SUBACROMIAL BURSITIS

BURSA
• Bursa is a sac that is filled with liquid that can be found
between tissues (bone, skin, tendons and muscle).
Because of that fluid the bursa can be used as a cushion
that has the function to decrease the friction and the
irritation between the tissues that move between each
other.
• When the bursae is not irritated, joints move smoothly and
painless, But when it becomes inflamed and swollen, will
experience pain during physical activity.
 MAJOR BURSAE IN SHOULDER REGION
• Subscapular Bursa or the Scapulothoracic Bursa: between the tendon of the
Subscapularis muscle and the shoulder joint capsule.
• Subdeltoid Bursa: between the Deltoid muscle and the shoulder joint cavity.
• Subacromial Bursa: below the acromion process and above the greater
tubercle of the humerus. It's function is to reduce friction in the space
under the acromion.
• Subcoracoid Bursa: between the coracoid process of the scapula and the
shoulder joint capsule.
• The subacromial and the subdeltoid bursa are often taken as a single bursa,
the subacromial deltoid bursa
• The bursae do have a nerve supply, for instance the Subacromial
Bursae has Suprascapular and Axillary nerve endings.
• Nociceptors such as free nerve endings would give information
about painful stimulation and inflammatory responses to the
brain. But also mechanoreceptors in the bursae of the shoulder
are capable of giving proprioceptive information of shoulder
joint position.
• This shows that bursae don’t strictly function as a lubricator
between tissues.
 FACTORS THAT COULD BE RELATED TO
BURSITIS
• Trauma: Due to an accident, the bursa could become irritated and
inflamed.
• Inflamed joint: When the whole joint is inflamed, the bursa can become
inflamed as well as other structures. i.e. arthritis, gout.
• 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, …
• Chronic irritation
• Upper extremity muscle weakness
• Degeneration of muscle tendons
• Calcium deposition
• Adjacent inflammation of the Supraspinatus tendon
• Glenohumeral instability (excessive movement of the joint)
• Degeneration of the acromioclavicular (AC) joint
• Tears of the surrounding rotator cuff
• Impingement by the coraco-acromial ligament
• Coracoid impingement
• Impingement on the posterosuperior aspect of the glenoid
• Bursitis could also be related to some professional activities (e.g.
painter, …), although, this is not always the case in shoulder bursitis.
• Bursitis often develops secondary to injury, impingement, overuse of
the muscle, or calcium deposits.
 SUBACROMIAL BURSITIS

• Subacromial bursitis is a condition caused by inflammation of

the bursa that separates the superior surface of
the supraspinatus tendon from the overlying coraco-acromial ligament,
acromion, coracoid (the acromial arch) and from the deep surface of
the deltoid muscle.
• The subacromial bursa helps the motion of the supraspinatus tendon of
the rotator cuff in activities such as overhead work.
• Primary inflammation of the subacromial bursa is relatively rare and may
arise from autoimmune inflammatory conditions such as rheumatoid arthritis;
crystal deposition disorders such as gout or pseudogout; calcific loose
bodies, and infection.
• More commonly, subacromial bursitis arises as a result of complex factors,
thought to cause shoulder impingement symptoms. These factors are broadly
classified as intrinsic (intratendinous) or extrinsic (extratendinous).
• They are further divided into primary or secondary causes of impingement.
• Secondary causes are thought to be part of another process such as shoulder
instability or nerve injury.
 SIGN AND SYMPTOMS

• Subacromial Bursitis typically presents with lateral or anterior shoulder

pain.
• Patients only occasionally report a single macro traumatic event
leading to persisting pain. Overhead lifting or reaching activities
become uncomfortable, and the pain is often worse at night;
interrupting sleep.
• 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 in 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.
• Patient who suffer from Subacromial Bursitis should have a
glenohumeral abduction greater than 45 degrees to distinguish from
patients with established "frozen shoulders".
• The Subacromial bursitis pattern of symptoms may occur in relation to
rotator cuff tears, an impingement syndrome, frozen shoulder, or a
systemic inflammatory disorder such as polymyalgia rheumatica (PMR)
or rheumatoid arthritis (RA).
• Activities of daily living, household tasks and hygiene may be affected,
due to limited and painful overhead movements.
• 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.
• Other activities like contact sports are difficult to perform because they
can cause more pain.
 PATHOPHYSIOLOGY

• Pathophysiology of bursitis describes inflammation as the primary cause of

symptoms. Inflammatory bursitis is usually the result of repetitive injury to the
bursa.
• In the subacromial bursa, this generally occurs due to microtrauma to
adjacent structures, particularly the supraspinatus tendon. The inflammatory
process causes synovial cells to multiply, increasing collagen formation and
fluid production within the bursa and reduction in the outside layer of
lubrication.
• Less frequently observed causes of subacromial bursitis include hemorrhagic
conditions, crystal deposition and infection.
• The bursa facilitates the motion of the rotator cuff beneath the arch, any
disturbance of the relationship of the subacromial structures can lead
to impingement.
• These factors can be broadly classified as intrinsic such as tendon
degeneration, rotator cuff muscle weakness and overuse.
• Extrinsic factors include bone spurs from the acromion or AC joint,
shoulder instability and neurologic problems arising outside of the
shoulder.
 DIAGNOSIS

• Bursitis is typically identified by localized pain and/or swelling,

tenderness, and pain with motion of the tissues in the affected area.
• X-ray testing can sometime detect calcification in the bursa when
bursitis has been chronic or recurrent, with bursa fluid puncture is it
possible to rule out infections..
• While MRI scanning can be used to identify bursitis, but it is
uncommonly used for the diagnosis.
• It is often difficult to distinguish between pain caused by bursitis or
that caused by a rotator cuff injury as both exhibit similar pain patterns
in the front or side of the shoulder.

• Subacromial bursitis can be painful with resisted abduction due to the

pinching of the bursa as the deltoid contracts.
• The Subacromial Deltoid bursa comes into conflict with the Acromioclavicular
joint dysfunction. Positive painful arc ( pain between 60 and 120 degrees of
abduction) indicates Subacromial Deltoid Bursitis.
• To test the painful arc, patient stands up with arms alongside the body. then
actively abduct the shoulder from 0° to 180°. Test is positive when the patient
complains of pain between 60°-120° abduction.
• The pain results from compression of the Supraspinatus tendon and the
Subacromial Bursa in the subacromial space which becomes narrower at this
range. Beyond 120° the pressure on the bursa decreases and the pain is
lessened.
• If the therapist performs a treatment direction test and gently applies
joint traction or a caudal glide during abduction (MWM), the painful
arc may reduce if the problem is bursitis or adhesive capsulitis (as this
potentially increases the subacromial space).
 OUTCOME MEASURES

• Visual Analogue Scale

• Shoulder Pain and Disability Index (SPADI)
• DASH Questionnaire
 MANAGEMENT

• A common treatment for bursitis is the use of injections with or without

the use of ultrasound guidance or palpation. These injections could
contain steroids or other analgesic substances.
• Inflammation can also be treated with anti-inflammatory medication.
These 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.
• Since the appearance of bursitis is due to another medical condition, treating
the cause of this bursitis should be the first step. But since the bursa is still
painful, injection is often used to cure this pain. This injection can be in the
bursa, or in the muscle itself. A recent study has shown that both methods
reduce the pain, but there is no significant difference between the two
methods.
• Injection could be either ultrasound-guided or palpation-guided. However,
studies show that the ultrasound-guided injection is more precise to find the
exact location of the bursa.
 PHYSIOTHERAPY MANAGEMENT

Initial phase of physiotherapy rehab:

• Educate the patient about their condition and advise to avoid painful
activities and the importance of relative rest of the shoulder
• Grade 1 and 2 accessory mobilisations of the glenohumeral joint
• Soft tissue massage
• Gentle pendulum range of motion exercises
• Scapular exercises such as shoulder shrugs and shoulder retraction
exercises
• Stretching of tight muscles such as the levator scapula, pectoralis
major, subscapularis and upper trapezius muscle
• Rotator cuff strengthening - isometric contractions in neutral and 30
degrees abduction
• Ice
• Low intensity pulsed ultrasound
• Kinesio tape : for head of humerus repositioning
Intermittent phase of Physiotherapy Rehab:
• Advise the patient that they must perform all activities and exercises
pain free
• Mobilization with movement e.g. caudal glide with active abduction
• Specific muscle strengthening exercises especially for scapular
stabilization (serratus anterior, rhomboids and lower trapezius
muscles) e.g. strengthening lower trapezius muscle - bilateral external
rotation using a theraband, strengthening of serratus anterior,
punching with theraband resistance
• Active internal and external rotator exercises with the use of a bar or a
theraband
• Heat
• Kinesio Tape: for head of humerus repositioning, if necessary
Return to Functional Phase:
• Education about the importance of a home based exercise program in the
late stage of rehabilitation
• Correction of techniques performed
• Education to ensure that the patient performs activities and exercises within
pain free limits
• Exercises specific for the patient’s functional needs e.g. functional reaching
• Strengthen the shoulder elevators – deltoid, flexors and also latissimus dorsi.
• Progress strengthening exercises to incorporate speed and load to
make more functional
• Ice after exercise