Shoulder Bursitis

Search strategy

Databases:
Physiopedia: “Gout”; “Osteo-Arthritis”; “Frozen Shoulder”; “Rotator Cuff Tears”; “Dash questionnaire”; “Constant Murley score”;
                    “Adhesive Capsulitis”
PubMed: “Prevalence Shoulder Bursitis”; “Shoulder Bursitis”; “Subacromial Bursitis”; “Scapulothoracic bursitis”;
              “Therapy Management Shoulder Bursitis”; “Upper Extremity Bursitis”; “Snapping Scapula”
Pedro: “ Shoulder Bursitis”
ResearchGate: “SPADI”;
University of Washington: “SST questionnaire”;

Search words:
shoulder, shoulder bursitis, shoulder bursitis treatment

Definition

Bursitis is a medical condition where a bursa is inflamed and painful. This can lead to reduced mobility and cause problems in daily activities . Bursitis can be the result of a trauma or an overload. In and around the shoulder joint we can distinguish 4 bursae.They function as gliding surfaces to reduce friction between moving tissues of the body and to aid in movement. These tissues can be bone, ligament, muscles and joint capsule. For more information about bursitis, see the physiopedia page of bursitis. www.physio-pedia.com/Bursitis

Clinically relevant anatomy

There are 6 bursae in and around the shoulder joint:
1) The subscapular bursa or the scapulothoracic bursa: between the tendon of the subscapularis muscle and the shoulder joint capsule.
2) The Subdeltoid bursa: between the deltoid muscle 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.
5) The Infraspinatus bursa: between the infraspinatus tendon and the capsule of the joint.
6) The subcutaneous acromial bursa: is located above the acromion just beneath the skin.
The subacromial and the subdeltoid bursa are often taken as a single bursa, the subacromial deltoid bursa.[1]

Epidemiology/ etiology

There are many factors that may cause shoulder bursitis: [2],[3]
We can distinguish two major kind of causes: Aseptic and septic. In case the bursitis is caused by the presence of bacteria in the bursa, we speak of a septic bursitis.
There are several causes in order to get a bursitis;
- Overload: the repetition of a certain motion too often can lead to the inflammation of the bursa because of the friction between the bursa on                      the one hand and another structure on the other hand. This can be a tendon, bone, a ligament, …
- Trauma: Due to an accident, the bursa could become irritated and become inflamed.
- Inflamed joint: When the whole joint is inflamed, the bursa can become inflamed as well as other structures. We keep in mind arthritis and                              gout.
- older age: older age is a frequent cause of bursitis. It strikes most of the times in the shoulder joint, because it has the greatest range of                          motion of all joints in the human body.

A bursitis could also be the cause of some professions (e.g. painter, …), although, this is not often the case in shoulder bursitis.
www.physio-pedia.com/Gout
www.physio-pedia.com/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. [4]
One study mentions that they found no significant difference of incidence between men and women specific for subacromial bursitis. [5]

Subacromial bursitis typically present with lateral or anterior shoulder pain. Patients only occasionally report a single macro traumatic event leading to persistent pain. Overhead lifting or reaching activities are uncomfortable, and the pain is often worse at night, interrupting sleep. In a study focused on the treatment of subacromial bursitis they state that this type of bursitis has the presence of following symptoms: shoulder pain and limitation of movement for longer than one month but less than one year (after one year it becomes chronic bursitis), the presence of pain during at least one activity (such as sleep, dress, work, grooming and sports) and at the end range of at least one ROM test (scapulothoracic tilting, scapulothoracic abduction, glenohumeral flexion, glenohumeral abduction, internal rotation, external rotation) with also a loss of 10 degrees or more in one or more of these tests. [6] 
Patient who suffer from subacromial bursitis should have a glenohumeral abduction greater than 45 degrees to distinguish from patients with established "frozen shoulders".

Patients who suffer subacromial deltoid or subcoracoid 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 bursa 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. [7], [8]

Differential diagnosis

Bursitis is frequently caused by another medical condition. For example, patients who suffer from subacromial bursitis, are likely to suffer from adhesive capsulitis, rotator cuff tendinitis, supraspinatus tendinitis or bicipital tendinitis. [9]
www.physio-pedia.com/Adhesive_Capsulitis

Therefore it is hard to distinguish whether a patient is suffering from bursitis, tendinitis or another injury that usually occurs when the bursa is inflamed. This makes it hard to determine the cause of bursitis when a patient seeks for medical help. One of the methods used by doctors is by extending the arm in front of the body actively. The doctor will try to extend the arm even further away from the patient's body while the patient has to resist this force. If pain occurs, a bursa injury may be the cause of this pain. Nonetheless, this may also mean that indicate a rotator cuff injury or tendinitis, which can give the same kind of pain. The positive impingement test is another example of a diagnostic test, although it doesn’t exclude the other medical conditions that can be confused with bursitis.

To differentiate a bursitis from a supraspinatus tendinitis, which are often confused, we can perform a test to where we isolate the supraspinatus muscle. The patient abducts the arms to 90 degrees with the elbows extended and the arms internally rotated. The arms are placed 30 degrees anteriorly (in the coronal plane), and the patient resists as the examiner forces the arms downward. This is often referred to as the "empty beer can" test.

Frozen shoulder is another medical condition which can be confused with bursitis. In this case, we can differentiate the two symptoms with an easy test: if the patient cannot abduct the arm (glenohumeral abduction), this means the patient has a frozen shoulder. The downside of this test: we can not say with certainty that this patient is suffering from bursitis, only whether this person has a frozen shoulder or not. [10]

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