Shoulder Impingement & Bursitis

Also known as:

• Subacromial bursitis

• Subdeltoid bursitis

What is subacromial bursitis?

Shoulder bursitis is inflammation of a small fluid filled sac in our shoulder called the subacromial bursa. Everyone has bursae in their shoulders and their job is to reduce friction between different structures – such as the rotator cuff muscles and tendons, bones and ligaments. 

What causes subacromial bursitis?

Shoulder bursitis is most often brought on by a sudden increase in exercise or demands on the shoulder, especially the rotator cuff muscles and muscles of the shoulder blade. This can be from everyday activities such as gardening, housework or activities such as overhead sports or weight lifting. It is very important to note that none of these activities are inherently bad, or will cause bursitis, it is the sudden increase in the amount of an activity being performed compared to recent months. For example, if someone lifts weights consistently for work or leisure, then working above head for prolonged periods would likely cause no discomfort, whereas for someone who hadn’t done this type of activity in a while it may cause subacromial bursitis.

Shoulder Bursitis Physiotherapy

The first and most important aspect of physiotherapy is that we listen to your story, how this has impacted your life, your concerns and your goals. Once we have established this, we can then work on finding the cause and providing a solution and helping the affected area.

To start your treatment, a physiotherapist will perform a thorough assessment of your upper back, shoulder blade, and rotator cuff muscles. They will then be able to give you clarity on what may be causing your shoulder pain by taking a detailed assessment of the history of your pain and the presenting painful limitations. We will also ask you questions about other aspects of your life that research has shown to play a large role in the pain experience such as diet, lifestyle, and sleep. Being able to understand how these lifestyle factors affect your symptoms of bursitis may help us to provide a solution to your pain, which will ensure the shoulder bursitis treatment we do and shoulder bursitis exercises we prescribe are even more effective.

We will then focus on getting you out of pain as fast as possible through different physical therapy techniques according to your individual case. Often we will start with hands-on manual therapy to settle things down, before progressing to self-release techniques that empower you to be in control of your pain and your life.

Throughout the pain relief process we will focus on helping you to regain the full range of motion and strength in your shoulder, shoulder blade and upper back through various simple exercises that we will plan out together and work into your daily routine. We firmly believe that simple is best and we will adjust our approach accordingly to fit our management plan into your schedule. The exercises will be the main part of your shoulder bursitis treatment.

The next stage of our rehab together is to gradually load you back into the type of exercise that you would like to return to doing pain free. Our bodies are designed to be very robust and respond extremely well to graded exposure. Whilst there are numerous ways we could do this, what this may look like is lifting 10kg overhead and increasing this by 10% each week until we hit your goal. We will also start gradually exposing the affected area to higher load each week to make sure the rotator cuff muscles and the bursa slowly get used to the increased load on the affected joint.

The final stage of your rehab journey is to complete a preventative program, which will allow you to decrease the chance of this type of injury occurring again in the future. There are many different types of injury prevention programs – some may focus on increasing rest between strenuous activities and others may involve certain muscles being strengthened to allow the affected joint to function optimally. The most important thing is that it is individualised to you and your issue, which your physiotherapist will be able to do for you. Treatment should have a focus on exercise rehabilitation of the rotator cuff, upper back and shoulder blade muscles.

What are the symptoms?

In some cases we can see what is known as a painful arc of pain – this means we can have relatively no pain at the start of lifting our arm up, pain throughout the middle (the arc from 60 to 90 degrees) and then none again once you reach the top of the movement. This type of symptom is why it can also be referred to as an impingement of the shoulder/shoulder joint or impingement syndrome.

Shoulder Bursitis symptoms may be less specific and even hard to pinpoint, however this is completely normal. These other typical complaints include a dull/sharp pain in the front/side of your shoulder, which can either feel really deep in or close to the surface. It is important to know that everyone will experience this differently, however the physiotherapy treatment solutions remain the same.

Other common symptoms of bursitis are:

• Pain when lifting overhead

• Pain with throwing

• Decreased range of motion of your affected shoulder joint

• Pain with tasks such as brushing teeth, doing hair/make up with arm elevated

• Pain when sleeping on the affected side

• Painful to touch

Should I be concerned about shoulder bursitis?

Bursitis of the shoulder is one of the most common findings on a scan such as an ultrasound, CT or MRI; however, this is not actually a cause for concern. Contrary to popular belief, even in much of the medical world, unfortunately, evidence of bursitis on a scan is not cause for concern and in many people does not cause any pain at all.

There is little to no correlation between shoulder bursitis diagnosed on a scan and pain.

This is great news for you because it means that just because you have a scan that shows damage or degeneration, you can be completely pain free with a fully functioning shoulder. Unfortunately too many people have been mislead into allowing degenerative findings on a scan dictate their life moving forwards. 

In line with the best available research we actively discourage getting a scan unless we believe there is cause for concern, as getting a scan has been shown to increase pain in people when they learn that they have degenerative changes in their joint. Most people who present with shoulder pain and find degenerative changes on a scan, have actually had those findings for many years pain-free – the pain is coming from a different source and our main role together is to settle the pain down and gradually strengthen the joint to its previous level.

Degenerative changes within joints are akin to grey hairs or wrinkles, they are normal changes that happen as we age, however pain associated with them is not normal.

At Physio Fit we firmly believe in treating the person and their presenting complaint, not the scan they bring in.

How do we diagnose the condition?

A clinical diagnosis by a physiotherapist will be more than sufficient in order to create you a rehab plan to become pain free. 

An inflamed subacromial bursa in the shoulder can be diagnosed by a scan – ultrasound, CT or MRI. It is important to note that the diagnosis via scan of shoulder bursitis is not necessary and will often do more harm than good; and is recommended against by the best available research. For people who insist on diagnosis via a scan, we encourage them to have the pain free shoulder scanned too, in order to show that the ‘abnormal findings’ are likely on the pain free side too and are therefore not the cause of their pain

How long will it take me to recover?

This is a very individualised question because it depends largely on the history of your condition. For someone who has had pain for years, it is likely it will take longer than someone who has just experienced the onset of symptoms. Typically we would expect most shoulder pain to have resolved (short term) within 12 weeks, on the basis of the person following the management protocol given to them by their physiotherapist.

Issues can arise where you return too quickly to previously aggravating activities and you can experience episodes where the pain gets worse. The most important thing is to follow your individualized plan for your shoulder bursitis designed by your physiotherapist. 

Will I need cortisone?

The evidence shows that it is unlikely that cortisone will help your shoulder at all.

Recent research has shown little benefit of cortisone in the treatment of shoulder bursitis and this may be due to people being referred for a cortisone injection after getting a scan which shows degenerative changes and inflammation in the subacromial bursa. As mentioned above, if as the research has shown, this is not the cause of the pain a person is experiencing, then the injection is simply treating an asymptomatic structure within the shoulder.

Cortisone for too long has been prescribed as a ‘quick fix’ due to the theory that it should help to decrease inflammation in the bursa in the shoulder and thus reduce pain. As our understanding of shoulder pain and bursitis continues to improve, we will see less and less cortisone being prescribed for such issues.

If the medical advice you have been given is to get a cortisone as the first line of treatment, we highly recommend you get a second opinion of your shoulder bursitis.

Will I need surgery for shoulder bursitis?

You will most likely not need surgery.

Recent research has shown that surgery is no more effective than sham surgery (where the surgeon will make an incision but not perform any decompression). This aligns with our understanding that the bursa and surrounding structures are not the main cause of your shoulder pain. Therefore the risks associated with surgical intervention for shoulder bursitis would simply be too high when conservative management of physiotherapy and exercise rehabilitation has been shown to elicit much greater long-term results.

It is unlikely that medical advice will be to have a surgical decompression of your shoulder joint and we highly recommend at least 12 months of conservative rehabilitation before considering this option.

Will sleeping on my shoulder cause shoulder pain?

Whilst you have shoulder pain we would advise you not to sleep on your painful side as it can cause discomfort and broken sleep. However, the research has shown that when your shoulder is not in pain, there is no benefit to not sleeping on your side.