Shoulder bursitis

You’re experiencing sharp pain on the side of your shoulder. Raising your arm above your head has become difficult. At night, you wake up when you roll onto that side. Our shoulder abduction control exercise can help you regain controlled movement. These symptoms can accompany various types of shoulder pain; they do not necessarily indicate that the cause is bursitis.

Shoulder pain can improve with non-surgical treatment, but how long it takes to improve varies depending on the situation.¹ A systematic review, which methodically compiles studies on recovery from shoulder pain, reaches the same conclusion: the studies do not allow for a definitive prediction of an individual’s recovery.² An evaluation is used to identify symptoms that require medical attention and to discuss treatment options.

What the science shows:

• Studies on treatments and exercises that help people resume activities after shoulder pain often focus on several conditions grouped together. Their results do not provide a specific recovery timeframe for isolated bursitis.³
• The examination does not always allow for the identification of a single source of pain in the shoulder. Progressive exercises have been studied for certain types of rotator cuff-related pain, but no specific response rate has been established for isolated bursitis.⁴ The Cochrane review on manual therapy and exercise for rotator cuff disorders explains why: the participants included in the trials are very different from one another, and no subgroup with confirmed bursitis was identified.⁵
• Pain in the subacromial region—below the bony tip of the shoulder blade—may occur after a change in activity or an increase in the physical demand placed on the shoulder. This context helps guide the evaluation, without establishing that a specific bursa is causing the symptoms. A meta-analysis combining the results of several studies shows that working for long periods with the hands raised above shoulder level is associated with an increased risk of shoulder disorders; however, this association pertains to a group of diagnoses and does not identify the bursa as the source of the symptoms.⁶

This guide explains how this type of pain can occur, how it is assessed, and what options can be discussed for gradually resuming important activities.

What is shoulder bursitis?

Shoulder bursitis refers to inflammation of a bursa, a small fluid-filled sac that helps tissues glide smoothly against one another.¹ The known function of this sac is to reduce friction between the acromion—the tip of the shoulder blade that forms the roof of the shoulder—and the rotator cuff tendons during movement.¹ However, the symptoms may resemble those of other rotator cuff-related pain, and evaluation does not always allow for the identification of a single structure. In the shoulder, the most commonly affected bursa is the subacromial bursa, located between the acromion (a part of the shoulder blade) and the tendons of the rotator cuff—the group of four muscles that stabilize and rotate your shoulder.

The bursa may appear thickened or contain more fluid on imaging. These findings should be interpreted in conjunction with the symptoms and physical examination, as they do not always explain the pain.

Symptoms and tests do not allow for a precise determination of which structure in the shoulder is causing pain, nor do they allow for a reliable estimate of the prevalence of symptomatic bursitis.¹ A review of studies on physical examination tests of the shoulder confirms this: taken individually, these tests have limited diagnostic value, and none has proven to be significantly superior to the others.⁷ Manual therapy and exercise have been studied in populations with rotator cuff disease, without confirming isolated bursitis. The Cochrane review cited here includes 60 trials, but only 10 contribute to its primary comparisons, and the participants differ greatly from one trial to another: no subgroup with confirmed bursitis stands out.⁵

If you recognize these characteristics, you're probably wondering what distinguishes acute bursitis from chronic bursitis.

Is my bursitis acute or chronic?

Acute bursitis refers to a recent episode; chronic bursitis refers to a persistent problem; and recurrent bursitis returns after an improvement. The onset and duration of the pain help describe your situation, though they do not, on their own, confirm the exact location of the pain.¹ In a study on test accuracy, combining multiple findings from the physical examination helped identify pain under the acromion. No single response to symptom-related questions was sufficient, on its own, to identify or rule out a specific structure.⁸

Acute bursitis

Shoulder pain may begin shortly after an event or a change in activity, although this timing does not confirm which tissue is involved:

• Direct trauma to the shoulder (fall, blow)
• Intense, unusual exertion (moving furniture, painting a ceiling)
• Sudden repetitive movement

A sudden onset, sharp pain, or difficulty raising the arm can guide the evaluation. The course of the condition and response to treatment vary.

Chronic Bursitis

Chronic pain persists over time, whether it began suddenly or gradually. The evaluation focuses in particular on repetitive activities, work, sports, sleep, and other health issues. The following scenarios can help describe the demands placed on the shoulder:

• A painter who works on ceilings daily
• A swimmer who trains intensively
• A factory worker who performs the same movements with their arms raised for years

Pain may also develop gradually, come and go, or occur at night. Its duration and the recommended treatment depend on the evaluation and how the condition progresses.

What can cause shoulder bursitis?

Shoulder bursitis may result from trauma, an inflammatory condition, an infection, or irritation caused by calcium deposits. Repetitive work involving raised arms may also be a contributing factor. The evaluation looks for these factors without assuming that a single cause accounts for all the pain.^{1, 9}

Your healthcare provider will ask you if you have made any changes to your activities, had a fall, or noticed any other symptoms, such as a fever. This information will guide the tests and adjustments to your treatment.

Pain under the acromion can have several causes. Signs of inflammation have been observed in bursa tissue. However, a systematic review notes that the current understanding of this topic is limited and incomplete. These findings are insufficient to establish a link between a specific change in the bursa and a person’s symptoms.¹⁰

1. The "stuck" syndrome

The term “snapping syndrome” has long been used to describe this type of pain. It does not prove that a tendon or bursa becomes pinched during movement. In fact, a general review of rotator cuff-related pain classifies snapping syndrome as part of a broad category of pain conditions for which the cause, the source of the symptoms, and the identification of the affected tissue remain uncertain.¹¹ Bursitis has long been explained as a pinching of the bursa under the acromion, caused by posture or the shape of the bone. Recent research calls this explanation into question.⁴ However, a distinction must be made: a synthesis of the results from several studies does find a link between certain shapes of the acromion and rotator cuff tears, so the shape of the bone is not unrelated to the condition of the tendons. This link does not, however, indicate who will experience pain, nor does it prove that impingement causes the symptoms.¹² A recent increase in physical activity may be part of the context, without proving that it overloaded the bursa and caused the symptoms. Our comprehensive guide to shoulder impingement syndrome explains this nuance in depth.

2. Repetitive overhead arm movements

A job or sport that frequently requires raising the arm may be part of the assessment context. Symptoms alone are not sufficient to confirm bursal overload or irritation; however, the activity and the observed response can guide adjustments. A systematic review of work involving arms raised above shoulder level reports a link—supported by limited to moderate evidence—between such activities and shoulder disorders, which varies depending on the angle of the arm and the duration of exposure.¹³

3. A direct blow to the shoulder

After a direct blow to the shoulder, an evaluation helps document symptoms, range of motion, and signs that warrant medical attention. The incident alone is not sufficient to confirm bleeding or inflammation of the bursa. In a study on the accuracy of the examination, even several observations combined were not sufficient to rule out pain under the acromion. Nor did they confirm a specific change, such as bleeding or inflammation of the bursa.⁸

More rarely, a shoulder bursa can become infected with bacteria, a condition known as septic bursitis; reported cases are rare and have primarily occurred following a blood infection, trauma, or a weakened immune system.¹⁴ Bursitis can also occur alongside a systemic inflammatory disease, such as rheumatoid arthritis or gout—two conditions that cause joint inflammation—although studies specifically addressing these diseases are rare and date back many years.¹⁰Calcium deposits in adjacent tendons are another possible cause of shoulder pain and can sometimes spread to the bursa and irritate it. Imaging studies have observed this migration of calcified deposits in association with bursitis.^{9, 15}

Key point: Your symptoms and the physical exam help identify possible causes. They do not automatically indicate that the pain is due to a reaction in the bursa or to a specific force applied to it.

What are the symptoms of shoulder bursitis?

Shoulder bursitis may be accompanied by pain on the side of the shoulder, when raising the arm, or at night. These signs guide the evaluation but, on their own, are not sufficient to confirm that a bursa is the source of the pain. A review of studies on physical tests of the shoulder concludes that no single test can be unreservedly recommended to establish a definitive diagnosis.¹⁶

Certain signs can guide the evaluation of subacromial pain, even if they do not follow a predictable pattern or confirm bursitis:

Pain on the side or in front of the shoulder

Shoulder pain can be felt in different areas and described in various ways. Where the pain is located and how you describe it are helpful for the evaluation, but they do not allow us to identify the bursa as the specific source.

Painful arc when raising the arm

Slowly raise your arm out to the side, as if you were trying to touch your ear. Pain during part of the arm-raising motion may be part of the picture. Its location and intensity vary, and this movement alone is not enough to determine which structure is contributing to the symptoms. This is called the "pain arc."

Night pain

Pain can disrupt sleep, especially in certain positions. You can try using a pillow or changing your position, and continue doing so only if it makes the night more bearable. Nighttime pain alone does not mean that the shoulder is being damaged during sleep.

Morning Stiffness

Stiffness may be felt upon waking, and its progression varies. This symptom alone is not sufficient to identify the bursa as the source of the pain.

Difficulty with daily activities

Certain activities, such as combing one's hair, reaching for a shelf, or throwing a ball, may be more difficult. The specific movements involved and how well a person can perform them vary from person to person.

Apparent weakness

Shoulder pain may be accompanied by reduced effort during a strength test. This result should be interpreted in conjunction with your description of symptoms and the rest of the examination. It is not sufficient on its own to explain the weakness or predict how strength will change over time.

How is shoulder bursitis diagnosed?

The healthcare professional evaluates a possible case of bursitis based on your description of your symptoms, a physical examination of your range of motion, and, when necessary, imaging tests. This evaluation does not always confirm that a single bursa is the source of your symptoms.

Medical history

Your professional will ask you specific questions:

• When the Pain Began
• If there was a triggering event
• Which movements increase or decrease the pain
• If you experience night pain
• Your job or your sports activities

This information helps explain your symptoms and determine which tests to order, although it does not, on its own, confirm that a bursa is the source of the pain.

Clinical tests

Several maneuvers can reproduce pain in the subacromial region, without confirming that it originates in the bursa:

• Painful arc: Pain during part of the arm-raising motion can help clarify the symptoms. This movement alone is not sufficient to determine which structure is contributing to the symptoms.
• The Neer and Hawkins-Kennedy tests: In both cases, the examiner lifts your arm in a specific direction to see if the movement triggers pain. These tests often reproduce the pain when the area under the acromion is tender, but no single shoulder test can confirm the source of the pain on its own. Sensitivity measures the test’s ability to identify individuals with the condition; specificity measures its ability to identify individuals without the condition being tested for. A meta-analysis combining the results of several studies reports a sensitivity of 72% and a specificity of 60% for the Neer test, compared with 79% and 59% for the Hawkins-Kennedy test: these results correspond to approximately 28 missed cases out of 100 for the Neer test and 21 out of 100 for the Hawkins-Kennedy test. The tests also yield positive results in some individuals who do not have the disorder being screened for.¹⁶ A study on the accuracy of these tests yields similar results, showing good sensitivity and low specificity for cases of bursitis and rotator cuff lesions.¹⁷ They provide guidance; they do not provide a definitive diagnosis.

Medical Imaging

• X-ray: May be indicated following certain types of trauma or as part of an examination to look for fractures, calcifications, or other bone changes; a normal result does not rule out all lesions.
• Ultrasound: This allows the bursa to be visualized and any thickening or fluid to be measured. It also shows the surrounding tendons. Changes may be visible even in the absence of pain. The results should therefore be compared with your symptoms and the physical examination of your shoulder. A review of ultrasound studies included only three studies on bursitis. This number was insufficient to statistically pool their results, as the method used required at least four studies. The participants received specialized care; therefore, the results may not necessarily apply in the same way to patients seen in primary care settings.¹⁸ Another systematic review reports that abnormalities in the subacromial space are common in asymptomatic adults, often just as common as in painful shoulders.¹⁹
• Magnetic resonance imaging (MRI): This may be considered if your description of symptoms, the physical exam, or your clinical course raise concerns that could affect your care; it is not necessary for all cases of shoulder pain.

Note: Imaging may sometimes show signs of bursitis in people without symptoms. Abnormalities visible on shoulder imaging are common even in people who have no symptoms. In the study cited here, 123 people who had pain in only one shoulder underwent MRI scans of both shoulders: most of the abnormalities were found just as often in the pain-free shoulder as in the painful one. An abnormality on an imaging test does not, therefore, mean that it is causing your pain.²⁰ The healthcare professional relies primarily on your description of your symptoms and the physical examination.

Abnormalities of the capsula, bursa, and other structures may be visible in people who are not experiencing pain. Imaging can supplement the evaluation, but an abnormality does not prove that it is the cause of your symptoms. Therefore, an abnormality detected on imaging alone is not sufficient to determine the course of treatment.²¹

What are the treatments for shoulder bursitis?

Treatment for shoulder bursitis may include temporarily adjusting your activities, exercises, and pain management strategies. Medication, an injection, or another medical procedure may be discussed based on your diagnosis, risks, and preferences.

The professional explains the options to you, clarifies the goals, and takes your feedback into account to adjust the plan.

Temporarily adjust the activity

Depending on your symptoms, certain activities may need to be temporarily adjusted, and movements that you can tolerate should be maintained. Avoid keeping your shoulder immobile unless directed to do so by a healthcare provider; instead, look for movements and positions that you can tolerate. Significant stiffness may warrant an evaluation, particularly to rule out another condition such as frozen shoulder.

• You can try applying ice for relief, placing a cloth between your skin and the cold source. Stop if it makes your symptoms worse; it is not a substitute for exercise or other necessary treatments.
• If you are considering taking a pain reliever, check with a pharmacist or doctor to make sure it is appropriate for your situation and compatible with your other medications.
• After an injury, severe pain, deformity, or a new inability to raise your arm requires prompt medical evaluation. A sling is no substitute for this evaluation.

Exercises and Complementary Treatments

According to the assessment, a plan may include:

• A manual technique can complement the exercises to provide short-term pain relief. The physical therapist guides movements with their hands. The choice depends on the assessment, your goals, and your preferences; the study results are explained below.
• Progressive mobility exercises: let your arm swing gently or slide your hands along a wall
• Targeted strengthening of the rotator cuff muscles and those that control the shoulder blade
• Temporary Adjustments to Your Posture : If a certain way of standing or moving triggers pain, it’s okay to avoid it for a while, until your shoulder gets used to it again. No posture is inherently bad

Medical options to discuss depending on the situation

A corticosteroid injection—often called a cortisone shot—may be considered for certain types of subacromial pain following a clinical evaluation. The expected benefit, its duration, the risks, the medical reasons to avoid it, and other options should be discussed with the healthcare professional recommending the procedure; there is no universal threshold or fixed number that applies to everyone. A trial comparing treatments randomly assigned to 708 adults with a rotator cuff disorder provides a rough estimate: the subacromial injection resulted in a small improvement at eight weeks, with no measurable benefit at six or twelve months.²²

Cortisone injections also carry risks. Studies of patients who underwent surgery to repair the rotator cuff have found a higher incidence of repeat surgeries and infections following preoperative injections, especially when the injections were repeated or administered close to the time of surgery. This observed association does not, on its own, prove that the injection caused each complication.²³ In the trial of 708 people described above, no serious adverse effects were observed during the 12-month follow-up period; however, this timeframe is not sufficient to rule out all long-term risks.²²

In a Cochrane review of rotator cuff disease with impingement symptoms, subacromial decompression—a surgical procedure that removes bone and tissue to widen this space—did not provide any clinically significant benefit in terms of pain, shoulder function, or quality of life compared to a sham procedure that did not perform this decompression, for up to one year. The review rates this evidence as having high certainty, but it excluded complete rotator cuff tears.²⁴ This result does not demonstrate the efficacy or superiority of any specific non-surgical treatment. The decision to proceed with surgery depends on the diagnosis, other injuries, patient preferences, and the course of the condition.

Does physical therapy work for shoulder bursitis?

Physical therapy, particularly exercises, can improve pain and shoulder function in cases of pain in the area under the acromion. Programs and responses vary, and these studies do not allow the effect to be attributed to the treatment of a specific bursa. A review included 177 trials, 99 of which provided the data needed for a network meta-analysis, a method that compares multiple treatments. This analysis reported small to moderate improvements in pain and shoulder function with exercise. Confidence in the results regarding shoulder function was moderate after excluding studies whose methods were most likely to bias the conclusions.²⁵ A review synthesizing sixteen systematic reviews also supports exercise for pain, range of motion, and shoulder function in subacromial pain, without establishing a specific effect for isolated bursitis.²⁶

For symptoms of muscle tightness, a review found an additional reduction in pain when manual techniques were added to exercises, but only at the most frequent follow-up. The confidence in these findings was very low.²⁷ A synthesis of sixteen reviews also recommends adding manual techniques at the start of treatment for subacromial pain.²⁶ A previous review of twelve trials supported exercises and mobilizations—guided movements performed by hand—but the small sample sizes and limited quality of the studies reduced confidence in the long-term results.³

Results vary depending on the study and program. In the Cochrane review cited earlier, a trial involving 120 participants compared a program of manual techniques and exercises to a sham treatment—designed to resemble the actual treatment but without the active technique being studied. At 22 weeks, the program produced a small benefit in terms of shoulder function, with no clear difference in pain. Temporary pain after treatment was more common. The authors did not consider these differences large enough to be clinically significant for patients. This result applies to a specific program and population, not to all forms of physical therapy.⁵ Complementary techniques are therefore selected based on your needs and then adjusted according to their effect on your activities.

The physical therapist will assess the movements, strength, and activities that are causing you problems. They may recommend exercises for you to do at home, along with instructions on the number of repetitions, frequency, and how to gradually increase the difficulty. These exercises will be adjusted based on your progress.

The response to the program is followed up with concrete actions, such as sleep, exercise, or an activity. If no meaningful change occurs, the plan and diagnosis are reevaluated. The time required for complete resolution varies greatly depending on the situation.

What can you do at home to relieve your bursitis?

Home care includes adjusting your activity level, finding comfortable sleeping positions, and moving within the limits of your tolerance. Monitor how your shoulder responds, and seek an evaluation if your symptoms worsen or continue to limit your activities.

After a shoulder injury

After an injury, avoid movements that cause severe pain, then gradually resume activity according to the instructions you received. The general PEACE and LOVE principles provide guidelines for soft tissue injuries such as those to muscles and tendons; they must be adapted to the shoulder and the specific diagnosis.²⁸

• Prevention: After an injury, temporarily adjust any movements that cause severe pain, and seek an evaluation if the pain, weakness, or loss of mobility is significant.
• Elevation: Support your arm with a pillow if this position makes you more comfortable
• Resuming the load: Resume the movements and activities according to the instructions you received and based on how your shoulder responds
• General physical activity: Continue walking or another activity you can tolerate to stay active during recovery
• Exercises: Choose the movements based on your goals and adjust their difficulty according to the instructions you've received.

If the pain began without any trauma

Keep track of the activities that affect your symptoms and temporarily adjust them based on how you respond. This temporal association does not prove that an activity caused bursitis.

Possible indicator: If an activity is followed by a significant or persistent increase in symptoms, temporarily reduce its duration or intensity and reassess the response. This change alone does not prove that a specific tissue is being overtaxed.

Strategies for night pain

• You can try a different position if it makes for a more comfortable night's sleep
• You can try placing a pillow in front of your body to support your arm, and then remove it if it doesn't make you more comfortable
• You can try placing a small pillow under your arm if you sleep on your back, depending on how comfortable it feels
• Choose a comfortable position for your neck; you can change positions throughout the night
• Adjust the room temperature for a comfortable night's sleep

Simple exercises

Pendulum movements:
For a pendulum movement, lean your torso slightly forward while supporting yourself with your other hand on a table. Let the affected arm hang down and gently rock it back and forth in a comfortable range of motion. Start with a short duration and reduce the range of motion or stop if symptoms worsen significantly or remain severe.

Wall Slides:
Stand facing a wall and slowly slide your hands upward as high as possible without causing excessive pain. Choose a comfortable range of motion and adjust it based on how you feel during and after the exercise.

These exercises are possible options; their selection, number, and progression depend on your goals, tolerance, and response.

How long does shoulder bursitis last?

The duration of shoulder bursitis varies from person to person, and there is no specific timeframe that applies to everyone. To put this uncertainty into perspective, a review of studies on recovery reports that about half of new episodes of shoulder pain had fully resolved by six months; this figure encompasses several shoulder conditions, with populations and measurement methods that vary greatly from one study to another, and therefore does not predict how long your bursitis will last.² The follow-up compares your pain, sleep, and activities to your initial condition.

What are the signs of improvement?

You can see your progress in the activities that matter to you:

• You'll sleep more comfortably
• You can raise your arm more easily
• You are gradually resuming your work, leisure, and household activities

Improvement may vary. Monitor the trend over several days and discuss any ongoing difficulties with your healthcare provider.

Longer recovery time

Chronic bursitis, or bursitis associated with other shoulder problems, may require a longer period of non-surgical treatment. If surgery is necessary, full recovery takes additional time, which varies from person to person.

Items to Document During Follow-Up

• Your health and the activities that are important to you
• When the symptoms began and how they progressed
• The strategies tested and their observed effects
• The presence of associated conditions (rotator cuff tendinopathy, a problem with the shoulder tendons, severe impingement syndrome, osteoarthritis—that is, changes in the joint that can cause pain and stiffness)
• Your type of work or activities

If your pain persists despite following non-surgical treatment as directed, consult a healthcare professional again to have your condition reevaluated.

When should you consult a physiotherapist for shoulder bursitis?

A physical therapy appointment is recommended when shoulder pain persists, limits movement, or disrupts sleep. Severe pain following a fall, a deformity, or a new inability to raise the arm requires prompt medical evaluation instead.

During an evaluation, you can describe the following:

• You have the symptoms described above (pain on the side of the shoulder, a tender arc, and nighttime pain)
• Your pain persists despite rest
• You have a lot of trouble moving your shoulder
• Nighttime pain regularly disrupts your sleep

Access to Care: In Quebec, you can see a physical therapist directly. However, your insurance policy may require a prescription for reimbursement.²⁹ A red or warm shoulder accompanied by a fever or chills should be evaluated promptly by a doctor, particularly to rule out an infection.³⁰

What happens during your first visit

Your physiotherapist will conduct a comprehensive assessment:

• Range of motion of the shoulder
• Quality of your movements (the way your shoulder and shoulder blade move together)
• Strength and stability
• Depending on your symptoms, the examination may also include tests of your neck, sensation, strength, or the nerves in your arm.
• Posture

Based on this, your physiotherapist will create a personalized treatment plan tailored to your goals, physical condition, and lifestyle constraints.

If you have shoulder pain from a different cause, check out our comprehensive guide to shoulder pain, which outlines the main possible causes. To learn more about treatment options, check out our article on physical therapy for shoulder pain. If your pain is caused by another rotator cuff issue, our guide on rotator cuff tears may be helpful.

Ready to treat your shoulder bursitis?

Our physical therapists at Physioactif can assess your condition and create a personalized treatment plan. The plan includes specific goals and milestones to track your progress.¹

If your bursitis is the result of a work-related injury or a traffic accident, please visit our dedicated pages to learn about the steps you need to take.

Contact Physioactif to schedule an evaluation if your symptoms are causing you concern or limiting your activities.

References

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