Impingement and bursitis

What it is

Shoulder impingement and bursitis are common causes of shoulder pain, particularly pain when lifting or reaching with the arm. You may notice a painful arc as the arm moves through shoulder height, discomfort reaching into a cupboard or putting on a coat, or pain when lying on the affected side at night. The rotator cuff is a group of muscles and tendons that work together to control the movement of the shoulder. A small fluid-filled structure called the bursa sits around these tendons and helps them move smoothly. When the rotator cuff becomes irritated or overloaded, the bursa can also become inflamed and painful. These symptoms are often part of what we now describe as rotator-cuff-related shoulder pain. For some people this may represent an early stage in a spectrum of rotator cuff problems, but it does not mean that everyone with bursitis or impingement will go on to develop a rotator cuff tear.

How it usually presents

• Pain when lifting or reaching with the arm, often through a painful arc
• Discomfort reaching into a cupboard, putting on a coat or reaching behind you
• Pain lying on the affected side at night

Why does it happen?

There isn't always one single cause. Sometimes symptoms begin after an unusual amount of activity, sport or repetitive overhead work. In other people they develop gradually. Importantly, pain doesn't necessarily mean that something is being permanently pinched or damaged every time you move your arm. The way the rotator cuff and the muscles around the shoulder blade work together is important in controlling the shoulder. Changes in strength, endurance, posture or movement patterns can contribute to symptoms. This is why physiotherapy is such an important part of treatment. Good rehabilitation isn't simply about resting the shoulder or doing a few generic exercises. It aims to restore strength and coordinated muscular control around the shoulder and shoulder blade, gradually allowing the tendons to tolerate normal activity again.

What about a steroid injection?

When the bursa is particularly inflamed, an ultrasound-guided steroid injection can sometimes be very effective at settling pain. This can be especially useful when pain is disturbing sleep or preventing you from progressing with physiotherapy. However, an injection treats the pain and inflammation; it does not necessarily address the factors that allowed the shoulder to become painful in the first place. An injection is therefore best thought of as creating a window of opportunity. Once the pain has settled, physiotherapy and progressive strengthening can be used much more effectively to improve how the shoulder functions and reduce the chance of symptoms returning.

Do I need a scan or surgery?

Usually, surgery is not the first treatment for this type of shoulder pain. The important first step is making sure that the diagnosis is correct. Other conditions — including frozen shoulder, calcific tendinitis, arthritis, rotator cuff tears and problems arising from the neck — can produce similar symptoms. The consultation covers how your symptoms began, a careful examination of the shoulder, and imaging only where it is likely to change how the problem is managed. The best approach — physiotherapy, activity modification, an injection, further investigation or, in a smaller number of cases, surgery — is then decided together.

The aim isn’t simply to make the pain disappear temporarily. It is to help your shoulder move and function well enough that it stays better.