Physical Therapist's Guide to Shoulder Bursitis
Shoulder bursitis is a painful condition that affects people of all ages. The condition tends to develop more in middle-aged, elderly, and individuals who have muscle weakness. Shoulder bursitis can have many causes, but the most common is a repetitive activity, such as overhead reaching, throwing, or arm-twisting, which creates friction in the upper shoulder area. Athletes often develop shoulder bursitis after throwing, pitching, or swimming repetitively. The condition can happen gradually or suddenly, or can be a result of an autoimmune disease. It can also occur without any specific cause. Physical therapy can be a very effective treatment for shoulder bursitis to reduce pain, swelling, stiffness, and associated weakness in the shoulder, arm, neck, and upper back.
Shoulder impingement and tendinitis can occur along with shoulder bursitis. A physical therapist can effectively treat all of these conditions together.
What is Shoulder Bursitis?
Shoulder bursitis (also called subacromial bursitis) occurs when the bursa (a fluid-filled sac on the side of the shoulder) becomes damaged, irritated, or inflamed. Bursitis ("-itis"); means "inflammation") means the bursa has become irritated and inflamed, which causes pain. Normally, the bursa acts as a cushion for the rotator cuff tendon of the supraspinatus muscle that sits under the bursa, and prevents the tendon from rubbing on the acromion bone above the bursa. Certain positions, motions, or disease processes can cause friction or stress on the bursa, leading to the development of bursitis. When the bursa becomes injured, the tendon doesn't glide smoothly over it, and can become painful.
Shoulder bursitis can be caused by:
- Repetitive motions (overhead reaching or lifting, throwing, or twisting of the arm)
- Muscle weakness or poor muscle coordination
- Incorrect posture
- Direct trauma (being hit, or falling on, the side of the shoulder)
- Shoulder surgery or replacement
- Calcium deposits in the shoulder
- Overgrowth or bone spurs in the acromion bone
- Autoimmune diseases, such as rheumatoid arthritis, gout, psoriasis, or thyroid disease
- Muscles or tendons in the shoulder area rubbing the bursa and causing irritation
How Does it Feel?
With shoulder bursitis, you may experience:
- Pain on the outer side or tip of the shoulder
- Pain when you push with your finger on the tip of the shoulder
- Pain when lying on the affected shoulder
- Pain that worsens when lifting the arm to the side
- Pain when rotating the arm
- Pain when pushing or pulling open a door
How Is It Diagnosed?
If you see your physical therapist first, the physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist also will ask you detailed questions about your injury, such as:
- How and when did you notice the pain?
- Have you been performing any repetitive activity?
- Did you receive a direct hit to the shoulder, or fall on it?
Your physical therapist also will perform special tests to help determine the likelihood that you have shoulder bursitis. Your physical therapist will gently press on the outer side of the shoulder to see if it is painful to the touch, and may use additional tests to determine if other parts of your shoulder are injured. The physical therapist also will observe your posture, and how you lift your arm.
Your physical therapist will test and screen for other, more serious conditions that could cause shoulder pain. To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests, such as an X-ray to confirm the diagnosis and to rule out other damage to the shoulder, such as a fracture.
How Can a Physical Therapist Help?
Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but results can often be achieved in 2 to 8 weeks, when a proper stretching and strengthening program is implemented.
During the first 24 to 48 hours following your diagnosis, your physical therapist may advise you to:
- Rest the area by avoiding lifting or reaching overhead, or any activity that causes pain.
- Apply ice packs to the area for 15 to 20 minutes every 2 hours.
- Consult with a physician for further services, such as medication or diagnostic tests.
Your physical therapist will work with you to:
Reduce Pain and Swelling. If repetitive activities have caused the shoulder bursitis, your physical therapist will help you understand how to avoid or modify the activities to allow healing to begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, specific exercises, and hands-on therapy, such as specialized massage.
Improve Motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the shoulder and arm. These might begin with "passive" motions that the physical therapist performs for you to gently move your shoulder joint, and progress to active exercises and stretches that you do yourself.
Improve Flexibility. Your physical therapist will determine if any shoulder, arm, chest, or neck muscles are tight, start helping you to stretch them, and teaching you how to stretch them.
Improve posture. If posture problems are found to be related to your condition, your physical therapist will work with you to help improve your posture to help alleviate your pain, and prevent future recurrence.
Improve Strength. Shoulder bursitis is often related to weak, injured, or uncoordinated shoulder muscles. Certain exercises will aid healing at each stage of recovery; your physical therapist will choose and teach you the correct exercises and equipment to use to steadily restore your strength and agility. These may include using cuff weights, stretch bands, and weight lifting equipment.
Improve Endurance. Regaining your muscular endurance in the shoulder is important after an injury. Your physical therapist will teach you exercises to improve your muscular endurance, so you can return to your normal activities. Cardio-exercise equipment may be used, such as upper-body ergometers, treadmills, or stationary bicycles.
Learn a Home Program. Your physical therapist will teach you strengthening and stretching exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.
Return to Activities. Your physical therapist will discuss your activity goals with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.
Speed Recovery Time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you safely heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.
If Surgery Is Necessary
Surgery is not commonly required for shoulder bursitis. But if surgery is needed, you will follow a recovery program over several weeks, guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.
Can this Injury or Condition be Prevented?
Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your shoulder, arm, chest, and neck to help prevent future injury. These may include strength and flexibility exercises for the shoulder, arm, chest, neck, and core muscles.
To help prevent a recurrence of the injury, your physical therapist may advise you to:
- Follow a consistent flexibility and strengthening exercise program, especially for the shoulder muscles, to maintain good physical conditioning, even in a sport's off-season or after you retire from sports.
- Always warm up before starting a sport or heavy physical activity.
- Learn and maintain good posture.
- Gradually increase any demanding activity, rather than suddenly increasing the activity amount or intensity. This includes household activities, office work, or athletics.
- Learn and maintain correct posture
Real Life Experiences
Beatrice is a 45-year-old professor who enjoys fixing up her century-old house on the weekends. After a long weekend of painting ceilings and hammering-in ceiling molding, her right shoulder was sore on the outermost tip of the shoulder area. She didn’t think anything of it, and went to bed. She awakened several times that night when she rolled onto her right side and felt a sharp pain in her right shoulder. When she got up the next morning, she felt pain when she tried to raise her right arm higher than her shoulder. She called her physical therapist.
Beatrice’s physical therapist asked her to describe her activities, and how her pain started and felt during the night. He gently touched the soft tissues on the outside of her shoulder, and noted the severe tenderness she felt. He tested the strength, flexibility, and motion in Beatrice’s shoulder, arm, chest, and neck, and concluded that her shoulder bursa was irritated and inflamed. He also found that Beatrice had some tight and weak muscles in the chest and shoulder areas. He diagnosed shoulder bursitis.
Beatrice said she wanted to get back to painting the last few rooms in her house, and to install some wallpaper before her relatives visited in 2 months. She also wanted to be able to write pain free on the whiteboard during her lectures at the university.
Her physical therapist began treatment that day by gently stretching her muscles that were found to be tight. He performed manual therapy on her shoulder area—gentle massage techniques to loosen those same muscles and coax the swelling out of the bursa area. He also applied ice and electrical stimulation to the area to help halt and reverse the inflammation process.
He recommended that Beatrice avoid activities like reaching overhead, lying on her right side, or lifting heavy objects with the right arm for a few days, until her pain subsided. Beatrice was also instructed in how, and when, to apply ice to the injured area.
When Beatrice returned for her next treatment in 2 days, she was already feeling less pain. She was able to lift her arm almost the whole way up before she felt pain. Her physical therapist taught her strengthening exercises for her shoulder muscles. Only light weights were used to avoid causing new pain. As Beatrice improved, the weights were gradually increased.
Two weeks later, Beatrice reported that she was able to sleep on her right side without pain. She was able to reach fully overhead, but her discomfort returned after 20 minutes of painting. Beatrice continued physical therapy, regaining more and more strength each week.
By the fourth week, Beatrice was able to use her arm overhead for an hour at a time. She reported she was able to write as needed on the whiteboard at school. She added some of the special strength exercises that she had learned into her weekly gym routine, to help prevent a recurrence of the bursitis.
By the fifth week, Beatrice had completed her visits to the clinic, and was continuing an independent home-exercise program. She called her physical therapist 1 week later to report that all her symptoms were gone. With her strength restored, she completed the painting and wallpapering of her house in record time!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat shoulder bursitis. However, you may want to consider:
- A physical therapist who is experienced in treating people with musculoskeletal injuries. Some physical therapists have a practice with an orthopedic or sports focus.
- A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of this condition. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther. 2004;17(2):152-164. Article Summary on PubMed.
Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis: a double blind trial. Phys Ther. 1986;66:194-199. Free Article.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.
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