Injuries and conditions

Subacromial Bursitis

Subacromial Bursitis

Subacromial bursitis usually presents with pain over the side of the shoulder, difficulty undertaking tasks overhead, and trouble sleeping on the affected side.

Subacromial bursitis may occur with other conditions in the shoulder and therefore it requires careful workup and investigation to exclude shoulder spurs, biceps tendonitis, biceps tendon tears, SLAP tears, supraspinatus and subscapularis tendon tears.

There are a number of areas that may be pain generators within your shoulder joint and subacromial space. A careful history, examination, and review of your imaging will identify the areas of concern.

Subacromial bursitis

  • The bursa may become inflamed and swell with more fluid resulting in pain

Acromion bone spur

  • The acromion forms the roof of the shoulder joint; over time a bone spur may form under the acromion narrowing the subacromial space

Impingement Syndrome

  • This is caused by a bone spur and bursitis above your tendon and below the roof of the shoulder (acromion)
  • Spurs can cause impingement when your shoulder is elevated and this can lead to “pinching” of the tendon below, especially when the bursa is inflamed


  • The above three issues may cause the tendon below to become irritated or damaged, leading to inflammation of the tendon and eventually even tearing

Medical image showing the shoulder anatomy pointing out Subacromial Bursitis and Acromion Bone Spur leading to shoulder impingement

There are three general reasons that may cause subacromial bursitis, impingement and tendonitis:

Shoulder trauma

  • Due to an accident at home, work or during sport. Some patients may recall a clear incident, in others it may be more gradual with smaller episodes of minor trauma.
  • This is typically in younger active patients

Shoulder overload

  • Repeated motion, particular overhead, may lead to an overuse syndrome and result in inflammation of the bursa with eventual bone spur formation and rotator cuff tendonitis.
  • Workplace injury may occur this way with manual occupations that involve heavy lifting and/or overhead work – such as painters, construction workers, electricians and carpenters.
  • This typically occurs in middle age

Inflamed shoulder joint

  • When the entire shoulder joint is inflamed (such as with shoulder arthritis or gout) the subacromial space may also become inflamed.

Other factors that may lead to subacromial bursitis:

  • Shoulder instability can present with shoulder impingement
  • Calcium deposition in the rotator cuff
  • Acromioclavicular joint arthritis with a bone spur compressing the subacromial space
  • Rotator cuff tears
  • Coracoid impingement

Subacromial bursitis commonly causes local swelling and tenderness over the side and front of the shoulder. Patients often report pain, pinching, or stiffness when lifting their arms. There may also be a pain when the arm is lowered from an elevated position.

Initially, the symptoms are often mild and tolerable – in such cases patients do not often seek treatment.

These symptoms of Subacromial Bursitis are typically:

  • Pain that is present with activity and rest
  • Pain radiating from the top of the shoulder (either at the front or the side) down the side of the arm
  • Sudden pain with reaching or lifting movements
  • Overhead athletes may report pain with particular actions (such as a tennis serve or throwing a ball)

As the condition progresses the symptoms may worsen and not respond with periods of rest and activity modification:

  • Night pain (particularly waking you up at night)
  • Inability to lie on the affected side at all
  • Reduced strength and range of motion
  • Difficulty with activities that require the arm behind the back – such as buttonon, zipering, putting on bra etc.

When the symptoms persist and affect your quality of life then it is important to seek review.


A thorough examination of the shoulder is required, including checking areas of tenderness, range of motion, associated pathology (such as biceps tendon or rotator cuff tears) and then special impingement tests to isolate the subacromial space.


A plain X-ray will often show a spur under the acromion, and in some cases, there may be an exaggerated curve under the acromion (a type 2 or type 3 acromion). Patients with type 2 or 3 acromion are at increased risk of shoulder impingement and tendon tears.

MRI will show the soft tissues in greater detail and demonstrate any fluid or inflammation in the bursa. It will also show the rotator cuff and biceps  – looking for any partial or complete tears.

The goal of treatment is to reduce pain and restore function; in planning your treatment your age, activity level, occupation, and general health will be considered.

In most cases, the initial treatment for subacromial bursitis is non-surgical; it may take weeks or months to notice gradual improvement and return to function. The principles around non-surgical treatment include rest, activity modification,non-steroidal anti-inflammatory drugs (NSAIDs), and physiotherapy. An ultrasound-guided cortisone injection is very effective with both diagnosis and treatment of subacromial bursitis. Such injections may provide relief for anywhere between a few weeks to a few months. Generally, it is best not to have more than two injections per year as the cortisone may weaken the rotator cuff tendons and lead to tendon rupture.

If your condition does not improve with nonsurgical treatment, then surgery may be an option for you. Surgery may also be a better option if you have other associated shoulder problems, particularly those that are time urgent.

Surgery for subacromial bursitis is performed arthroscopically (keyhole); this allows your surgeon to assess the condition of other structures in the shoulder, such as the biceps tendon, rotator cuff, and acromioclavicular joint. The goal of surgery is to remove the inflamed bursa (subacromial decompression), smooth out the bone spur (acromioplasty) and create more space for the rotator cuff. The surgery involves a few small keyhole incisions and can be done as a day procedure or with an overnight stay (depending on what else needs to be addressed in the shoulder).

Shoulder Function

  • If you are unable to undertake basic tasks or to look after yourself, unable to drive, unable to get dressed, or have difficulty with hygiene and toileting.

Shoulder Pain

  • Pain with activity and even at rest
  • Night pain, especially if it wakes you from sleep
  • Unable to sleep on your affected shoulder
  • Increasing requirements of pain relief tablets
  • Multiple failed cortisone injections
  • Not responding to physiotherapy


  • If it is limiting your ability to work
  • Especially if you are in a manual job requiring repeated overhead activity


  • If you are unable (even after a period of rest and activity modification)  to participate in your chosen leisure activity or sport and you wish to continue to do so

Preventing further shoulder damage

There are certain conditions (such as subacromial bursitis with high-grade partial rotator cuff tears) where it may be better to decompress your shoulder and repair your rotator cuff before tears become full-thickness, retracted, or irreparable.

Dr Pant will carefully analyse your MRI scan and determine if this is the case for you (especially in younger patients).

Patient results

AC Joint Arthritis

This 48 year old gentleman presented with pain over the top of his shoulder over many months. A diagnosis of AC Joint arthritis was made and he responded well to an ultrasound guided cortisone injection initially. However, that wore off over a few months and he was unable to sleep on the affected shoulder and very keen to get back to his active lifestyle, so he elected to proceed with surgery.

He underwent an Arthroscopic Acromioclavicular Joint (ACJ) excision via 3 small keyhole incisions. His procedure was routine, he stayed overnight in hospital, and was discharged home the following morning with oral painkillers.

He commenced immediate range of motion and discarded his sling between 1 -2 weeks after surgery. At three months, he is back to the gym and kayaking and is happy with his outcome; his keyhole incisions were only barely visible at the 3 month follow up.

Arthroscopic AC Joint excision is a very successful operation when non-surgical measures have been exhausted.

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