Shoulder Pain Bursitis
What is Subacromial bursitis?
Subacromial Bursitis of the shoulder is one of the most common forms of Bursitis seen in an MSK therapy clinic setting, with Trochanteric Bursitis of the hip being a close second. The condition relates to restricted shoulder mobility and pain due to inflammation of the Subacromial bursa in part of the shoulder.
Image of Right Shoulder and Subacromial Bursa (highlighted)
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
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Many types of shoulder injuries may seem to have similar symptoms yet require different treatment. The reason there are so many types of shoulder injury is in part due to the complex nature of the shoulder joint system. Equally, an issue with one shoulder can impact other areas and vice versa. The body has made various tradeoffs, such as increased mobility over structural stability. The hip is a single joint with a great deal of stability, which one needs to carry the body's weight. However, the hip joint has far less mobility than the shoulder. Shoulders consist of between four and five types of joints, depending on how one views them. Many joints mean that the shoulders are very mobile, though at the cost of stability. The stability that exists comes from the fascia, a large number of muscles, ligaments and tendons. After all, the only bone that attaches the shoulder to the torso is the relatively small clavicle. Hence, a lot can go wrong when structures are not moving as they should. Due to injury, habits, diseases, and infections, issues can arise with any joints or other soft tissue structures.
Shoulder Bursitis and Pain
Many types of trauma injury involve the shoulders, directly or indirectly. There are many examples, such as falls and road traffic accidents. In the case of falls, landing on a hand, elbow, or shoulder will affect the shoulder and other structures. Seat belts in road traffic accidents also involve the shoulders, as does holding the steering wheel at the time of impact. However, many traumas involve the entire body and changes in mobility in one area affect other areas (see related articles biotensegrity and adaptation). For example, a lower leg or hip injury could require crutches for an extended period, affecting the shoulders. The author is often surprised at how many people never seek treatment after severe traumas, besides the life-saving skills at A&E at the time of injury. Instead, people can put up with pain and a lack of mobility for months, which can easily lead to the condition becoming chronic and resulting in Persistent Pain. During this time, the body adapts and learns to move differently to avoid pain, allowing one to function fairly normally and tissues to heal to some extent. The adaptations in movement can also affect how tissues heal, and the new ways of moving soon become normal and second nature. Hence, one may not feel the pain of the original injury, but one is not moving in the same way as before the trauma. Such tissue adaptations and mobility changes can gradually cause other issues elsewhere as other tissues adapt to changed movement patterns. All the changes can easily cause extra friction, which can then lead to tissue inflammation and Bursitis.
Why might the Subacromial bursa become inflamed?
As with many MSK injuries, shoulder bursitis can typically occur due to many reasons, and the onset can vary based on the injury mechanism:-
- A specific trauma or injury
- Previously unresolved injuries affecting shoulder mechanics
- Habitual behaviours and posture
- Lack of activity or use
- Overuse, such as incorrect form when exercising
- Other MSK conditions, including lower body
- Bursa Infection
These injury mechanisms can result in Subacromial Bursitis due to inflammation of the bursa and surrounding tissues. As with various MSK conditions, research has shown links between trauma and myofascial trigger points. Equally, research has demonstrated the presence of trigger points within a range of shoulder-related conditions and myofascial pain. The Subacromial bursa sits above the supraspinatus muscle effectively in a narrow bone channel. Hence, there is very little room for tissues to move even in a normal shoulder and without any swelling. Often people will find it very painful to sleep on the affected shoulder, though this is true of other MSK shoulder conditions. Also, besides the pain, shoulder mobility tends to be very restricted and often in multiple ways, though other MSK conditions can create a similar situation.
Professional help and treatment
Various treatment options range from non-invasive hands-on treatment to more invasive forms, including cortisone injections and surgery. It is always worth doing some research (not on social media) before having invasive procedures and of a non-life saving variety. The author has treated many shoulder injuries and bursitis conditions for over 16 years and found a non-invasive approach to work very well with acute and chronic cases. Such an approach often involves some hands-on treatment and a small number of prescriptive exercises that build on the hands-on work. Often there may also be a need to alter habits or activities during the recovery process. The process is a joint effort and requires the patient to put some work in, which speeds up recovery and reduces the amount of treatment needed. He has seen cases where surgical intervention was the best option due to other factors (calcific tendinopathy), which was causing Bursitis. Equally, there is nothing that an MSK therapist can do about an infected bursa, as that requires G.P. intervention. The author has only seen one infected bursa to date and referred that to a G.P. and the infection resolved with antibiotics.
There have been considerable advancements in general medicine, which has become exceptionally good at treating severe trauma and successfully keeping people alive. However, it is fair to say that such advances in treating common ailments and musculoskeletal conditions are less prevalent. GPs have relatively limited treatment options when it comes to many MSK conditions. Often the possibilities involve rest, pain medication, anti-inflammatories, muscle relaxants, exercises or referral. Referrals usually take the form of Physiotherapy or a visit to a Specialist. Physiotherapists may try and treat conditions with a combination of manual therapy, prescriptive exercises and possibly anti-inflammatories, including Cortizone injections. Specialists may also treat with Cortizone injections or surgery. Sadly, many patients or patients can embark on the general medical model approach and end up having to have surgery. However, it is often worth looking at other options before Cortizone injections and surgery. Professionals within the same field may approach a problem differently based on training, experience and acquired knowledge. Equally, different professions may look at the same problem differently, resulting in a different outcome. Surgery really should be a last resort. There are many other very effective manual therapy options, though these do not fit into the standard general medicine model. Surgical interventions often look to create space within the affected shoulder joint. Typically, either by removing the subacromial bursa (bursectomy) or removing bone from the area.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
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About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession due to a planned move back to Australia, where his training and education are not recognised. Terry no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. He developed an early interest in soft tissue therapy techniques and advanced myofascial release methods in 2006 for treating various conditions. Terry's interests in human performance and trauma have naturally led to him developing a specialism in treating work and sports-related musculoskeletal injuries and Chronic Pain symptoms.
The author possesses an unusual background for somebody who trained in the McTimoney Chiropractic technique. His education, training, and practical experience span over two decades and relate to health's physical and mental aspects. He also needed to push his body and mind to the limits of physical and psychological endurance as part of his time serving in Britain's elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications (see the about section for more details). His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. He has also taught as a senior course coach at the Advanced Diploma level (Myotherapy / Musculoskeletal Therapy) in Australia, both theoretical and practical aspects, including advanced Myofascial Release Techniques and has certification in training and assessment. Terry will have taught many of the first students to train as Myotherapists in Brisbane. Terry's combination of knowledge through education, training, elite military service, and personal injury history has paid dividends for the patients he sees and has treated over the last 16 years. Terry is still extremely active and enjoys distance running, kayaking, mountain biking and endurance-type activities.