Shoulder Bursitis

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Definition

Definition of bursitis: Bursitis

When the bursae are not irritated and working well, your joints move smoothly and painless.
When a bursa becomes inflamed and swollen, we speak of a bursitis and you will experience pain during physical activity.

Clinically relevant anatomy

In the shoulder region, we have 8 bursae, the most of any single joint in your body. The major bursae in the shoulder are: the subscapular bursa, the subdeltoid bursa, the subacromial bursa and the subcoracoid bursa.
1) The subscapular bursa: between the tendon of the subscapularis muscle and the shoulder joint capsule.
2) The subdeltoid bursa: between the deltoid musle and the shoulder joint cavity.
3) The subacromial bursa: below the acromion process and above the greater tubercle of the humerus.
4) The subcoracoid bursa: between the coracoid process of the scapula and the shoulder joint capsule.

Epidemiology/ etiology

There are many factors that may cause shoulder bursitis: {8}, {9}
• Chronic irritation
• A trauma
• Bacterial infection
• Involved with the inflammatory response of rheumatoid arthritis

Characteristics/ clinical presentation

Bursitis of the shoulder occurs commonly in people over 30 years old with a greater incidence of females. Younger and middle-aged patients are much more likely to experience acute bursitis than older patients with chronic rotator cuff syndrome. {1}
Patients with subdeltoid or subacromial bursitis will experience painful shoulder movements, particularly during activities requiring abduction and extension.
The pain starts gradual, originating deep inside your shoulder and develops over a few weeks or months. The pain is on the outside of the shoulder and may spread towards the elbow.
Activities like washing, where you raise your arm above your head, will worse the pain.

Patients suffering shoulder bursitis may also have interrupted sleep patterns. Rolling over the affected shoulder during sleeping can cause pressure on the inflamed ursa increasing the pain. The pain depends on the degree of inflammation in the shoulder

The range of motion of patients with shoulder bursitis is increased and the shoulder muscles are weaker.

Differential diagnosis

To diagnose bursitis, the doctor will ask to extend the arm out and he will apply resistance and the patient will try to move it back towards his body. If the pain increases, the patient may be suffering from bursitis, although other rotator cuff injuries and tendonitis can produce pain with this test.
An additional diagnostic accuracy is obtained by a positive impingement test, in which the subacromial bursa and rotator cuff are forced against the under surface of the overhanging acromion {1}

Physical examination

The physical examination of the affected shoulder will show tenderness and usually warmed and swelling of the bursa and possible the tendons.
The tenderness will appear over the lateral shoulder and the subacromial space.
There may be redness on your skin on the area. {4}

Medical management

Inflammation can be treated with anti-inflammatory medications such as Motrin, Advil, Aleve, Celebrex, or one of many others. These all fall within the category of 'non-steroidal anti-inflammatory medications.' Taken by mouth, these medications help with the inflammation of the tendons and bursa, and also help reduce the discomfort. {5}

Physical therapy management

Immediate treatment: discontinue all activity, RICE regime to reduce inflammation and treat pain. Then heat to promote blood flow and healing. {2}

The aim of the therapy:
1) Reduce the symptoms
2) Minimize damage
3) Maintain rotator cuff motion and strength

The first step in treating bursitis is applying cold to the bursa. It will help decrease the swelling and redness around the bursa.
Apply ice every day 12-20 minutes.
In the acute stage, also use Codman’s pendulum exercises and AAROM exercises. {7}
Once the inflammation has been reduced, you can begin using ultrasound therapy to continue the healing process. {4}

Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis. {3}
The treatment is easy, painless, and generally requires between 5 - 10 minutes of your time.
Another important part of the rehabilitation is to restore atrophied muscles and improve shoulder strength and mobility. The type op physical therapy and duration are depending on the tissue damage and the symptoms.{10}
Once the pain starts to diminish, the physiotherapist will set up an individualized shoulder strengthening and stretching exercise program. It is important to strengthen your muscles properly as they may have weakened during the period of non-use.
Patients with shoulder bursitis can learn ways to move the shoulder that will not cause inflammation. {6}

References

{1} J. Willis Hurst, Douglas C. Morris, Chest pain, Futura publishing company, 2001.
Level of evidence: D

{2} Walker B., The anatomy of sports injuries, lotus publishing, 2007, p 131-132
Level of evidence: D

{3} Chen et al, Ultrasound-Guided Shoulder Injections in the Treatment of Subacromial Bursitis, 2006.
Level of evidence: A1

{4} Williams, bursitis of the shoulder, home therapy, 2001
Level of evidence: B

{5} Cluett J., Shoulder bursitis treatment, 2009.
Level of evidence: D

{6} O. Dreeben-Irimia, introduction to physical therapy for physical therapist assistants, 2011, p 84-85.
Level of evidence: D

{7} O. Dreeben, physical therapy clinical handbook, Jones and Barlett, 2008, p209-211.
Level of evidence: D

{8} Van Alfen N, Van Engelen B, Van Der Tas P, Walravens C, onderzoek en behandeling van de schouder, Bohn stafleu van Loghum,2007.
Level of evidence: D

{9}H. B. Skinner, Current Diagnosis & treatment in orthopaedics, the McGraw-Hills companies, 2008.
Level of evidence: D

{10}JJ. Calabro, Sustained-release indomethacin in the management of the acute painful shoulder from bursitis and/or tendinitis, 1985
Level of evidence: A1