what we’ll be working on during this phase – stability and endurance of your shoulder girdle. Your shoulder blade (scapula) is where most of your shoulder muscles originate. This means that it’s basically an anchor or stable base of support when your arm moves. Even though your arm won’t float away like a ship without an anchor, the muscles over and around your shoulder won’t have any strength or control without it.

During this phase of rehabilitation we will focus on strengthening all the muscles around your shoulder and upper back that stabilize and control your scapula. Your exercises will also focus on further strengthening of your rotator cuff and all the other muscles that move your arm.

By the end of this phase you should be able to put on any shirt or jacket, lift a kettle (or jerry can) full of water and put heavy shopping bags into the boot of your car.

Phase 7: From full range of motion to clearance

When you reach this phase of rehabilitation you should have full range of movement, be able to get dressed comfortably and sleep on your shoulder without pain or discomfort. Your shoulder muscles should be strong enough to pick up and carry your grocery bags. Reaching up to open curtains, hang clothes in your cupboard or get a cup from a high shelf should be effortless.

At this point we will do stress tests to confirm that your shoulder bursa can handle pressure and tension. We will also do strength tests of the individual rotator cuff muscles and impingement tests to determine if the tendons can glide underneath the subacromial bursa without friction, fatigue or pain.

How long will my shoulder bursitis take to heal?

Physiotherapy for shoulder bursitis usually follows an eight week treatment protocol. Initially, pain and limited movement of your shoulder will be the biggest problems, so you will see your physiotherapist twice in the first week. As your shoulder bursa heals, you will notice that stiffness is mostly the limiting factor with some pain at times. By then you will have an appointment once a week where you will also get home exercises to do in between sessions.

As you progress through rehabilitation pain will go away and you will only have stiffness or discomfort in certain positions. Movements like lifting your arm all the way up or putting your hand behind your back will make you remember that your shoulder bursa isn’t completely healed yet. During this phase of treatment your last sessions will be spaced further apart with 2-3 weeks between appointments. This gives your shoulder time to adapt to the more difficult exercises and you can test which everyday activities you still struggle with. It is also the perfect time to test the self-management strategies you’ve learnt from your physiotherapist.

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Other medical treatments

Orthopaedic surgeon

If the swelling of your shoulder bursa doesn’t improve with conservative techniques, an orthopaedic surgeon can inject cortisone into the bursa.

Sling

Using a sling for a couple of days can help with pain relief by removing some of the tension on the swollen bursa. However, using a sling for too long will cause further weakness of your shoulder muscles.

General practitioner

A GP can prescribe medication to help with pain relief.

Biokineticist

A biokineticist can help with further strengthening and return to sport once your mobility and movement patterns are restored. This is especially true if you also have other conditions like cervical spondylosis, scoliosis or general muscle weakness and balance problems with your shoulder bursitis. Our bodies take time to adapt and get stronger, so your physiotherapist may refer you to a biokineticist for long-term management after you have completed physiotherapy treatment.

Surgery

Acromioplasty and debridement

If 3 months of non-surgical treatment for your shoulder bursa pain is unsuccessful, you may be a candidate for an acromioplasty and debridement. During this procedure the surgeon removes a piece of bone at the top of your shoulder (the acromion) and also removes the thickened bursa. The goal of this surgery is to remove pressure from the tendons running underneath the shoulder bursa.

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What else could it be?

  • Rotator cuff injury – the most painful area will be the outside part of your upper arm instead of the top, bony part of your shoulder. However, subacromial bursitis can often lead to a rotator cuff injury, so it’s possible to have both conditions at the same time.
  • Shoulder joint pain – if your pain feels deep or more towards your armpit, it could be a joint injury rather than bursitis.
  • SLAP lesion – pain feels like it’s inside your shoulder joint and you may also have a painful click with shoulder movements.
  • Frozen shoulder – shoulder movements are very limited, especially rotation movements like putting your hand behind your back or neck.
  • Biceps tendinopathy – you will be able to pinpoint the painful area on the front part of your shoulder.
  • Shoulder arthritis – a deep pain, usually at the back of the shoulder that develops over time (gradual onset).
  • Referred pain from your neck or upper back – pain is described as a vague, dull ache that doesn’t get worse with shoulder movements.

Also known as

  • Subacromial bursitis
  • Subdeltoid bursitis
  • Subacromial impingement
  • Shoulder bursa pain
  • Rotator cuff impingement
  • Inflammation of shoulder bursa
  • Shoulder inflammation
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