Shoulder Bursitis
- Fysiobasen
- Sep 13
- 8 min read
Shoulder bursae are small fluid-filled sacs around the shoulder joint that contain synovial fluid. Their primary function is to reduce friction between tendons and bone, as well as between tendons. Shoulder bursitis, which refers to inflammation of a bursa, is one of the most common causes of shoulder pain and can lead to reduced work capacity and, in some cases, disability.
Symptoms
The symptoms of shoulder bursitis may vary depending on the type and severity, but often include:
Swelling
Increased warmth at the affected area
Tenderness
Pain, especially with shoulder movement
Fever (in cases where infection is present)
Treatment
Treatment of shoulder bursitis depends on the underlying cause and type, but common approaches include:
Activity modification: Reduction or adaptation of activities that strain the shoulder
Immobilization: Use of a splint or support to relieve stress on the area
Cold therapy: Application of ice to reduce swelling and pain
Pharmacological treatment: Use of antibiotics in cases of infection or anti-inflammatory medications to reduce inflammation
Injections: Corticosteroids may be injected into the bursa to reduce inflammation
Aspiration: Removal of fluid from the bursa with a syringe
An early and targeted treatment plan can help alleviate symptoms, improve function, and prevent chronic issues.¹²
Clinically Relevant Anatomy
The shoulder contains five main bursae that help reduce friction between tendons and bone structures. These bursae are:
Subacromial-subdeltoid (SASD) bursa
Subscapular recess
Subcoracoid bursa
Coracoclavicular bursa
Supra-acromial bursa
Some sources also include a sixth structure:
Medial extension of the subacromial-subdeltoid bursa¹
Nerve Supply
The bursae in the shoulder have nerve supply that plays a role in both pain perception and proprioception:
The subacromial bursa receives innervation from the suprascapular nerve and axillary nerve
These nerves contain nociceptors, which are free nerve endings that detect painful stimuli and inflammatory processes
In addition, mechanoreceptors are present in the bursae, providing proprioceptive information about shoulder joint position⁴
This shows that the bursae of the shoulder not only serve as lubricating structures between tissues but also have a sensory role that contributes to maintaining joint function and stability.
Etiology
Shoulder bursitis usually develops as a result of overuse of the bursa but can be divided into three main types based on cause:
Chronic bursitis
The most common type, developing gradually due to repeated irritation of the bursa
Risk groups include people with:
Gout or pseudogout
Diabetes
Rheumatoid arthritis
Uremia or other chronic conditions
Infectious bursitis
Occurs when the bursa becomes infected by bacteria
The infection can spread and cause serious complications
Traumatic bursitis (acute traumatic bursitis)
Caused by an accident or injury that irritates and inflames the bursa
Clinical Presentation
Typical symptoms of bursitis include local pain, swelling, tenderness, and pain with movement of the affected structures. Specific features of shoulder bursitis include:
Patient groups
Younger and middle-aged patients more often experience acute bursitis, while older patients with chronic rotator cuff syndrome are at higher risk for chronic bursitis⁵
Associated conditions
Shoulder bursitis often occurs alongside tendinitis of nearby tendons, such as those of the rotator cuff
Subacromial bursitis
Typically presents with lateral or anterior shoulder pain
Overhead activities such as lifting or reaching become painful
Pain often worsens at night and can disturb sleep, especially when rolling onto the affected shoulder
Impact on daily activities
Activities such as personal hygiene and household tasks may become difficult due to limited and painful movement
Physical activity
Contact sports and other shoulder-loading activities can cause significant pain
A thorough history and clinical examination are crucial to differentiate shoulder bursitis from other shoulder conditions, such as rotator cuff tears or tendinopathies, and to initiate appropriate treatment.
Treatment of Shoulder Bursitis
Treatment of shoulder bursitis depends on the type of inflammation. The approach ranges from conservative measures to medical and physical interventions.
Chronic Bursitis
Activity modification: Reduce or avoid activities that trigger swelling
Pharmacological treatment: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or celecoxib for several weeks can reduce inflammation and pain
Cold therapy: Apply ice 2–3 times daily for 20–30 minutes at a time to reduce swelling
Note: Heat should be avoided, as it may worsen inflammation
Steroid injections: Cortisone may be injected into the bursa to reduce swelling and inflammation, but should only be used when other measures are ineffective
Precautions: Injection into an infected bursa should be avoided, and side effects such as infection, skin atrophy, and chronic pain may occur
Infectious Bursitis
Medical evaluation: Immediate assessment is necessary to determine the severity of the infection
Aspiration: Removing fluid from the bursa with a needle can reduce swelling and provide material for biopsy and diagnosis
Antibiotics: Prompt treatment with antibiotics is essential to eliminate bacteria and prevent spread to the bloodstream
Supportive measures: Ice, rest, and NSAIDs can help reduce inflammation and swelling
Traumatic Bursitis
Aspiration: Using a needle to drain fluid or blood from the bursa helps reduce swelling and pressure
NSAIDs: Anti-inflammatory medications help relieve inflammation
Cold therapy: Reduces swelling and alleviates pain
Physiotherapy
Physiotherapy is an important part of rehabilitation, especially if bursitis is accompanied by frozen shoulder (adhesive capsulitis). Treatment focuses on:
Gradual restoration of range of motion
Strengthening of the stabilizing muscles in the shoulder
Reduction of pain and inflammation
Restoration of function in daily activities
A tailored treatment plan, adapted to the type and severity of bursitis, is necessary to achieve optimal recovery. Early intervention and proper follow-up can prevent chronic problems.
Differential Diagnosis
Shoulder bursitis may often be secondary to other medical conditions. Some conditions that may present with similar symptoms or coexist include:
Subacromial impingement
Adhesive capsulitis (frozen shoulder)
Rotator cuff tendinopathy
Supraspinatus tendinopathy
Biceps tendinopathy
A thorough evaluation of symptoms and clinical findings is essential to distinguish shoulder bursitis from other conditions.
Diagnostic Procedures
Clinical Examination
Typical findings include local pain, swelling, tenderness, and pain with movement of the affected area.In subacromial bursitis, reduced active movement may be observed, especially in:
Elevation
Internal rotation
Abduction
Painful arc: Pain occurs most severely in the range between 70° and 120° of abduction, which is typical of subacromial pain syndrome.
Imaging
X-ray: May show calcifications in the bursa, especially in chronic or recurrent bursitis
MRI: Provides detailed visualization of the bursa and surrounding tissues, which can confirm the diagnosis
Outcome Measures
To assess pain levels, functional limitations, and treatment effect, the following tools are used:
Visual Analogue Scale (VAS): Measures pain intensity on a 0–10 scale
DASH questionnaire: Evaluates function and symptoms related to the arm, shoulder, and hand
Shoulder Pain and Disability Index (SPADI): Measures shoulder pain and functional limitations
Constant-Murley Score (CMS): A comprehensive measure of pain, function, mobility, and strength
Shoulder Disability Questionnaire (SDQ): Specific for disability caused by shoulder problems
These diagnostic tools and outcome measures are useful for establishing a diagnosis, monitoring disease progression, and evaluating treatment effectiveness.
Physiotherapeutic Treatment of Shoulder Bursitis
Treatment in the Acute Phase
In the acute phase, treatment focuses on reducing inflammation and pain while maintaining shoulder mobility and preventing stiffness. Interventions include:
Rest: Avoid activities that worsen symptoms
RICE regimen: Rest, Ice, Compression, Elevation to reduce inflammation and pain
Codman’s pendulum exercises and AAROM exercises: Maintain joint mobility, prevent stiffness, and promote healing
Shoulder taping: Provides pain relief and improves function
Therapy goals:
Reduce symptoms
Minimize tissue damage
Maintain movement and strength in the rotator cuff
Further Rehabilitation
As pain subsides, the physiotherapist develops an individualized program of strengthening and stretching exercises. Treatment of chronic shoulder bursitis also includes:
Correction of posture and scapular dyskinesis
Shoulder mobility exercises
Strengthening of the rotator cuff and other shoulder muscles
Exercises for Shoulder Bursitis
Table Slides (flexion):
Stand with your hand on a table, resting on a towel. Slide the arm forward on the table and feel a stretch under the arm.Repetitions: 20–30
Scapular Wall Slides:
Stand with your back against the wall, arms at 90° abduction and elbows bent at 90°. Press your arms against the wall and slowly raise them while extending the elbows. Return slowly to the starting position.Repetitions: 10–12
Upper Trapezius Stretch:
Sit and stabilize the affected shoulder downward by gripping under the table with your hand. Use the opposite hand to gently pull your head toward the other shoulder while keeping your gaze forward.Hold: 30 seconds. Repetitions: 1–3, twice daily
Open Book Stretch:
Lie on your back with a rolled towel placed between the shoulder blades. Hold your hands together in front of your body and open your arms like a book. Feel a stretch in the front of the shoulder.Hold: 30–60 seconds. Repetitions: 1–3, twice daily
Rowing with Theraband:
Sit or stand with the theraband attached at chest height. Pull the band backward while focusing on squeezing the shoulder blades together.Repetitions: 2 sets of 10–20, three times per week
Low Row Isometric:
Focused on scapular stabilization through low-load isometric exercises.
Advanced Phases of Rehabilitation
In later stages, emphasis is placed on:
Progressive resistance training
Proprioception and coordination training
Activity- and sport-specific exercises
A comprehensive approach combined with appropriate progression in the rehabilitation program helps restore shoulder function and prevent recurrence.
Summary
Shoulder bursitis is a common cause of shoulder pain. It often arises due to overuse, trauma, inflammation in adjacent joints, or age-related changes. The bursa, located between muscles, bones, and other structures, becomes irritated and inflamed.
Because shoulder bursitis is often secondary to other nearby pathologies, distinguishing it from other shoulder conditions can be challenging. The most common symptoms include pain, reduced range of motion, decreased strength, and impaired function.
Studies show that a combination of ultrasound-guided injections and physiotherapy can contribute to pain relief and effective recovery of shoulder function. A targeted treatment and rehabilitation approach is therefore crucial for achieving optimal outcomes.
Sources
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Shoulder Flexion Table Slides - Ask Doctor Jo. Available from: https://www.youtube.com/watch?v=pgsPQ1_5e0w
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Open Book Reach Stretch. available from: https://www.youtube.com/watch?v=MJNCJOFhVtI
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isometric low row. available from: https://www.youtube.com/watch?v=y3KoUkInlMc
