What are the physical examination findings in chronic bursitis of the shoulder?

Physical Examination Findings in Chronic Bursitis of the Shoulder

Chronic bursitis of the shoulder presents with specific physical examination findings that can help establish the diagnosis. On physical examination, patients with chronic shoulder bursitis typically demonstrate point tenderness over the subacromial-subdeltoid area, pain with active and passive range of motion, and positive impingement signs. 1

Key Physical Examination Findings

Pain and Tenderness

• Localized tenderness over the subacromial-subdeltoid bursa
• Pain that worsens with overhead activities
• Pain with palpation of the lateral or anterior aspect of the shoulder
• Pain may be present at rest in more severe cases 2

Range of Motion Assessment

• Pain with active and passive shoulder abduction, particularly in the 60-120° arc (painful arc)
• Pain with internal rotation, especially when the arm is in an elevated position
• Limitation of motion due to pain rather than true mechanical restriction 1

Special Tests

• Positive Neer impingement sign: pain with passive forward elevation of the arm with the scapula stabilized
• Positive Hawkins-Kennedy test: pain with forward flexion of the humerus to 90° followed by forcible internal rotation
• Pain with cross-body adduction test (may indicate associated acromioclavicular joint involvement) 1

Associated Findings

• Possible mild swelling over the lateral or anterior shoulder
• Weakness of the rotator cuff muscles due to pain inhibition rather than true weakness
• Crepitus may be felt during shoulder movement in chronic cases
• Reduced active range of motion compared to passive range of motion 1

Examination Technique

For proper assessment of shoulder bursitis, the patient should be positioned as follows:

• Sitting position
• 90° flexion of the elbow joint
• Hand positioned in supination on top of the patient's thigh
• Dynamic examination with active and passive external and internal rotation 1

Differential Findings

It's important to distinguish chronic bursitis from other shoulder pathologies:

1. Rotator Cuff Tears:

   • Present with weakness in specific muscle testing
   • May have positive drop-arm test
   • Often have more significant functional limitations 1

2. Calcific Tendinopathy:

   • Often has more acute, severe pain
   • May have visible calcifications on imaging
   • Can coexist with bursitis 3

3. Adhesive Capsulitis:

   • Shows limitation in both active and passive range of motion
   • Characteristic loss of external rotation
   • Global restriction of shoulder movement 1

Clinical Pearls

• The presence of effusion in the subacromial-subdeltoid bursa is frequently associated with shoulder pain, often independently from underlying pathology 3
• Chronic bursitis rarely presents with inflammatory leukocytic cell infiltration but rather shows proliferative or degenerative changes 4
• Rice bodies (free-floating echogenic bodies) may be present in rare cases of chronic subacromial-subdeltoid bursitis and can be detected on advanced imaging 5
• Pain at night and at rest may indicate more severe inflammation or associated pathologies 2

Common Pitfalls

• Misdiagnosing shoulder pain as solely bursitis when it may be part of a broader impingement syndrome
• Failing to assess for associated rotator cuff pathology, which commonly coexists with bursitis
• Not differentiating between pain from bursitis and pain from acromioclavicular joint arthritis, which can present similarly 3
• Overlooking the possibility of referred pain from cervical spine pathology

Remember that while physical examination is valuable for diagnosis, imaging studies such as ultrasound or MRI may be necessary to confirm the diagnosis and rule out associated pathologies, especially in cases of chronic shoulder pain that don't respond to initial treatment 1.