Shoulder Bursitis (Subacromial Bursitis)

**Shoulder bursitis** refers to inflammation of one of the bursae (fluid-filled sacs) around the shoulder joint. The **subacromial bursa** is the most commonly affected — it sits between the rotator cuff tendons below and the acromion bone above, allowing smooth gliding during shoulder movement. **The Subacromial Bursa:** - **Largest bursa in the body** - Located between rotator cuff tendons and acromion - Normally contains thin layer of fluid for lubrication - When inflamed, fills with excess fluid and thickens - Causes pain with shoulder movement **Why Shoulder Bursitis Develops:** **1. Mechanical Impingement (Most Common):** - Repetitive compression of the bursa between bone and tendons - Common with [shoulder impingement](/condition/shoulder-impingement-syndrome) - Overhead activities particularly aggravating - Sports: tennis, swimming, baseball, volleyball - Work: painters, electricians, construction **2. Direct Trauma:** - Fall onto shoulder - Direct blow - Acute inflammatory response - Less common but possible **3. Inflammatory Conditions:** - Rheumatoid arthritis - Gout (rare in shoulder) - Pseudogout - Autoimmune conditions **4. Infection (Rare but Serious):** - Septic bursitis requires urgent treatment - Bacterial spread to bursa - Fever, severe pain, redness, warmth - Medical emergency **Acute vs Chronic:** **Acute Bursitis:** - Sudden onset (days to weeks) - Often after specific trigger - Significant pain - Usually responds quickly to treatment **Chronic Bursitis:** - Develops over months - Often related to ongoing impingement - Bursa wall thickens - More difficult to treat - May need injections or surgery **Common Coexistence:** Subacromial bursitis rarely occurs in isolation. It commonly coexists with: - [Rotator cuff tendinitis](/condition/rotator-cuff-tear) (70-80%) - [Shoulder impingement](/condition/shoulder-impingement-syndrome) (most cases) - [Biceps tendonitis](/condition/biceps-tendonitis) (30-40%) - AC joint arthritis (in older adults) This is why treatment must address the entire shoulder complex, not just the bursa.

## Root Causes **Mechanical Overuse (Most Common):** - Repetitive overhead motions - Throwing sports (baseball, javelin) - Swimming (freestyle especially) - Tennis (serving) - Painting, electrical work overhead - Manual labor with overhead reaching **Anatomical Factors:** - **Hook-shaped acromion** (Type III) — predisposes to impingement - **Acromial spurs** — develop with age - **AC joint arthritis** — narrows subacromial space - **Os acromiale** — unfused acromion fragment - **Reduced subacromial space** **Age-Related Changes:** - **Cumulative microtrauma** - **Decreased tendon vascularity** - **Acromial spurring** - **Rotator cuff degeneration** - **Decreased tissue resilience** **Inflammatory Causes:** - Rheumatoid arthritis - Crystal arthropathies (gout, pseudogout) - Connective tissue disorders - Reactive inflammation **Acute Injury:** - Direct fall onto shoulder - Sudden forceful overhead activity - Heavy lifting incident - Repetitive injury accumulation **Risk Factors:** - Age 40-60 (peak) - Overhead occupations - Overhead sports - Previous shoulder injury - Poor posture (forward head/rounded shoulders) - Diabetes (slower healing) - Smoking (impaired blood flow) **Posture and Biomechanics:** - **Forward head posture** — alters shoulder mechanics - **Rounded shoulders** — narrows subacromial space - **Weak scapular stabilizers** — abnormal scapular motion - **Tight pectoralis muscles** — pulls shoulders forward - **Poor thoracic mobility** — limits proper arm elevation

## Conservative Treatment (First-Line) **Treatment focuses on reducing inflammation, restoring function, and addressing underlying mechanical issues.** ## Acute Phase (Weeks 1-2) **Activity Modification:** - Avoid aggravating overhead activities - Modify work tasks if possible - Avoid heavy lifting temporarily - Continue gentle daily activities - Sleep with pillow under affected arm **Pain Management:** - **NSAIDs** (ibuprofen 400-800 mg every 6-8 hours, naproxen 220-500 mg twice daily) - **Topical NSAIDs** as alternative - **Acetaminophen** for those who can't take NSAIDs - **Ice** 15-20 minutes, 3-4x daily - **Compression** rarely needed **Initial Movement:** - **Pendulum exercises** — gentle gravity-assisted swinging - **Passive range of motion** — avoid pain - **No aggressive stretching yet** - **No strengthening yet** ## Strengthening Phase (Weeks 2-6) **Goals:** - Restore full range of motion - Strengthen rotator cuff - Improve scapular stability - Correct postural issues **Rotator Cuff Strengthening (Critical):** - **External rotation with band**: Elbow at side, rotate outward — 3 sets of 15 - **Internal rotation with band**: Similar but inward — 3 sets of 15 - **Empty can holds**: Light weight at side, gradual progression - **Side-lying external rotation**: Building strength systematically **Scapular Stabilization:** - **Rows with band**: Squeezing shoulder blades together - **Scapular squeezes**: Isometric - **Wall slides**: Working scapular mechanics - **Y-T-W raises**: Targeting different scapular muscles - **Prone scapular retraction** **Posterior Capsule Stretching:** - **Cross-body stretch**: 30 seconds, 3 reps - **Sleeper stretch**: Side-lying, gentle - **Doorway stretch**: For pectoral muscles ## Corticosteroid Injection **When Conservative Treatment Insufficient:** - **Subacromial corticosteroid injection** - Triamcinolone or methylprednisolone - 60-80% provide significant short-term relief - Effective for several months typically - Limit to 2-3 injections per year - Should be combined with rehabilitation **Injection Considerations:** - More effective in acute cases - Less effective in chronic bursitis - Ultrasound-guided improves accuracy - Risk of tendon weakening with repeat injections - May mask underlying pathology ## Posture and Ergonomic Correction **Critical for Long-term Success:** - Workplace ergonomic assessment - Computer monitor at eye level - Avoid prolonged overhead work - Take breaks during repetitive tasks - Address forward head posture - Strengthen postural muscles **Specific Postural Exercises:** - **Chin tucks**: Strengthen deep cervical flexors - **Thoracic extension**: Foam roller or specific exercises - **Pectoral stretching**: Doorway stretch - **Upper trap stretching**: Side neck flexion ## Other Interventions **Physical Therapy:** - Comprehensive rehabilitation program - Manual therapy techniques - Modalities (ultrasound, electrical stimulation) - Movement re-education - Sport-specific or work-specific training **Other Options:** - **PRP (Platelet-Rich Plasma)** — emerging evidence - **Hyaluronic acid injection** — limited evidence for shoulder - **Shockwave therapy** — for calcific bursitis - **Acupuncture** — some evidence for pain relief ## Surgery (Rarely Needed) **Indications:** - Failed 6+ months of conservative treatment - Persistent disabling pain - Associated rotator cuff pathology requiring repair - Significant calcium deposits (calcific bursitis) **Procedures:** - **Arthroscopic bursectomy**: Removal of inflamed bursa - **Subacromial decompression**: Address impingement - **Bone spur removal**: If contributing - **Rotator cuff repair**: If torn **Outcomes:** - 70-90% good results - Recovery 4-12 weeks for return to most activities - Strengthening continues for months ## Septic Bursitis (Emergency) **Recognize Warning Signs:** - Fever - Severe pain - Marked warmth and redness - Rapidly worsening symptoms - Recent injury or skin breakdown **Treatment:** - **Immediate medical evaluation** - **Aspiration** for fluid analysis and culture - **IV antibiotics** if confirmed - **Possible drainage** procedure - **Hospitalization** in severe cases