Hassan QureshiA comprehensive guide to self-assessment and management of shoulder pain and bursitis
Shoulder pain is very common. In fact, each year 1 in 2 people will have at least one episode of shoulder pain.
A common cause of shoulder pain is shoulder bursitis. This blog post is your guide to understanding, assessing and managing shoulder pain, specifically bursitis.
The blog post is broken down into the following sections:
Understanding shoulder bursitis
Self-assessment of shoulder movement
Treatment approach for shoulder rehabilitation
Part 1: Understanding shoulder bursitis
What is bursitis?
Many joints of your body have fluid-filled sacs called bursae (plural for bursa). A bursa's job is to act as a cushion between tendons, muscles and bones to stop friction and irritation between them. Trouble is, sometimes the bursa itself gets a bit irritated (aka inflamed). The inflammation of a bursa is known as bursitis.
What causes shoulder bursitis?
Remember, shoulder bursitis in an inflammation or irritation of the bursa. This is commonly caused by either over-using or over-stretching the bursa.
Overuse
Frequent and repetitive work with the hands, especially with the hands above your head, can lead to shoulder bursitis. Also, repetitive lifting (usually with less-than-ideal technique) can cause shoulder bursitis.
Overstretch
A rapid stretching of the shoulder joint may also lead to shoulder bursitis. We often see this in athletes playing sports which require throwing (e.g. baseball, cricket). However, the overstretch can also occur due to a fall. That is, as one is falling, they try to catch something like a pole or wall which can cause an overstretching at the shoulder joint.
Other causes of shoulder bursitis include:
Poor posture
Chronic conditions such as Rheumatoid Arthritis
Other shoulder issues such as torn tendons
How common is shoulder bursitis?
Shoulder bursitis is a very common cause of shoulder pain. It is difficult to establish exactly what percentage of people have shoulder pain as a direct result of shoulder bursitis as there is rarely ever a single cause of pain. In other words, someone may have shoulder bursitis, but may also have other causes of pain (e.g. muscle or tendon tear).
Do I have shoulder bursitis?
If you are experiencing shoulder pain, it may be due to shoulder bursitis. Understanding the common signs of shoulder bursitis as well as its causes can help you decide whether your shoulder-related symptoms are due to shoulder bursitis or not. However, it is worth noting that other causes of shoulder pain may also feel very similar to bursitis. For a proper diagnosis of your shoulder pain, please speak to your doctor.
What are common signs of bursitis?
Pain – Especially while lifting the arm above your head or when lifting something. Shoulder bursitis also often causes pain at night.
Limited movement – shoulder bursitis may make it difficult to lift the hand above your head.
Note: The symptoms you experience as a result of shoulder bursitis might be different to someone else's. This is partly because there is more than one bursa in the shoulder (in fact, there are 6).
How is shoulder bursitis diagnosed?
While the above symptoms may sound familiar, they can also be the result of other causes. In order to diagnose a case of shoulder bursitis, you will need to speak to a doctor. The doctor may choose to send you for some diagnostic imaging (that's doctor speak for getting scans).
What scans do I need for shoulder bursitis?
An ultrasound can detect whether you have shoulder bursitis.
Your doctor may also recommend an x-ray. While this is not specifically for shoulder bursitis, it can help rule out other conditions such as a broken bone (which is nice to know).
A CT or MRI scan will also reveal whether or not you have shoulder bursitis.
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Part 2: Self-assessment of shoulder movement
The below assessment is designed to highlight how much (or little) your shoulder movement has reduced. It is not intended to diagnose the cause of shoulder pain.
Before you start your self-assessment, there are few things we need to discuss.
Terms - The painful shoulder will be referred to as your affected side, while the other arm is referred to as your other side.
Compare the pair - For each of the assessments below, we want to compare your affected side to the other side. So, first do the assessment with your other arm, and then repeat it with the affected side. This will also allow you to feel what that movement feels like normally.
Slow and steady - Each movement is to be performed at a slow and steady speed. Avoid jerking or using momentum to lift your arm beyond what it is comfortable with.
Word to the wise – the below assessment is intended for people with mild shoulder pain. If you have severe pain, or can see clear signs of swelling, redness, heat or other such symptoms, do not perform this self-assessment and consult your doctor.
There 5 tests outlined below will allow us to assess your shoulder movement. Please read the instructions carefully.
Shoulder flexion - raising the arm in front of you
How to perform?
Stand with your arm by your side. Then, keeping the arm straight, lift your hand in front of you as high as you can. The movement is measured by angle of shoulder movement (0-180 degrees).
How did you go?
Can you do the full movement? Yes or No
If not, how high can you lift the arm?
Is it painful? Yes or No
Ask yourself these questions after each movement below.
Note - Please note the degrees of shoulder movement illustrated in red. If you were not able to do the full movement, estimate your performance in degrees where START is 0 degrees, MIDDLE is 90 degrees and END is 180 degrees.
Shoulder abduction- raising the arm out to the side
How to perform?
Stand with your arm by your side. Then, keeping the arm straight, lift your hand to your side as high as you can. The movement is measured by angle of shoulder movement (0-180 degrees).
External rotation - rotating your shoulder away from body
How to perform?
Stand with your back against the wall. Touch the wall with your elbow and bend your elbow to 90 degrees. Then, rotate your shoulder outwards to touch the back of your hand to the wall behind you. The movement is measured by angle of shoulder movement (0-90 degrees).
Internal rotation - Sliding your hand behind your back
How to perform?
Keeping the arm straight, place your hand behind your body. Then, bend your elbow to slide your hand up your back. The movement is measured by angle of elbow movement (0-90 degrees).
Shoulder extension - raising the arm behind you
How to perform?
Stand with your arm by your side. Then, keeping the arm straight, lift your hand behind you as high as you can. The movement is measured by angle of shoulder movement (0-45 degrees).
Part 3: Treatment approach for shoulder rehabilitation
By now, you know what shoulder bursitis is. You also know whether the shoulder movement on your affected side is reduced compared to the other side. Now what?
In the rest of this post, we will outline the principles of shoulder rehabilitation. We will give you some examples to illustrate each principle.
However, there are other aspects of treatment, such as pain management, medication, steroid injections or surgery that we will not discuss. For these matters, please speak to your doctor. You might be able to get some answers on our online community.
How to approach shoulder rehabilitation?
If you have shoulder bursitis or other causes of shoulder pain, you need to Rest, Ice, Compress, Exercise (R.I.C.E). The following section is broken down into these four categories.
Rest
Sounds simple, but it's not. You need to avoid whatever it is that caused the bursitis in the first place – duh!
First step is to figure out what that is. Going back to the causes of shoulder bursitis, it may be something you did once or it could be (and more likely is) something you do all the time. Whether that's cleaning tall windows, hanging the washing up or throwing a ball, avoid doing the activities which are hurting your shoulder (for now).
I have to keep [insert activity] even though it hurts my shoulder. What can I do?
The hardest thing for people to do is nothing. I often hear my clients tell me that they cannot avoid the very activity that is causing their shoulder pain. They insist, their tall windows must be cleaned, the washing must be hung and the ball simply must be thrown. So, is there any hope for such people?
While there is no single answer to each of these clients, I generally follow the steps below to try to minimize pain and avoid further upsetting the shoulder.
Warm up before activity - We normally do our warm up before we exercise and find the shoulder feels ok. But when doing housework, gardening or other physical activities we don't warm up and find the shoulder hurts. The thing is, your shoulder doesn't know the difference between exercise and housework. So, make sure to warm up the shoulder before performing any strenuous physical activity.
Technique correction - Perhaps we can still do the painful activity, but with a different technique. For example, while cleaning a tall window with a long handle, try switching the positions of the hands. Or, while doing other types of physical activity, bring the elbow closer to the body mid-line to reduce shoulder strain.
Find another way - Think about the goal of performing the painful activity. Then, think how else this can be achieved, preferably without causing your shoulder any grief. For example, hanging the washing on the line hurts the shoulder. The goal of hanging the washing is dry clothes, right? Well, can the clothes be hung on a rack which is only waist high?
It is pretty simple. Your shoulder needs rest. You need to find a way to give it that rest. We suggest to make a list of activities which hurt the shoulder and find a way to perform them without shoulder pain.
Ice
Bursitis is an inflamed shoulder. Think heat and swelling. So to help reverse the injury, cool it down with ice.
Do I use ice or heat for shoulder bursitis?
Short answer - Ice. Ice will reduce the inflammation in your shoulder and help it to heal.
While the heat may feel nice and even reduce pain, it won't help the healing process. Having said that, if there is no swelling or heat around the shoulder, you may apply a hot pack or have a hot shower to help ease the pain.
How to ice the painful shoulder?
Apply up to 15 minutes at a time, making sure to avoid direct contact with skin. Use a thin cloth to act as a barrier.
Compression
Compression is used to help reduce swelling and pain. If you have a lot of swelling and pain in the shoulder, you may consider using compression. But it is best to discuss this with your physiotherapist.
In our experience, people with shoulder bursitis rarely need to apply compression. In fact, it may even slow down the healing time as your shoulder movements are restricted unnecessarily.
Exercise
Can exercise help shoulder bursitis?
Exercise is a crucial component of shoulder bursitis treatment. Before we dig into how to exercise, it is worth noting what we mean by exercise. Exercise is any physical activity performed to improve or maintain your health. It doesn't have to be strenuous, or cause pain in order for it to work. In fact, most of these exercises should be performed without pain.
How to exercise for shoulder bursitis?
Your exercise program can be broken down into 3 phases:
Flexibility (aka range of motion)
Strength
Functional training
How to increase shoulder flexibility (aka range of motion)?
The first step to your shoulder rehab is to be able to move your shoulder normally. That's what we call full range of motion. If you discovered you were unable to move your shoulder through it's full range during Part 2: Self-assessment of the shoulder, then the following section is for you.
We will use shoulder flexion – lifting the arm in front of you – as an example for demonstrating the following principles. However, each of the movements you saw in the self-assessment can be improved by following these principles.
Passive – sleeping passenger
Passive range of motion is when your shoulder is taken through the full range of motion while the shoulder does nothing. It acts as a sleeping passenger.
One way to achieve passive range of motion is by someone else (e.g. therapist or friend) lifting your arm while you keep the shoulder relaxed.
For those who want to help themselves (or do not have any friends), you can use aids to carry your arm up. The trick is to use your other side. Below is an example.
Passive shoulder flexion - passively raising the right arm in front of you using the left hand
How to perform?
Hold the pulley handles in each hand and start with your affected arm by your side. Then, using the other hand, pull the handle such that the affected hand is passively raised. Keep your affected arm straight and relaxed.
HQ's tip – the better you can relax the shoulder, the less pain you will feel. In fact, this should be an entirely pain-free exercise. Remember, let the shoulder be a sleeping passenger.
How to increase shoulder strength?
You can move your shoulder through the full range, with or without some help, what's next?
You need to start re-building strength.
Now, before your shoulder can start driving again (moving by itself), it needs to become an awake passenger. That is, it will still be driven around but will start taking some responsibility for it's own movement.
Passive - awake passenger
Have your affected arm lifted passively (by someone else or using the above aids). Once it reaches the full range passively, then slowly lower the arm by using the shoulder muscles of your affected side. Initially, you may still hold onto the aid which helped raise the arm but eventually you want to remove this completely. See examples below.
Passive shoulder flexion with eccentric strength - passively raising the right arm in front of you using the left hand, then controlling the descent of the right hand by using right shoulder muscles.
How to perform?
Hold the pulley handles in each hand and start with your affected arm by your side. Then, using the other hand, pull the handle such that the affected hand is passively raised. Keep your affected arm straight and relaxed. Then, slowly lower your affected hand by using the shoulder muscles on that side.
Driver
Once your arm becomes a confident awake passenger, it is time to start driving. That is, going up and down by itself.
Shoulder flexion - raising the arm in front of you
How to perform?
Stand with your arm by your side. Then, keeping the arm straight, lift your hand in front of you as high as you can. Full range is having your hand right above your shoulder.
Carrier
Finally, your affected shoulder is able to move itself up and down, just like the other side. Now, it's time to start moving against some resistance. It is time, to be a carrier.
Strengthening - raising the arm against some resistance (e.g. dumbbells)
How to perform?
Stand with your arm by your side holding a small weight. Then, keeping the arm straight, lift your hand up to shoulder height. Perform the movement 10 times.
Once a client is able to achieve full range of motion and normal strength with their affected shoulder, they may need some coaching on functional training. This is in order to reduce the risk of future injury. An example of functional training is learning correct ball throwing technique.
However, functional training is beyond the scope of this blog post.
This section demonstrated how to approach shoulder rehabilitation, from flexibility to strength training. We outlined the principles that are used in the clinic. However, to design an exercise program that is right for you, you may need further help or find an exercise physiologist near you.
What's next?
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Get in touch - If you need help to manage your shoulder pain, we can help you! Find us at a clinic near you or simply drop us an email.
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ABOUT THE AUTHOR
Hassan Qureshi is the founder and owner of Holistic Exercise Physiology. He believes educating and communicating good science to the wider public is not only important but is the responsibility of every clinician. For this reason he started the Holistic blog.
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If you would like to see Hassan Qureshi, you can meet him online or visit him at a clinic.