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Sports Injury Prevention & Rehabilitation

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Subacromial Bursitis

What is subacromial bursitis?
Subacromial bursitis is a condition characterized by tissue damage and inflammation of the subacromial bursa (a small fluid filled sac located beneath the bony prominence at the top / outer aspect of the shoulder) causing pain in the shoulder.
The shoulder joint is a ball and socket joint. The socket arises from the outer aspect of the shoulder blade, whilst the ball arises from the upper aspect of the humerus (upper arm bone). Just above the ball and socket joint of the shoulder is a bony prominence known as the acromion. Beneath the acromion lies a bursa known as the subacromial bursa. A bursa is a small sac filled with lubricating fluid and is designed to reduce friction between adjacent soft tissue or bony layers. The subacromial bursa reduces friction between the bony prominence of the acromion (above the bursa) and the tendon of the supraspinatus muscle (which attaches to the upper aspect of the humeral head – below the bursa).
During certain activities such as arm elevation, rotating the shoulder, lifting, pushing or pulling or lying on the shoulder, friction and compressive forces are placed on the subacromial bursa. Pressure may also be placed on the subacromial bursa following a direct impact or fall onto the point of the shoulder, elbow or outstretched hand. When these forces are excessive due to too much repetition or high force, irritation and inflammation of the bursa may occur. When this occurs, the condition is known as subacromial bursitis.
Subacromial bursitis often occurs in association with other conditions of the shoulder such as a rotator cuff tear or tendinopathy.

Causes of subacromial bursitis
Subacromial bursitis most commonly occurs due to repetitive or prolonged activities placing strain on the subacromial bursa. This typically occurs due to repetitive arm elevation activities, activities involving rotating the shoulder, lifting (especially overhead), pushing or pulling activities (placing strain on the bursa via the supraspinatus tendon), placing weight through the affected arm or lying on the affected side. Occasionally, the condition may occur suddenly due a direct blow to the point of the shoulder or due to a fall onto the shoulder, elbow or outstretched hand.
Anomalies to the acromion bone, degenerative changes to the AC joint, or bony spurs known as osteophytes, may predispose a patient to developing subacromial bursitis.

Signs and symptoms of subacromial bursitis
Patients with this condition typically experience pain at the top, front, back or outer aspect of the shoulder. Pain may also radiate into the upper arm as far as the elbow. In less severe cases, patients may only experience an ache or stiffness in the shoulder that increases with rest following activities placing strain on the bursa. These activities typically include arm elevation activities, shoulder rotating activities, lifting, pushing or pulling, placing weight through the arm or lying on the affected side. The pain associated with this condition may also warm up with activity in the initial stages of injury.
As the condition progresses, patients may experience symptoms that increase during activity or sport, affecting performance. Patients with subacromial bursitis may also experience pain on firmly touching the top / outer aspect of the shoulder. A painful arc of arm elevation and / or a feeling of shoulder weakness may also be present particularly when attempting to lift or elevate the arm overhead.

Diagnosis of subacromial bursitis
A thorough subjective and objective examination from a physical therapist may be sufficient to diagnose subacromial bursitis. An ultrasound is usually the common investigation used to identify subacromial bursitis. Further investigations such as an X-ray, CT or MRI scan are often required to assist diagnosis and assess the severity of the condition or the presence of other conditions.

Prognosis of subacromial bursitis
Most patients with this condition heal well with appropriate physical therapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time, or, in those with other associated injuries such as rotator cuff pathology. Early physical therapy treatment is vital to hasten recovery in all patients with subacromial bursitis.

Treatment for subacromial bursitis
The success rate of treatment for this condition is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from any activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate, appropriate treatment in patients with subacromial bursitis is essential to ensure a speedy recovery. Once the bursitis is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
Patients with this condition should follow RICE in the initial phase of injury. RICE is beneficial in the first 72 hours following injury onset or when inflammatory signs are present (i.e. morning pain or pain with rest). RICE for subacromial bursitis primarily involves resting from aggravating activities and regular icing. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
Manual "hands-on" therapy from the therapist such as massage, trigger point releases, joint mobilisation, manipulation, dry needling, stretches and electrotherapy can also assist with hastening healing and improving flexibility and function in patients with subacromial bursitis.
Patients should also undergo a graduated flexibility and strengthening program of the surrounding muscles to ensure an optimal outcome. Particular emphasis is placed on improving shoulder blade stability, posture and rotator cuff function. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
Often, a corticosteroid injection by a sports physician into the subacromial bursitis is effective in reducing symptoms and allowing earlier rehabilitation progression.
In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating physical therapist provided there is no increase in symptoms.

Contributing factors to the development of subacromial bursitis
There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physical therapist. Some of these factors include:
  • joint stiffness (particularly the shoulder, neck or upper back)
  • shoulder instability
  • bony anomalies of the acromion or AC joint
  • muscle tightness (particularly the rotator cuff, pectorals and deltoid)
  • poor posture
  • inappropriate or excessive training
  • inadequate warm up
  • muscle weakness (especially the rotator cuff and scapula stabilizers)
  • muscle imbalances
  • inadequate rehabilitation following a previous shoulder injury or surgery
  • inappropriate technique (e.g. swimming stroke, tennis serve, throwing)

Physical therapy for subacromial bursitis

Physical therapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence in all patients with subacromial bursitis. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound, TENS etc)
  • stretches
  • joint mobilization
  • joint manipulation
  • ice or heat treatment
  • exercises to improve strength, flexibility, posture and scapula stability
  • correction of abnormal biomechanics or technique
  • education
  • postural taping
  • the use of a postural support
  • anti-inflammatory advice
  • activity modification advice
  • a gradual return to activity program

Other intervention for subacromial bursitis
Despite appropriate physical therapy management, some patients with this condition do not improve adequately. When this occurs the treating physical therapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition.