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Subacromial bursitis

Shoulder bursitis is among one of the most common causes of shoulder pain (Starr & Harbhajan, 2001). Bursa are strategically placed throughout the body to produce smooth and friction free movement between structures within joints. Bursitis is inflammation of the bursa with the most common cause being impingement. There are eight bursa in the shoulder joint, with the largest being the subacromial bursa, located between the deltoid and the capsule. The subacromial bursa is an essential structure as it allows gliding of the acromion and rotator cuff tendon (Starr & Harbhajan, 2001). 



The shoulder is the most mobile joint in the body which requires the simultaneous, friction free movement of structures found in the subacromial space for optimal function (Perry, 1983). Bursa, which are small sacs of synovial fluid, facilitate this friction free movement between structures, contributing to the large range of motion found at the shoulder. "The subacromial bursa acts as a joint between the rotator cuff and the overlying structures, allowing free motion of the rotator cuff relative to the acromion and the deltoid muscle” (Van Holsbeeck & Strouse, 1993, p.561). The biomechanics of the shoulder are affected by bursitis because the associated pain often results in inhibition of shoulder stabilising muscles altering scapulo-humeral rhythm.


The literature on the pathophysiology of bursitis describes inflammation as the primary cause of symptoms. Inflammatory bursitis is usually the result of repetitive injury to the bursa. In the subacromial bursa, this generally occurs due to microtrauma to adjacent structures, particularly the supraspinatus tendon. The inflammatory process causes synovial cells to multiply, increasing collagen formation and fluid production within the bursa and reduction in the outside layer of lubrication (Ishii et al, 1997). The influx of foreign material further stimulates an inflammatory response with leukocyte reaction (Yanagisawa et al, 2001). If rotator cuff thickening coexists with bursa thickening and fibrosis, the end result is ultimately leads to impingement of the supraspinatus tendon (Blaine et al, 2005).

Less frequent observed causes of subacromial bursitis include hemorrhagic conditions, crystal deposition and infection. If there is direct trauma to the site, may result in hemorrhage into the bursa  and associated swelling and pain. Crystal deposition can result from rheumatoid arthritis, gout, pseudogout and spondylarthropathies (Butcher, 1996). Here, deposits of crystal, for example calcium pyrophosphate dihydrate crystals, form within the shoulder joint weakening the cartilage and causing it to degenerate more rapidly. This causes the bursa to become irritated further increasing the inflammatorry response (Butcher, 1996). Research into the causative factors of bursitis reveals that inflammation of the bursa itself is most often the catalyst of the condition but will end up the final presentation. Bursitis that is caused by rheumatoid arthritis and gout is triggered by the processes of these systemic conditions which finally leads to inflammation.


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.

Probable Presentation

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).

Special Considerations

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

Initial phase of physiotherapy rehabilitation

Goals of treatment

  • Reduce inflammation
  • Reduce pain
  • Prevent weakness and atrophy of muscles as a result of disuse
  • Increase the patient’s awareness of bursitis
  • Prevent/reduce impingement and further tissue damage




Advice and education

Educate the patient about their condition and advice to avoid painful activities and the importance of relative rest of the shoulder

Prevention of pain and impingement which delays the healing process

Educate the patient about the importance of correct posture

Puts muscles in the optimal length tension relationship, reducing impingement

Manual therapy

Grade 1 and 2 accessory mobilisations of the glenohumeral joint

Has a neurophysiological affect reducing pain and improving synovial fluid flow, improving healing

Soft tissue massage

Lengthens tight muscles and reduces muscle spasm

Therapeutic exercise

Gentle pendulum range of motion exercises


Maintenance of range of motion and prevention of adhesive capsulitis

Scapular exercises such as shoulder shrugs and shoulder retraction exercises

Improve muscular control and scapular coordination

Centring of humeral head


Helps to facilitate adequate muscle timing and recruitment

Stretching of tight muscles such as the:

Levator scapula, pectoralis major, subscapularis and upper trapezius

To lengthen tight muscles which may improve scapulohumeral rhythm, posture and increase the subacromial space

Rotator cuff strengthening – isometric contractions in neutral and 30 degrees abduction


Improves rotator cuff strength which is integral to the stability of the shoulder and functional activities

Electrophysical modalities



To reduce inflammation and pain

Low intensity pulsed ultrasound (3Hz)

To reduce inflammation and facilitate healing

External physical aids

May use head of humerus repositioning tape

To maintain the head of humerus in its central position for optimal muscle recruitment

 Middle/ intermittent

Intermittent phase of physiotherapy rehabilitation

Goals of treatment

  • Improve muscle control
  • Improve scapulohumeral rhythm
  • Improve active and passive range of motion
  • Restore strength of scapular and rotator cuff muscles




Advice and education

Advise the patient that they must perform all activities and exercises pain free

To prevent reinjury and damage to the bursa

Manual therapy

Grade 3 and 4 accessory mobilisations of the glenohumeral joint


Improves range of motion and increases synovial fluid movement, improving healing

Proprioceptive neuromuscular facilitation (PNF) in functional diagonal patterns


Strengthens muscles, improves motor control and scapulohumeral rhythm

Mobilisation with movement eg caudad glide with active abduction

Improves range of motion and decreases pain

Therapeutic exercise

Specific muscle strengthening exercises especially for scapular depressors (serratus anterior, middle and lower trapezius muscles) eg strengthening lower trapezius muscle – bilateral external rotation using a theraband, strengthening of serratus anterior, punching  with theraband resistance

Increases the strength of the scapular depressors which may help to reduce impingement of the bursa by increasing the subacromial space, strengthening also prevents atrophy


Active assisted range of motion - creeping the hand up the wall in abduction, scaption and flexion and door pulley manoeuvre

Help to improve active range of motion and gravity assists with shoulder depression

Active internal and external rotator exercises with the use of a bar or a theraband

Improves strength of rotator cuff and improves mobility in internal and external rotation

Electrophysical modalities


Improves muscle extensibility

Low intensity pulsed ultrasound (3Hz)

Facilitates healing

External physical aids

May use head of humerus repositioning tape if necessary

To maintain the head of humerus in its optimal position for optimal muscle recruitment

 Late/ return to function

Return to function phase of physiotherapy rehabilitation

Goals of treatment

  • Return the patient to their previous level of function
  • Achieve full active and passive range of motion




Education and advice

Education about the importance of a home based exercise program in the late stage of rehabilitation

Ensures patient compliance


Correction of techniques performed


Ensures that the correct target muscles are being used

Education to ensure that the patient performs activities and exercises within pain free limits

This reduces the chance that they patient may work too hard and cause reinjury

Manual therapy

PNF functional patterns with increasing resistance


Continues to strengthens muscles, improves motor control and scapulohumeral rhythm

Therapeutic exercise

Exercises specific for the patient’s functional needs eg functional reaching

To improve the patients functional ability


Proprioception exercises eg Wall push ups with the hands resting on medicine balls or dura disks

Improves proprioception important to reduce reinjury as return to function/sport

Strengthen the shoulder elevators – deltoid, flexors and also lat dorsi.


Important in this phase of the rehabilitation following strengthening of the shoulder depressors.

Progress strengthening exercises to incorporate speed and load to make more functional


Adding speed and load to exercises ensures that the patient is prepared for more functional tasks and activities

Electrophysical modalities

Ice after exercise

May assist to reduce any inflammation post exercise

External physical aids

May use head of humerus repositioning tape if necessary

May assist with 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).


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This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Subacromial_bursitis". A list of authors is available in Wikipedia.
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