Shoulder Bursitis: Clinical Presentation and Management
Primary Symptoms
Shoulder bursitis typically presents with pain and tenderness localized to the affected bursa, most commonly the subacromial-subdeltoid bursa, with pain worsening during overhead activities and shoulder abduction. 1
Cardinal Clinical Features
Pain with overhead movements and abduction - The subacromial bursa becomes compressed during these motions, causing characteristic pain that limits functional activities 2
Point tenderness - Direct palpation over the affected bursal area (typically anterolateral shoulder) elicits localized pain 3
Limited range of motion - Particularly painful arc between 60-120 degrees of abduction when subacromial structures are maximally compressed 2
Swelling - May be visible or palpable in superficial bursitis, though subacromial bursitis swelling is typically not externally apparent 1
Night pain - Lying on the affected shoulder frequently disturbs sleep 4
Associated Findings
Weakness - Often secondary to pain inhibition rather than true motor deficit 4
Crepitus - Grinding or popping sensation may occur with scapulothoracic motion 5
Warmth and erythema - These signs suggest septic bursitis requiring immediate bursal aspiration for Gram stain, culture, cell count, and crystal analysis 1
Diagnostic Approach
Clinical Diagnosis
Diagnosis is primarily clinical, based on characteristic pain patterns and physical examination findings. 6 The key is distinguishing bursitis from rotator cuff pathology, arthritis, and nerve compression 3.
When to Image
Radiographs are NOT typically indicated for isolated bursitis but should be obtained if trauma, fracture, or chronic symptoms suggest underlying structural pathology 4
Ultrasound is useful for detecting bursal effusion, distinguishing bursitis from cellulitis, and identifying associated rotator cuff tears or tendinopathy 7, 1
MRI demonstrates 95% sensitivity and specificity for rotator cuff tears and degenerative changes that perpetuate bursitis, reserved for chronic or refractory cases 7
Critical Pitfall
If infection is suspected (warmth, erythema, systemic symptoms), bursal aspiration MUST be performed before initiating treatment - septic bursitis requires antibiotics effective against Staphylococcus aureus rather than conservative management 1
Treatment Algorithm
First-Line Conservative Management (All Non-Septic Cases)
Ice, activity modification, and NSAIDs provide short-term symptomatic relief but do NOT address underlying mechanical causes. 7
Rest from aggravating activities - Avoid overhead work and repetitive abduction 3, 1
Ice application - 15-20 minutes several times daily for acute symptoms 3
Topical NSAIDs - First-line pharmacological treatment for mild-to-moderate pain 6
Oral NSAIDs - Acetaminophen or ibuprofen if no contraindications 6, 3
Critical Error to Avoid
NEVER use overhead pulley exercises - these encourage uncontrolled abduction and dramatically increase shoulder pain risk 4, 7, 6
Second-Line Interventions
Corticosteroid injections provide short-term relief but require repeated administration and may cause tendon weakening with chronic use. 7
Subacromial corticosteroid injection - Consider when pain relates to inflammation in the subacromial region, though evidence for long-term benefit is limited 4, 6
Bursal aspiration - Generally NOT recommended for chronic microtraumatic bursitis due to iatrogenic septic bursitis risk 1
Addressing Root Causes to Prevent Recurrence
Chronic bursitis involves degenerative changes rather than acute inflammation, meaning anti-inflammatory treatments miss the underlying pathology. 7
Essential Rehabilitation Components
Eccentric strengthening exercises - Address mechanical causes by improving rotator cuff function 7
Stretching emphasizing external rotation and abduction - External rotation limitation relates most significantly to persistent shoulder pain 4, 7
Gradual active range of motion progression - Increase movement in conjunction with restoring scapular alignment and strengthening shoulder girdle muscles 6
Avoid complete immobilization - Causes muscular atrophy and deconditioning 7
Surgical Intervention
Surgery is reserved for recalcitrant bursitis unresponsive to 3-6 months of conservative management. 3, 5
Open or arthroscopic bursectomy demonstrates good-to-excellent outcomes in most patients 5
Partial scapulectomy may be considered for scapulothoracic bursitis 5
Special Considerations
Septic Bursitis Management
Outpatient oral antibiotics - For patients who are not acutely ill 1
Inpatient IV antibiotics - For acutely ill patients 1
Surgery - Reserved for antibiotic-resistant or recurrent septic bursitis 1
Post-Stroke Patients
About one-third of acute stroke patients show shoulder tissue injury on ultrasound (effusion in subacromial bursa, tendinopathy, rotator cuff tears) that may contribute to pain. 4, 6