Many of us will experience shoulder pain at some point in our lives. This pain can result from an acute injury or chronic overload, with various possible diagnoses presenting a unique set of symptoms and challenges. One of the most common sources of shoulder pain is related to the structures under the acromion, a bony projection on the scapula, as shown in the figure below. This type of pain is sometimes referred to as sub-acromial pain. The structures under the acromion, which include the sub-acromial bursa and rotator cuff tendons, can be susceptible to injury or inflammation, leading to two common problems: rotator cuff tears and sub-acromial bursitis.
What Is Shoulder Bursitis?
Shoulder bursitis is a condition that arises from inflammation of the bursa located in the shoulder area. A bursa is a small, fluid-filled sac that acts as a cushion, reducing friction between tissues such as bones, muscles, and tendons. These sacs are found throughout the body and help facilitate smooth movement.
In the context of the shoulder, the specific bursa in question is called the 'sub-acromial bursa.' This bursa is situated right under the acromion, a bony projection on the shoulder blade (also known as the scapula) as shown in the figure above. The sub-acromial bursa's primary function is to reduce friction and protect the underlying tissues like the rotator cuff (which we will discuss in more detail below) whenever you move your arm. Shoulder bursitis, also known as subacromial bursitis, occurs when the sub-acromial bursa becomes inflamed.
What Is The Rotator Cuff?
The rotator cuff is a group of muscles and their tendons that surround the shoulder joint, providing it with stability and enabling a wide range of arm movements. It comprises four main muscles: the Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. Each of these muscles originate on the scapula and attach to the head of the humerus (upper arm bone), forming a cuff over the shoulder as seen in the picture below. Their primary function is to stabilise the shoulder joint and facilitate movements such as lifting, reaching, and rotating the arm.
Rotator cuff injuries can range from mild fraying (often called a 'tendinopathy') to more severe conditions such as partial or complete tears of the tendons. These injuries often result from repetitive overhead motions or acute trauma such as a fall and landing on an outstretched arm.
Identifying The Cause Of Your Shoulder Pain
The sub-acromial bursa and the rotator cuff are two of the most common sources of shoulder pain and combined are by far the most common reason for a shoulder-related visit to a physiotherapy or GP clinic. Given the high prevalence of these injuries, the following questions should be considered:
Can we tell them apart;
Will this make a difference in our management, and;
What other possible diagnoses are there which could explain my symptoms
Due to the close anatomical proximity of the bursae and rotator cuff tendons in the shoulder, distinguishing between bursitis and rotator cuff injuries poses a diagnostic challenge. There are three elements to consider when trying to differentially diagnose any source of shoulder pain:
Signs & Symptoms: Both bursitis and rotator cuff pain are characterised by discomfort during movement, with symptoms such as a painful arc (as seen in the picture below) indicating potential irritation of structures beneath the acromion, (including the bursa and rotator cuff). Given their anatomical closeness, clinical tests may not always conclusively distinguish between the two, as symptom overlap is common (It's also worth noting both can become a source of pain simultaneously). Nevertheless, specific clinical indicators may lean more towards a rotator cuff injury, notably a persistent decrease in strength and range of motion that does not significantly improve with treatments like physiotherapy or steroid injections. This association becomes increasingly evident in cases of larger rotator cuff tears.
Mechanism of Injury: While both bursitis and rotator cuff tears can result from trauma, such as falling onto an outstretched arm, this mechanism is especially common for rotator cuff tears.
Medical Imaging: Ultrasound or MRI imaging offers clearer insights into the pain's origin, capable of identifying bursa inflammation or specific injuries like tendinopathy or tears in the rotator cuff. It's important to note, however, that imaging findings must be correlated with clinical tests, as there is the possibility of incidental findings that may not be contributing to symptoms in question.
Alternative Sources Of Shoulder Pain
When shoulder pain presents, it’s important to consider potential causes other than the above mentioned bursitis and rotator cuff pain. A number of conditions can manifest with similar symptoms, yet each is likely to require a distinct treatment strategy and carry different prognoses regarding recovery timelines. Other more common conditions include:
Frozen Shoulder: Characterised by pain and stiffness in the shoulder joint, this condition typically moves through stages, progressing from painful and transitioning to a stiff joint leading to a persisting limitation of range of motion. This condition can mimic or coexist with other shoulder pathologies and can take 8-12 months to resolve.
AC Joint Pain: The acromioclavicular (AC) joint, where the collarbone meets the highest point of the shoulder blade, can become painful due to injury or degeneration. AC joint pain is often characterised by localised pain and tenderness at the top of the shoulder and can worsen with overhead movements or when lying on the affected side.
Referred Pain: Shoulder pain may not always originate from the shoulder itself. Conditions like cervical radiculopathy, where nerve roots in the neck are compressed, can cause pain that is felt in the shoulder and arm.
Labral Tear: The labrum, a cuff of cartilage that surrounds the shoulder socket, helps stabilise the joint. Tears in this structure can cause similar symptoms to both rotator cuff injuries and bursitis but often also lead to feelings of clunking, catching and instability.
The Relevance Of Accurate Diagnosis: When Does It Truly Matter?
Achieving an accurate diagnosis holds significant importance in numerous scenarios, influencing the expected recovery timeframes, the nature of treatment protocols, and the necessity for specialist consultations. Particularly in instances like a large rotator cuff tear, understanding the precise nature of the injury not only changes our expectations regarding the healing process but also dictates the most effective treatment strategies. It can determine whether conservative management is appropriate or if surgical intervention needs to be considered. An accurate diagnosis may prompt timely referrals to specialists, ensuring that patients receive the most specialised care possible, thus improving recovery outcomes. This highlights the important role that an exact diagnosis plays in the management of shoulder injuries, marking the difference between a straightforward recovery and one that may require more intensive, targeted intervention.
Understanding The Causes: Why Am I Experiencing Shoulder Pain?
Shoulder pain typically occurs when the stress exerted on the structures around the shoulder exceed their capacity to cope. This threshold is affected by various factors, including:
Adaptations in muscles and tendons around the shoulder from recent physical activities or exercises and;
The tissue's recovery capability, which is influenced by overall health factors such as smoking status and medical conditions like diabetes, as well as sleep quality and nutrition.
This excessive strain (strain which exceeds the body's capacity to recover) may result from chronic overuse, unfamiliar activities that impose unusual stress on the shoulder, or acute trauma. Typical scenarios include:
Lifting heavy objects overhead without proper preparation
Engaging in repetitive sports movements, such as the serving action in tennis or the overhead swing in badminton, which can stress the same shoulder areas repeatedly.
Performing extensive yard work or gardening, especially activities involving reaching or lifting above shoulder level, like trimming hedges or trees.
Participating in manual labor tasks, such as construction work or painting, where the arms are frequently raised above the head for prolonged periods.
Falling onto an outstretched arm, leading to a sudden and significant increase in stress on the shoulder's structures
It is also important to consider the influence of posture and lifting technique on the strain imposed on the structures around the shoulder. Certain postural habits (such as rounded shoulders), for example, can alter the biomechanics of the shoulder joint, possibly leading to increased pressure and friction on the subacromial bursa and rotator cuff for a given load. This altered biomechanical environment in the presence of a sudden increase in tissue strain, (such as those encountered in the situations described above), may exacerbate the risk of developing shoulder pain.
Treating Your Shoulder Bursitis or Rotator Cuff Injury for Lasting Pain Relief
While path to recovery from shoulder pain involves a mix of therapeutic approaches tailored to each specific diagnosis, understanding the following two factors remain critical to effective relief for the vast majority cases:
Identifying and modifying the aggravating cause of pain: This seemingly simple yet crucial step can greatly reduce the likelihood of future pain in non-traumatic causes of pain. For example, in a scenario like repetitive overhead gardening, alternating arm use and spreading tasks over several days, instead of completing them all in one day, can help prevent aggravation. Additionally, optimising your posture and lifting technique can further reduce strain on the shoulder, helping to prevent flare-ups and promote long-term recovery. In the early stages of rehabilitation, avoiding the aggravating movement entirely, if possible, is recommended to accelerate recovery.
For many causes of shoulder pain, the aggravating factor may not be immediately obvious. At ProSport Physio, our experienced physiotherapists conduct a thorough assessment to identify the source of your pain, then provide personalised advice on modifying activities and optimising shoulder posture with subtle yet effective postural cues, helping to relieve pain and begin the recovery process.
Identifying and improving the current load capacity of the shoulder joint, muscles and tendons. This step is also crucial for managing and improving shoulder pain. Load capacity, as mentioned earlier, refers to how much stress the area can handle before fatigue or injury. If it’s too low, simple everyday activities like lifting or reaching can worsen pain.
At ProSport Physio, we assess your shoulder’s current strength and endurance, then develop a personalised exercise plan to progressively build the muscle and joint strength. The figure below shows a strength/load capacity profile of a right-sided shoulder injury, highlighting deficiencies in strength. This is an assessment you’ll receive during your first consultation with us. This visual representation highlights your strengths and weaknesses, allowing us to tailor a plan that improves your shoulder’s load tolerance, reduces pain, and reduces your risk of future injury. This enables you to safely return to normal activities, whether it’s gardening, heavy resistance training, or playing sports.
Below is a summary of treatment specifics for the two most common sub-acromial issues:
Shoulder Bursitis Treatment:
Activity Modification: Avoid activities that exacerbate the pain initially, progressively increase activity once the inflammation in the bursa has resolved, the cause has been identified and any underlying weaknesses have been addressed.
Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) are often effective in reducing inflammation and aiding recovery. Use should be guided by your pharmacist or GP.
Exercise: Engage in physiotherapy guided exercises to improve the strength of tissues around the shoulder without irritating the bursa.
Injections: Consider a corticosteroid injection into the bursa if symptoms persist despite conservative treatment.
Prognosis: Recovery time can vary significantly, but most patients see substantial improvement in 6-12 weeks.
Rotator Cuff Injury Treatment:
Activity Modification: Avoid or limit activities that exacerbate the pain initially (depending on the chronicity and severity of this injury). Progressively increase activity as the load tolerance of the rotator cuff improves, the initial cause of pain has been identified and any underlying weaknesses have been addressed.
Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) may help to manage pain. Use should be guided by your pharmacist or GP.
Exercise: Engage in physiotherapy-guided exercises to enhance the load tolerance of the rotator cuff muscles and tendons, as well as those of the surrounding muscles.
Injections: May help with short-term symptom relief however should be avoided due to the negative effect it can have on tendon health.
Surgical Intervention: Necessary for significant tears when conservative measures (exercise and activity modification) fail.
Prognosis: Recovery times vary; rotator cuff tendinopathy may respond to conservative measures within 2-4 weeks, while small tears typically take 6-12 weeks to become symptom free. Significant tears requiring surgery may need 6-12 months for full recovery. Your physiotherapist can advise you on the likely recovery times based on your specific scenario.
Overall Approach: In some cases, imaging may be indicated, and more invasive therapies may be required, such as corticosteroid injections or surgery for large rotator cuff tears unresponsive to conservative management. Ultimately, a holistic and individualised treatment plan, guided by a skilled physiotherapist and GP if needed, offers the best chance for relief from shoulder pain and a return to normal function.
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