Treatment of bursitis in the shoulder
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Pain in the shoulder is a common condition. There are many structures in and around the shoulder that can be a source for the pain.
The shoulder is the most mobile joint in the body, but is dependent on surrounding soft tissue structures for its stability.
The most important of these is the 'rotator cuff'. This consists of four muscles and their tendons that connect from the upper arm to the shoulder blade. A few of the tendons pass under the bony arch of the acromion. In addition, one of the tendons of the biceps muscle oribinates from the superior glenoid labrum of the shoulder joint and connects to the radius of the forearm. There is a bursa (a fluid-filled bag) that acts as a cushion that sits between the rotator cuff and adjacent bone. Disorders of the rotator cuff and bursa are the cause of most cases of shoulder pain.
Rotator cuff tendinitis or tendinopathy is inflammation and degeneration of the tendons of the rotator cuff; it is the most common shoulder disorder, accounting for 29% of cases.
Subacromial bursitis is inflammation of the bursa that sits between the acromion and the top of the humerus.
Both conditions occur when there is impingement of soft tissues by the bony arch of the acromion with subsequent wear-and-tear, and both produce similar symptoms.
The shoulder bursa can become inflamed from repetitive motion of the shoulder. Shoulder bursitis often occurs in sports with overhead activities such as swimming, tennis, or throwing. It may also occur in occupational activities such as painting or carpentry.
Bursitis and tendonitis are characterized by pain in the shoulder when lifting the arm out from the side of the body (abduction), causing restriction of movement. This phenomenon is referred to as a 'painful arc of abduction' when lifting the arm between ~60º and 120º.
Once raised beyond this point, there is little pain in conditions related to the rotator cuff or subacromial bursa. As the condition worsens, the pain becomes more persistent, and particularly severe at night. The patient may have pain on the outer front of the shoulder. The shoulder may hurt when the patient lifts the arm above their head. The outer side of the shoulder may become swollen and may at times feel warm. Eventually, if the tendinitis/bursitis continues without treatment, a rotator cuff tear may occur.
Before talking specifically about bursitis treatment, let’s discuss some other causes of shoulder pain that need to be ruled out first.
Calcific tendinitis is another condition of the rotator cuff that can cause pain and weakness in the shoulder. Calcium deposits in the tendons of the rotator cuff are seen in up to 20% of x-rays of adults with no symptoms. However, in some people (usually women, aged between 30-60 years, who have sedentary jobs) these deposits cause symptoms that can be severe. Initially there may be pain at rest or with abduction, a 'catching' sensation on movement of the shoulder, and pain at night. Severe pain and marked restriction of the shoulder then develops as calcium crystals from the tendon move into the subacromial bursa. The shoulder is red, warm and tender to touch, and the arm is usually held close to the chest.
The treatment consists of ultrasound guided needle lavage of the tendon to remove the crystals.
Another cause of painful shoulder is adhesive capsulitis or 'frozen shoulder'. This is a disorder in which there is inflammation in the ball-and-socket joint of the upper arm bone and shoulder, resulting in adhesions within the joint and contraction of its 'capsule'. Adhesive capsulitis may occur without any precipitating factors, or occur secondary to any condition that results in prolonged immobilization of the arm, including rotator cuff disorders, calcific tendinitis, mastectomy, or even fractures of the fore-arm.
Adhesive capsulitis results in limitation of both active and passive movement of the shoulder, causes pain at the extremes of motion, and interferes with daily activities. Night pain may be severe. There may be a sense of restriction of the joint when it is passively moved. It typically occurs in women aged between 40-60 years, and often in the non-dominant arm.
Pain localized to above the shoulder or the shoulder blade usually occurs because of problems in the acromioclavicular joint (i.e. between the shoulder blade and collar bone) or the neck.
A history and physical exam will be followed by imaging studies including x-rays, ultrasonography or occasionally, MRI.
The treatment of shoulder problems depends on their cause. Rotator cuff tendinitis and subacromial bursitis are initially treated with rest and ice packs on the shoulder for 20 to 30 minutes every 3 to 4 hours for 2 to 3 days or until the pain goes away.
Non-steroidal anti-inflammatory drugs and modification of activities that cause pain are helpful. An injection of a corticosteroid-local anesthetic mixture into the joint may be beneficial in those in whom the pain persists. The injection should be done using ultrasound guidance.
Physical therapy can be initiated to maintain flexibility and a full range of motion. There is still much debate as to which treatment is best, although many trials have compared different non-steroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections. One recent study noted that patients treated with corticosteroid injections appeared to get better faster than those who received physical therapy, although other investigators have found no difference between these treatments in their long-term effects. A home exercise program incorporating strengthening and stretching is advised.
The discomfort of shoulder bursitis may last several weeks to many months. It is important to modify activity or work routine to avoid any shoulder movements that make the bursitis worse.
In a study of patients with shoulder pain who visited their primary care physicians, almost one-quarter were completely recovered after one month, and almost 60% were completely recovered after one year. Patients whose pain was preceded by overuse or slight trauma were more likely to have a speedy recovery. Conversely, patients who presented with severe pain during the day or associated neck pain were likely to have resistant or recurrent complaints. This is most likely because the patients had concomitant neck problems as well as shoulder bursitis.
A newer treatment for tendonitis and bursitis may be very effective and prevent the need for surgery. Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the fascia. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality fascial tissue is stimulated to grow with natural healing.
For more information about this procedure, visit our sister site:
Tendonitis TendonitisandPRP.com provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.
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