Shoulder Bursitis – What You Need To Know

Introduction To Shoulder Bursitis

Shoulder bursae are synovial fluid-filled sacs located around the shoulder joint. Their role in life is to reduce friction at tendon-bone and tendon-tendon interfaces, promoting smoother movement. 

When glenohumeral bursae become inflamed, known as shoulder bursitis, we find a leading cause of shoulder pain. It can contribute to lost workdays and, in severe cases, disability. Symptoms of shoulder bursitis can vary depending on the severity and type but typically include swelling, localised warmth, tenderness, pain, and sometimes fever, indicating possible infection. Clinical signs often mimic other shoulder pathologies, necessitating a precise diagnosis.

Treatment approaches depend on the severity and underlying cause of the bursitis. Initial strategies may involve activity modification, immobilisation, icing, and anti-inflammatory medications. For persistent cases, options like corticosteroid injections or aspiration of the bursa may be required. However, emerging evidence highlights the efficacy of innovative treatments such as Extracorporeal Shockwave Therapy (ESWT) and High-Powered Laser (HPL), which are shown to be equally or more effective than traditional interventions, with fewer risks and complications.

Anatomy of The Bursae Around The Shoulder

The shoulder contains five primary bursae, which are crucial in reducing friction between tendons and bones and facilitating smooth movement. These include:

  • Subacromial-Subdeltoid (SASD) Bursa: The largest and most clinically significant, often implicated in shoulder impingement and bursitis.
  • Subscapular Recess: Located beneath the scapula, this bursa helps protect the subscapularis tendon.
  • Subcoracoid Bursa: Found near the coracoid process, it reduces friction during shoulder flexion and internal rotation.
  • Coracoclavicular Bursa: Situated between the coracoid process and the clavicle, this bursa helps ease movement in the acromioclavicular joint.
  • Supra-acromial Bursa: Located above the acromion, its role is less clinically prominent but still assists in movement.

Some authors include a sixth bursal space:

  • Medial Extension of The Subacromial-Subdeltoid Bursa: This can communicate with the SASD bursa and is considered by some to be a distinct space.

Shoulder bursae are innervated, with the subacromial bursa receiving sensory input from the suprascapular and axillary nerves. Nociceptors, such as free nerve endings, detect painful stimuli and inflammatory changes, transmitting these signals to the brain. Additionally, mechanoreceptors within the bursae provide proprioceptive feedback on joint position. This suggests that bursae contribute to lubrication and play a role in sensory and motor control of shoulder movement, adding another layer of complexity to their function in joint health and inflammation management.

How Common Is Shoulder Bursitis?

Shoulder bursitis is relatively common, accounting for about 0.4% of all primary care visits, with no significant gender differences. It frequently affects individuals engaged in repetitive overhead activities, such as athletes, factory workers, and manual labourers. Older adults are more susceptible, likely due to accumulated wear over time, contributing to subacromial impingement.

What Causes Shoulder Bursitis?

Bursitis typically develops from excessive stress placed on the bursa, leading to inflammation. The condition can be categorised into three main types based on the cause:

  • Chronic Bursitis: This is the most common form, resulting from repetitive irritation over time. Those with underlying conditions such as gout, pseudogout, diabetes, rheumatoid arthritis, or uremia are at a higher risk due to systemic inflammation or metabolic imbalances that affect joint health. But in most cases it is just caused by excessive movement of overuse. 
  • Infected Bursitis: In this type, bacterial infection infiltrates the bursa, causing inflammation. The infection can spread if left untreated, leading to more severe complications. This form requires prompt medical attention and often antibiotic treatment.
  • Traumatic bursitis (acute traumatic bursitis): This occurs following direct trauma to the bursa, such as a fall or impact, causing immediate irritation and swelling. Traumatic events may lead to rapid-onset inflammation, differing from the gradual progression in chronic cases.

Understanding the root cause is crucial for developing an effective treatment strategy, as management differs based on whether the bursitis is due to overuse, infection, or trauma.

What Are The Symptoms of Shoulder Bursitis?

Shoulder bursitis is typically marked by localised pain, swelling, and tenderness, with discomfort worsening during movement. Common symptoms include lateral or anterior shoulder pain, particularly aggravated by overhead lifting or reaching. Pain tends to intensify at night, often disrupting sleep.

Younger and middle-aged individuals are more likely to experience acute bursitis. At the same time, older patients with chronic rotator cuff issues may present differently. Tendonopathy in nearby tendons frequently accompanies shoulder bursitis, further complicating mobility. Daily activities, including household tasks and hygiene, can become difficult due to restricted and painful overhead movements. Contact sports or similar activities often exacerbate the pain.

How Is Shoulder Bursitis Diagnosed?

Bursitis is typically diagnosed through a combination of clinical examination and imaging studies. It is characterised by localised pain, swelling, tenderness, and discomfort with movement in the affected area. Healthcare providers often observe signs such as redness, warmth, and joint stiffness during a physical exam, particularly when inflammation is pronounced.

For subacromial bursitis, a physical examination usually reveals a reduced active range of motion, particularly in shoulder elevation, internal rotation, and abduction due to pain. The most significant discomfort often occurs during the arc of motion between 70 and 120 degrees of abduction, associated with subacromial pain syndrome.

Imaging studies can also aid in diagnosis. X-rays may reveal calcifications in the bursa in chronic or recurrent bursitis cases. Magnetic Resonance Imaging (MRI) is particularly effective for assessing the extent of inflammation and fluid accumulation in the bursa, providing a more detailed view of the condition.

But Not All Shoulder Pains Are Cauaed By Bursitis. 

There are many other issues that can occur within the shoulder region that mimic bursitis and can also be found in combination with bursitis.

  • Subacromial Impingement: This condition occurs when the space between the acromion and the rotator cuff narrows, leading to friction and irritation of the subacromial bursa. This repetitive impingement can lead to bursitis, making it a common co-diagnosis.
  • Adhesive Capsulitis (Frozen Shoulder): Patients with adhesive capsulitis experience significant restriction in shoulder movement, which can increase pressure on the surrounding structures, including the bursa. The immobility and compensatory movements often contribute to inflammation of the bursa.
  • Rotator Cuff Tendinopathy: Degeneration or inflammation of the rotator cuff tendons, particularly the supraspinatus tendon, can lead to secondary bursa irritation. The close anatomical relationship between the rotator cuff and the subacromial bursa makes this a frequent co-existing condition.
  • Supraspinatus Tendinopathy: This specific type of tendinopathy affects the supraspinatus tendon, one of the main components of the rotator cuff. Inflammation or degeneration of this tendon can easily extend to the subacromial bursa due to their proximity, often resulting in bursitis.
  • Bicipital Tendinopathy: Inflammation of the biceps tendon, mainly where it runs through the bicipital groove of the humerus, can cause pain and swelling that radiates into the shoulder joint and bursa, contributing to the development of bursitis.

Given the overlap in symptoms—such as pain with overhead movements, tenderness, and restricted mobility—it is essential to assess for associated conditions when diagnosing shoulder bursitis thoroughly. Accurately identifying the primary cause will guide more effective treatment and management strategies.

How Is Shoulder Bursitis Treated

Chronic bursitis is typically managed by reducing aggravating activities alongside anti-inflammatory medications like ibuprofen, Naprosyn, or Celebrex for a few weeks; however, these medications don’t address the underlying problem. Icing the shoulder 2-3 times daily for 20-30 minutes helps control swelling. Heat should be avoided as it worsens inflammation. Steroid injections into the bursa can reduce swelling. Still, they may lead to side effects, such as infection, skin atrophy, or chronic pain. Cortisone injections are usually reserved for cases that do not respond to other treatments. However, these pose risks. If infection is suspected, cortisone should be avoided.

Infected bursitis requires immediate medical attention. Aspiration of the bursa may be necessary to reduce swelling and obtain samples for biopsy, with antibiotics prescribed to eliminate bacteria. The critical risk is the potential for bacteria to spread into the bloodstream. As with other bursitis types, ice, rest, and NSAIDs are used to manage inflammation.

For traumatic bursitis, aspiration using a small needle is often required to remove excess fluid or blood from the affected bursa. Ice and NSAIDs help in reducing swelling. Physical therapy is also beneficial, especially if the condition is accompanied by frozen shoulder.

HPL Therapy (High Power Laser Therapy): HPL therapy is a non-invasive treatment that utilises focused light energy to deeply penetrate tissues. While data targeting bursitis is limited, studies on other musculoskeletal conditions show promising results. HPL therapy works by enhancing blood flow, accelerating the clearance of inflammatory mediators, and boosting cellular energy production (ATP), ultimately promoting tissue repair. It can be an effective adjunctive treatment in chronic or severe cases of shoulder bursitis. Some clinical studies report a significant reduction in pain, with patients experiencing up to a 40-60% improvement in pain and function after consistent use over several weeks.

ESWT: Extracorporeal Shockwave Therapy is widely recognised for treating chronic tendinopathies, but it has also shown promise for shoulder bursitis. The acoustic waves generated in ESWT stimulate tissue repair by promoting blood flow and reducing inflammation. Some clinical studies report a success rate of 60%–80% in reducing pain and improving function in patients with musculoskeletal conditions such as calcific shoulder tendinopathy. Data also shows that patients with chronic shoulder pain not responding to conservative measures saw significant improvements after several ESWT sessions.

Conclusion

Shoulder bursitis can be an extremely painful and frustrating condition to live with. And from a healthcare providers perspective it can be extremely tricky to diagnose. Yet the good news is that being diagnosed with bursitis is not a life sentence for shoulder pain. In fact there are many effective treatment options to be explored. Finding ways to reduce the pain whilst looking at the background to understand what the underlying cause of the bursitis is can be an extremely fruitful and satisfying way to find lasting freedom from the pain and limitation associated with shoulder bursitis.

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