Shoulder Bursitis: Physiotherapy Management

The shoulder being one of the most flexible joint contains bursa which is a liquid-filled sac that can be found between tissues (skin, tendons and muscle). Bursa reduces the pressure and tension between the tissues but its inflammation causes pain during physical activity.

It is found more in the young and middle-aged population. Pain usually occurs during external rotation, abduction and flexion of arm. Five bursa are present at the shoulder joint.

1. Subcoracoid bursa
2. Coracoclavicular bursa
3. Subacromial-subdeltoid (SASD) bursa
4. Subscapular recess
5. Supra-acromial bursa

 

Causes of Shoulder Bursitis

• repetitive overhead movements such as painting, lifting and throwing
• sports activities like baseball or tennis
• direct trauma to the shoulder
• poor posture
• weak shoulder muscles
• degenerative changes
• rheumatoid arthritis
• gout

 

Symptoms of Shoulder Bursitis

• pain during overhead activities
• swelling or tenderness
• limited range of motion
• erythema
• pain during the night
• cervical spine movement may produce pain in shoulder
• muscular weakness

 

Classification of Shoulder Bursitis

 

Diagnosis

1. Medical History:

The physiotherapist can ask questions related to symptoms, their onset, duration, and any activities or movements that worsen or alleviate the pain. Information related to past injuries or medical conditions which is relevant to shoulder health is also asked.

 

2. Physical Examination:

This involves assessing the shoulder joint and its range of motion. The physiotherapist looks for signs of inflammation, such as swelling, tenderness, and warmth around the affected area. Evaluation of muscle strength, posture, and any specific movements that provoke pain is also done. Certain questionnaires can be used for this purpose. This helps in developing management strategies.

1. The Constant-Murley Score
2. The American Shoulder and Elbow Surgeons (ASES) Shoulder Score
3. The Shoulder Pain and Disability Index (SPADI)
4. The Disabilities of the Arm, Shoulder, and Hand (DASH) Score
5. Visual Analog Scale (VAS) for Pain

 

3. Special Tests:

There are specific tests designed to pinpoint shoulder bursitis. Some common ones include:

Neer's Test:

It is done to assess for impingement of the rotator cuff and subacromial bursa.

Procedure: The arm is internally rotated and passively raised overhead, potentially reproducing pain if there's impingement.

Hawkins-Kennedy Test:

It is done to evaluate impingement of the supraspinatus tendon and subacromial bursa.

Procedure: The arm is positioned at 90 degrees of shoulder flexion, followed by forced internal rotation, potentially provoking pain.

Other related test:

Empty Can Test (Jobe's Test):

To assess supraspinatus tendon integrity, which can impact the subacromial space and bursa.

Procedure: The arm is raised in front at 90 degrees with thumbs pointing downward, resisted downward pressure may provoke pain.

Drop Arm Test:

To identify rotator cuff pathology or weakness, which might impact the bursa.

Procedure: The arm is raised laterally and slowly lowered by the individual; inability to control the descent is indicative of a positive test.

Speed's Test:

To detect biceps tendinitis or bicipital groove tenderness, which might affect the shoulder joint and bursa.

Procedure: The arm is flexed with the palm facing upward while the individual resists against downward pressure applied by the examiner.

Yergason's Test:

Evaluates the stability of the long head of the biceps tendon in the bicipital groove.

Procedure: The individual flexes the elbow at 90 degrees and resists supination and external rotation.

Cross-Body Adduction Test:

To check for acromioclavicular joint pathology or inflammation involving the bursa.

Procedure: The arm is passively adducted across the body, and pain at the acromioclavicular joint indicates a positive test.

4. Diagnostic Imaging:

Imaging tests like X-rays, ultrasound, or MRI scans may be recommended to confirm the diagnosis or rule out other shoulder conditions like rotator cuff injuries or arthritis.

 

Differential Diagnosis

• Rotator Cuff Tear or Tendinopathy
• Frozen Shoulder (Adhesive Capsulitis)
• Shoulder Impingement Syndrome
• Glenohumeral Joint Arthritis
• Biceps Tendinitis
• Supraspinatus Tendinopathy
• Acromioclavicular (AC) Joint Arthritis or Separation
• Cervical radiculopathy
• Cervical disc herniation
• Brachial Plexus Injury
• Septic arthritis
• Osteomyelitis

 

Shoulder Bursitis Physiotherapy Treatment

Range of Motion Exercises: 

In this controlled movements are performed to enhance the shoulder's flexibility and mobility.

• Flexion and extension
• Shoulder abduction and adduction
• Internal and external rotation
• Shoulder circles
• Cross-body adduction stretch
• Wall ladder
• Codman's pendulum exercises

Stretching Exercises:

Gentle stretching exercises can be done to improve flexibility in the shoulder joint and surrounding muscles, reducing stiffness.

• Pendulum stretch
• Cross-body shoulder stretch
• Towel stretch
• Wall crawl
• Arm circles
• Shoulder blade squeeze
• Doorway stretch
• Sleeper stretch

Strengthening Exercises: 

Targeted exercises to strengthen the muscles supporting the shoulder joint, especially the rotator cuff muscles. Gradual progression is made during sessions.

• External rotation with a thera band
• Internal rotation with a thera band
• Scapular squeezes
• Shoulder blade retraction
• Isometric of shoulder flexion
• Isometric of shoulder abduction
• Prone row

 

Manual Therapy Techniques:

• Soft Tissue Release: Techniques to release tension and improve blood flow to the affected area, promoting healing.
• Joint Mobilizations: Gentle movements to restore proper joint mechanics and reduce stiffness.

Posture and Ergonomic Education:

Physiotherapist provides guidance on maintaining proper posture related to activities of daily living and ergonomic adjustments to reduce stress on the shoulder joint. Some examples are listed below:

Occupational adjustments:

• computer should be at eye level
• keyboard and mouse should be at a comfortable height and close to body, to avoid reaching.
• use of wrist rests
• computer should be at a comfortable viewing angle
• ergonomic chair with adjustable armrests can be used
• using a chair with proper lumbar support that allows you to sit upright without straining your shoulders or neck
• taking regular stretch breaks 
• use of proper lifting techniques i.e. avoid lifting heavy loads with outstretched arms.
• Avoid slouching or hunching forward

 

Functional Rehabilitation:

Progressive exercise plan is used by physiotherapist focusing on functional movements specific to daily activities or sports requirements to regain shoulder strength and function.

Home Exercise Program:

Physiotherapist provides a personalized home exercise regimen to encourage ongoing rehabilitation and self-management.

Gradual Return to Activities:

Gradually reintroducing activities and exercises as symptoms improve to prevent recurrence or aggravation of the condition.

 

Research based Evidence on Shoulder Bursitis

Latest researches done for shoulder bursitis and the use of physiotherapy as a mode of treatment method has been found successful. Below are some methods that have been clinically found useful:

• Physiotherapy alone plan was found effective in shoulder bursitis patients with reduce recurrence rate as compared with individuals receiving corticosteroid injections plus physiotherapy sessions
• Range of Motion is significantly improved in individuals receiving mobilizations( distraction technique ) sessions along with intermittent stretching
• Positive results are seen if mobilization is done end and mid range, but end range mobilization (Kalternborn) gives immediate effective results
• Cycle Ergometer is useful
• Myofasial release technique on specific muscles upper trapezius, infraspinatus, pectoralis major and posterior deltoid muscles prior to heat application improved shoulder joint kinematics and pain.
• Inferior capsular stretching improves shoulder bursitis
• scapular proprioceptive neuromuscular facilitation is benefical in patients with night time pain complain
• matrix rhythm therapy
• cyclic stretching technique
• isometric and isotonic exercises with the use of a theraband and dumbbells for rotator cuff strengthening
• Ultrasound-guided corticosteroid injection into the subacromial and subdeltoid bursa are effective 

 

Frequently Asked Questions

Where is shoulder bursitis pain felt?

Shoulder bursitis typically causes pain and tenderness over the affected area of shoulder. The pain is usually present on the anterior aspect of the shoulder and may radiate along the upper arm. It worsen while performing overhead activities or at night, especially when lying on the affected shoulder. Subacromial Bursitis pain occurs on lateral or anterior aspect of shoulder.

 

What are shoulder bursitis exercises?

• Range of Motion Exercises
• Strengthening Exercises
• Stretching Exercises

 

Name shoulder bursitis test?

• Neer Test
• Hawkins-Kennedy Test
• Radiographs
• Magnetic resonance imaging
• Diagnostic ultrasound

 

Which exercises should you avoid in shoulder bursitis?

Exercises or movement which are repetitive or require overhead movement should be avoided.

• Overhead presses with weights or resistance bands
• Bench Press
• Lateral Raises (Abduction) using weights
• Pull-Ups/Chin-Ups
• Push-Ups

 

How long does shoulder bursitis last?

Acute shoulder bursitis resolves within a few days or weeks with rest, ice, and avoiding activities that exacerbate the condition. However, chronic cases take longer to heal and may require medical intervention such as physical therapy, corticosteroid injections, aspiration or, in rare instances, surgical intervention.