Subacromial bursitis: Causes, Symptoms, and Treatment

Subacromial bursitis is a common cause of shoulder pain that is usually related to shoulder impingement of your bursa between your rotator cuff tendons and bone (acromion).

This bursa is located between the tendon of the supraspinatus muscle and the acromioclavicular joint (acromioclavicular joint or AC joint, consisting of the coracromial process (acromion) and the outer end of the collarbone (clavicle)). Bursa sacs practically serve as a “shifting layer.” They reduce the mechanical stress on bones and muscles.

A distinction is made between an acute and a chronic form of this inflammation. It is one of the most common shoulder diseases and is accompanied by severe pain.

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Causes of subacromial bursitis

As a rule, subacromial bursitis is caused by excessive or incorrect loading of the affected shoulder.

Particularly at risk are persons who regularly have to perform a certain movement in which the arm must be raised above the head, for example, tennis players or teachers writing on the blackboard. If such a strain exists over a long period, there are always minimal injuries to the bursa, which are not noticeable at first. Over time, these so-called “micro-traumas” then lead to an inflammatory reaction in the bursa.

Certain cells proliferate and produce more fluid and collagen. Besides, lime is often formed as a reaction to the constant mechanical irritation and stored in the tendons under the acromion. When this calcium enters the bursa, it additionally promotes the inflammatory reaction.

A special feature of the shoulder joint is that the subacromial bursa has little opportunity to expand. The deltoid muscle, the bony structures, and the tendons limit the bursa very closely. For this reason, subacromial bursitis is less likely to cause pronounced joint effusions with swelling compared to another bursitis, and movement is restricted more quickly.

Other factors that can promote the development of bursitis in the shoulder are physical (excessive heat/cold, UV light, ionizing radiation) or chemical (heavy metals, toxins, acids, alkalis) irritation, a derailment of the body’s enzyme balance or foreign bodies in the shoulder.

It is less common for subacromial bursitis to occur as part of an underlying disease, for example, malignant tumors, rheumatic diseases (especially rheumatoid arthritis), or metabolic diseases such as gout.

Check our article about Rotator cuff tendonitis: Causes, Symptoms, and Treatment

Symptoms of subacromial bursitis

The main symptom of subacromial bursitis is severe pain. The pain of bursitis of the shoulder does not only exist during movements but also at rest and in many patients even during the night.

In the course of the disease, the pain is accompanied by a more or less pronounced restriction of movement of the shoulder joint, which can be accompanied by weakness in this very joint. Occasionally, other symptoms typical of inflammation, such as overheating or redness, are added. In contrast, swelling in the shoulder area is rarely found in subacromial bursitis.

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Night-time pain

Inflammations cause pain at the beginning, often only when the respective structure is strained or loaded. The more pronounced the inflammation is, the sooner the pain finally shows itself at rest or even at night. Especially an inflammation of the bursa in the shoulder (bursitis subacromialis) can disturb the night’s rest, as different sleeping positions can lead to irritation of the affected bursa or simply put pressure on the affected shoulder.

Restriction of movement

The clinical picture of “frozen shoulder” describes a chronic inflammation of the shoulder joint capsule (not the subacromial bursa!), which leads to a temporary stiffening of the shoulder joint through inflammatory adhesions. Patients between the ages of 40 and 60 are particularly frequently affected, with women more affected than men. In some cases, both shoulder joints may be affected at the same time, but the cause of this inflammatory disease has not yet been clarified. The symptoms can last for months or even years and range from minor pain in the shoulder to more or less pronounced movement restrictions. Therapeutic measures can include conservatively prescribed painkillers, joint anti-inflammatory injections, or surgical splitting of the shoulder joint capsule.

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Loss of strength

Since subacromial bursitis is an inflammation of the bursa below the acromion near the glenohumeral joint, it is often accompanied by a functional impairment of the joint. Because the affected bursa is located in the space between the shoulder joint and the acromion (part of the shoulder blade), and because this space becomes narrower, especially during arm movements such as lifting the arm between 80-120° to the side or forward, pain occurs during many everyday movements. Besides, movement restrictions and a significant reduction in strength in the shoulder can also become apparent.

Duration

The duration depends strongly on the severity of the inflammation and the triggering factors.

If the bursitis appears for the first time in the form of a slight irritation pain after an unusual movement in the shoulder, the duration of the symptoms is often short. If the patient does not move, the inflammation can subside within a few days. If the symptoms are ignored for longer, the duration of the complaints can be prolonged. Despite anti-inflammatory therapy, healing can take several weeks.

However, latent inflammation, which occurs due to permanent, e.g., work-related movement, can take a very long time to heal.

The pain can become chronic, persist for months, and not respond to conventional therapies. Pain that persists for more than six months is often referred to as chronic pain. The reason for chronification is often the fact that the triggering factor of subacromial bursitis is not treated.

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Diagnosis of subacromial bursitis

The diagnosis “Bursitis subacromial” can usually be made simply by taking the patient’s medical history (anamnesis) and a thorough clinical examination.

Very typical is the pain when the affected arm is lifted laterally between 80° and 120° (important differential diagnosis here is the impingement syndrome! Various clinical tests that suggest the presence of impingement syndrome, for example, the Neer sign or the speed test can help here). In case of doubt, an X-ray (in which calcifications become visible), sonography, or an MRI of the shoulder (magnetic resonance imaging of the shoulder) can be carried out additionally. Here the soft tissues such as muscles and ligaments can be visualized well, and any joint effusion can also be detected.

Important differential diagnoses (alternative causes) of subacromial bursitis are

  • Degenerative changes in the shoulder joint (arthrosis)
  • Rupture of the rotator cuff
  • Dislocations in the shoulder joint (luxation)
  • An impingement syndrome

Therapy of subacromial bursitis

The therapy of acute subacromial bursitis consists mainly of sparing the shoulder joint. It should initially be immobilized as far as possible. In particular, the movement that probably led to the bursitis should be avoided. Besides, many patients find cooling pleasant, as this reduces the inflammatory reaction on the one hand and relieves pain on the other.

If the pain cannot be brought under control, the use of medication is recommended. There are several ways to take medication orally. Painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or diclofenac, are particularly effective. Another option is to inject a drug, usually an anti-inflammatory glucocorticoid, directly into the subacromial space.

Physical measures can also be used. Classically, patients are treated with physiotherapy, but massages or TENS can also be useful. For some, acupuncture therapy also produces good healing results.

If all of these conservative therapy approaches achieve no or insufficient improvement of the symptoms, the patient should consider the possibility of surgery together with a doctor and weigh up the advantages and disadvantages. Every operation entails risks, but if it is successful in the case of subacromial bursitis, the patient can quickly achieve freedom from symptoms that will remain permanently. In such an operation, the bursa is usually removed as part of a minimally invasive procedure.

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Physiotherapy

In the therapy of subacromial bursitis, the main consideration is to avoid pain and to inhibit inflammation with medication.

If the drug treatment approaches fail, many orthopedic surgeons immediately resort to surgery and removal of the bursa.

But physiotherapy offers an important alternative in the treatment of bursitis.

Physiotherapy should only be performed if the movements can be performed without severe pain. Otherwise, the movements are carried out incorrectly due to the pain and can aggravate the disease in an emergency.

As soon as the inflammation has subsided to a large extent and the pain subsides, the joint must be moved and trained before movement is restricted.

A first possibility of physiotherapy is TENS, the transcutaneous electrical nerve stimulation. The aim is to influence the nerves in the shoulder via electrical signals on the skin in such a way that the pain is reduced.

Learn more about this under electrotherapy

Another possibility is shock wave therapy, whereby mechanical waves from outside are used to hit the inflammation and accelerate its healing process. Also, heat and cold therapies and massages are used.

To maintain and strengthen the joint function, physiotherapy exercises are in the foreground.

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Exercises during the subacromial bursitis

The exercises in case of subacromial bursitis must be performed with care and gently.

To avoid incorrect loading, the exercises should initially be instructed by a doctor or physiotherapist.

Severe pain also speaks against exercising physiotherapy.

The shoulder muscles should first be loosened. This can be achieved by standing up straight, pulling the shoulders up, and shaking the arms hanging limp and swinging them loosely around. Cramped muscles are a common cause of bursitis.

Lifting the arms and swinging them loosely, like in a virtual boxing match, also loosens the muscles.

An important exercise to strengthen the everyday head and shoulder posture is rolling the shoulders in a standing or sitting position. This is done by lifting the head, stretching the upper back, and pulling the shoulders as high as possible, then moving them back and letting them sink again. Each of these postures should be held for a few seconds.

It is important not to put too much weight on the arms and to avoid cramping them.

Especially when working above the head, many relaxation breaks must be taken during which these loosening exercises can be performed.

Prevention is particularly important after having already survived subacromial bursitis.

Teachers, for example, should keep the blackboard as low as possible so that the shoulder is not unnecessarily strained when writing at the same time.

Sitting activities should always be performed at the correct height. The desk must be at the correct individual height. Here too, relaxation exercises and sufficient breaks are important for prevention.

Read more about Acromioclavicular dislocation: Symptoms and Treatment

How much can physiotherapy help?

Physiotherapeutic treatment is an important area in the conservative therapy of subacromial bursitis. Before resorting to surgery, if drug therapy is not sufficiently successful, physiotherapy should first be considered. Within the scope of this, for example, pain relief can be achieved by so-called TENS (transcutaneous electrical nerve stimulation), and inflammation inhibition can be pursued by shock wave therapy. However, the focus is on cold and heat therapy, massages, and, above all, movement and strengthening exercises for the shoulder/trunk area to maintain and improve mobility and function in the shoulder joint. Any exercises must be only carried out if they are relatively painless; otherwise, they may be performed incorrectly. Often, a good result can be achieved by consistent physiotherapeutic training, in combination with anti-inflammatory and pain-reducing medication and injections, without the need for surgery.

When is an operation necessary?

Surgery is often performed at an early stage in cases of inflammation of the bursa of the shoulder.

However, since the bursa plays an important role in protecting the joints and tendons, all conservative therapeutic measures should be exhausted before an operation is performed.

In addition to drug therapy and immobilization, these include physical therapy, manual therapy, and physiotherapy.

However, the operation should be performed if there is an acute and extremely severe inflammation of the bursa, which can spread and lead to further damage to the joint.

However, surgery is excluded in cases of inflammation that is not physical but infectious.

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Prognosis

If subacromial bursitis is not detected and treated in time, it can change from an acute to a chronic form. In such patients, it is difficult to treat the disease without permanent damage.

If, on the other hand, this bursitis is treated appropriately at an early stage, the most important thing here is the consistent protection of the shoulder joint and the intake of anti-inflammatory painkillers, it can usually be brought under control.

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