Shoulder bursitis

The anatomy

A bursa is a small fluid filled, soft tissue ‘sac’.  They are found between tendons and muscles, between tendons and other tendons and also between tendons and bones.  They are designed to provide a cushion, protecting surrounding structures during movement or from direct impact.   The protection provided by a bursa helps to reduce irritation and inflammation caused by inappropriate levels of stress placed upon nearby structures. Unfortunately, bursas can themselves become injured and inflamed and when they do, they are very painful.

What is shoulder bursitis?

Shoulder bursitis is the most common cause of shoulder impingement syndrome(Wu et al., 2015).  It can be caused by direct trauma, or by a sudden increase in activity such as starting a new type of exercise/sport. Bursitis can also become chronic (pain that has been present for over 3 months).  Constant irritation of a bursa can cause it to become thickened.  This thickening can further irritate the bursa during movement causing a vicious circle of pain.

Research informs us that the sub acromial bursa of the shoulder (the focus of this blog) is the most common cause of pain for many different shoulder conditions.

The sub acromial bursa of the shoulder sits above the supraspinatus tendon (an important muscle of the rotator cuff) and the acromion (the bone at the corner of the collar bone and the shoulder blade).  Constant miss-use or injury causes this bursa to thicken and swell (known as bursitis).  When this happens, the bursa can get pinched under the acromion (known as an impingement).

The presence of shoulder bursitis is routinely associated with the following conditions.  The occurrence rates of bursitis in the following conditions have been documented by Draghi et al., (2015) and are as follows:

(Please click on the links below to find out more about each condition)

• Rotator cuff disease. 97% of the rotator cuff tendon tears present with bursitis.
• Calcific tendinitis.  Up to 100% of patients with painful calcific tendinitis present with bursitis.
• Shoulder osteoarthritis. 70% of patients with osteoarthritis of the shoulder present with bursitis.
• Acromioclavicular joint injury. 70% of patients with an acromioclavicular joint injury present with shoulder bursitis.

Other causes of shoulder bursitis include rheumatoid arthritis and infection which are not discussed in this blog.

Different conditions require very different management techniques and therefore, to effectively treat shoulder bursitis it is essential that the underlying cause of the inflamed bursa has been correctly identified.

What are the symptoms of a shoulder bursitis?

Symptoms of shoulder bursitis are typical of many different shoulder conditions (for which bursitis is often present, as previously discussed) however, these include;

• Pain that is felt over the shoulder and often down the arm, towards the elbow.
• Sharp pain especially with moving the arm upwards.
• Reduced movement of the arm due to pain.
• Sensation of weakness in the arm due to pain.
• Inability to sleep on the affected side.
• Night pain.  Many people wake regularly during the night due to pain.

How is shoulder bursitis diagnosed?

Due to the many reasons behind a shoulder bursitis, gaining a prompt and accurate diagnosis is essential for the most effective treatment.  It is therefore, recommended that you seek professional help if you think you may be suffering from a shoulder bursitis.

A shoulder assessment can be carried out by an orthopaedic consultant or a physiotherapist and involves a series of questions designed to reveal any underlying causes to your symptoms.  After the interview process the clinician will conduct a clinical assessment.  The clinical assessment involves asking you to move your arm, testing your strength and palpating different structures around your shoulder.  This process informs the clinician if your pain is coming from your shoulder, however  for a shoulder bursitis to be formally diagnosed you will need diagnostic imaging.

Diagnostic ultrasound imaging

Diagnostic ultrasound imaging has been shown, by the European Society of Radiology (2018),  to be as effective as MRI at assessing for the presence of shoulder bursitis and rotator tendon tears.  At Complete our team of experts are fully qualified physiotherapists and musculoskeletal sonographers who are highly experienced at assessing shoulder pain.  An assessment at Complete includes a clinical assessment and a formal diagnosis made under ultrasound imaging.  For further information, please do not hesitate to contact us by email, injections@complete-physio.co.uk or by telephone on 0207 482 3875

How do we treat shoulder bursitis?

A shoulder bursitis is treated depending on the underlying cause,  however, many people do very well with a combination of over the counter analgesics, physiotherapy, and a home exercise program, under the supervision of a physiotherapist.

Here are a few tips you may like to try:

• Don’t provoke your shoulder pain.  Constantly irritating your shoulder will stop it from “healing” and could make things worse.
• Try stretching before bed.  This may help reduce inflammation from the local area, allowing you to sleep better.
• Consider icing your shoulder. Frozen peas in a tea towel placed over the painful area for 10 minutes should help reduce your pain.
• Don’t sleep on the sore side.  Try to sleep on your back or on the opposite side.
• Try to maintain a neutral body position throughout the day.  Poor posture at work can irritate your shoulder even more.
• Try a short course of over the counter pain medication, however, please consult your pharmacist or G.P prior to starting any medication.

What if conservative treatments don’t work?

If you have tried physiotherapy and a regular home exercise program but your pain remains, it also affecting your ability to work or play sport and is waking you at night then you may need an injection.

At Complete our team of clinicians are fully qualified at performing ultrasound guided steroid injections.  This state of the art, evidence-based technique uses an ultrasound machine to watch, in real time, the advancement of the needle directly into the intended structure (in this case the sub acromial bursa). Ultrasound guided steroid injections have been shown to be significantly more accurate and safer than landmarked injections for shoulder bursitis (Wu et al., 2015).  Many patients also report this technique is more comfortable and yields faster results.

How do steroid injections work for inflamed bursae?

A strong anti-inflammatory medication called a corticosteroid (also known as steroid), is deposited directly into the bursa. The results have a fast-acting effect, significantly reducing the pain, irritation and inflammation of the bursa. The purpose of this is to then allow you to rehabilitate the shoulder.

Invariably, after an episode of shoulder pain the muscles become weak. We therefore highly recommend a program of physiotherapy, after any injection treatment. Physiotherapy can help bring the shoulder back to full strength and flexibility therefore reducing the risk of any recurrence.

Are injections for shoulder bursa painful?

Injections into the shoulder bursa are actually relatively pain-free and are performed with a very fine needle. They are well tolerated, with many patients hardly even feeling the needle at all!  Although a very small percentage of people will experience a spike in pain for a few days after the injection.

Do shoulder bursa injections hurt after the injection?

A steroid injection is mixed with a local anaesthetic. The local anaesthetic will help reduce any immediate discomfort from the injection, which generally is quite mild anyway.

If you have any questions about injections for a shoulder bursitis, please do not hesitate to contact us by email, injections@complete-physio.co.uk or by telephone on 0207 482 3875. We are always very happy to answer your questions.