Bursitis results in a variety of consequences for the patient which include the following

• Loss of abduction and internal and external rotation range of motion. There is a painful arc of movement between 80 and 120 degrees of abduction and most particularly in internal rotation, as a result of decreased space around the subacromial bursa.

• Pain may cause the patient to limit their range of motion before they enter a painful range. Reduced range of motion may produce adhesions of the inferior joint capsule further restricting joint range. Pain may also lead to altered movement patterns, which may in turn lead to the damage or weakening of other important muscles around the shoulder complex.

• Muscle weakness and atrophy will result from disuse of the muscles around the shoulder. Degeneration occurs quickly with associated losses occurring in the first one to three weeks of the condition.

Symptoms may include:

·             Achy pain and stiffness of the shoulder joint, to a burning that surrounds the whole joint (Donatelli, 2004).

·             Intermittent redness of the surrounding skin.

·             The pain may be a gradual build-up or sudden and severe, particularly in if calcium deposits are present (Anderson, 2000).

·             The pain is typically worse during and after activity and at night, and the bursa and surrounding area can become stiffer the next day (Donatelli, 2004).

·             Other symptoms may include joint swelling and tenderness and a decreased range of motion at the shoulder, especially abduction.

·             Pain caused by subacromial bursitis is often referred to the lower deltoid area and can even refer to the elbow or into the forearm or hand.

·             Subscapular bursitis may also cause subscapularis muscle spasm and tightness as a response to pain (Hartley, 1990).

 It is often difficult to distinguish between pain caused by bursitis or  that caused by a rotator cuff injury as both exhibit similar pain patterns in the front or side of the shoulder (Hartley, 1990). Subacromial bursitis can be painful with resisted abduction due to the pinching of the bursa as the deltoid contracts (Buschbacher & Braddom, 1994).  If the therapist performs a treatment direction test and gently applies joint traction or a caudal glide during abduction (MWM), the painful arc may reduce if the problem is bursitis or adhesive capsulitis (as this potentially increases the subacromial space). 

The following clinical tests, if positive, may indicate bursitis:

• The patient actively abducts the arm and a painful arc occurs between 80⁰ and 120⁰.  This is due to the compression of the supraspinatus tendon or subacromial bursa between the anterior acromial arch and humeral head.  When lowering from full abduction there is often a painful “catch” at midrange.  If the patient can achieve adequate muscle relaxation, passive motion tends to be less painful (Starr & Harbhajan, 2001).
• The patient performs an isometric flexion contraction against resistance of the therapist (Speed’s Test).  When the therapist’s resistance is removed, a sudden jerking motion results and latent pain indicates a positive test for bursitis (Buschbacher & Braddom, 1994).
• Neer’s Sign: If pain occurs during forward elevation of the internally rotated arm above 90⁰.  This will identify impingement of the rotator cuff but is also sensitive for subacromial bursitis (Starr & Harbhajan, 2001).

It is interesting to note that an irritation or entrapment of the lower subscapular nerve, which innervates the subscapularis and teres major muscles, will produce muscle guarding at the shoulder that will restrict motion into external rotation, abduction, or flexion.  The aforementioned tests will assist in diagnosing bursitis over other conditions (Hartley, 1990).

The general principles of physiotherapy and indeed healthcare practice must always be applied, being that you work to improve dysfunction and reach goals. When treating someone with bursitis in the shoulder, there are some considerations that need to be taken into account, to ensure that this primary objective is met. These relate to the healing properties and the course of the bursa along with the requirements of rehabilitation on the patient.

Firstly, the bursa itself is a relatively lifeless structure, having little vascular tissue within its structure. This has an impact on the healing properties of the bursa and its ability to contribute to the repair of neighbouring structures. During a rotator cuff lesion, it has been found that a number of angiogenic (blood vessel generating) cytokines are released from the bursa as well as possibly implicated tendons (Yanagisawa et al, 2001). This angiogenic response is largely mediated by vascular endothelial growth factor (VEGF) which is also found in chronic inflammatory conditions such as rheumatoid arthritis and reported as being at higher levels in type two diabetics (Handa et al, 2003). The higher incidence of these substances, which are known for attributing to pain, may play a role in the ongoing pathology found in chronic inflammatory conditions. Thus, when treating a patient for bursitis who has RA, for example, short term improvements cannot be taken as a sign of resolution and will require extensive long term treatment to ensure recurrence, or the risk of, is minimised. Joint contracture of the shoulder has also been found to be at a much higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).

The condition of bursitis itself, is actually one of the intial symptoms of impingement, according to the Neer stages of impingement. As such, it should be treated as with the symptoms of any condition, being directed as treating holistically to alleviate all symptoms and causes. The stage at which the patient presents (stage 1, 2 or 3) (Brox et al, 1999) will affect how the treatment is directed and the measures which are required to be taken. Certain factors such as the anatomical structure of the acromion and the extent of rotator cuff injury will affect the course of treatment pursued in rehabilitation. This is further compounded by the close relationship of both the tendon and the bursa on the healing of each other (Ian et al, 2005) and thus necessitates that the symptoms of both structures and any other implicated, be relieved for total success.

Shoulder bursitis rarely requires surgical intervention and generally responds favourably to conservative treatment (Starr & Harbhajan, 2001). Physiotherapy interventions are integral to the successful management of this condition (Andrews and Wilk, 1994). Effective physiotherapy interventions are multimodal involving patient advice and education, manual therapy, therapeutic exercise, electrophysical agents and external physical agents. Bursitis often presents concurrently with subacromial impingement and can be treated simultaneously (Andrews & Wilk, 1994). Physiotherapy treatment must be specific for each patient with shoulder bursitis and should be designed to reflect the patient’s goals and functional abilities (Andrews & Wilk, 1994).

Early/ initial

 Middle/ intermittent

 Late/ return to function

Other Treatment Options 

If conservative physiotherapy treatment is ineffective in reducing the symptoms of shoulder bursitis there are other options available.  Nonsteroidal anti-inflammatory drugs (NSAIDs) can be prescribed for moderate to severe symptoms (Starr & Harbhajan, 2001). NSAIDs are useful in the initial and intermediate phases of rehabilitation in reducing the inflammatory process (Andrews & Wilk, 1994). Corticosteroid injections may relieve pain and improve abduction range of motion (Starr & Harbhajan, 2001). If relief of symptoms is still not achieved removal of the bursa, a bursectomy may be successful in reducing the pain associated with inflammation of the bursa (Blaine, et al., 2005).