Subacromial Bursitis

Upper Limb

Overview

Subacromial bursitis is inflammation of the bursa located between the supraspinatus tendon and the acromion process, causing localized pain and restricted shoulder movement. This condition frequently coexists with rotator cuff dysfunction and impingement syndrome, resulting in painful arc of motion and night pain. Early intervention with manual therapy and targeted rehabilitation can significantly improve outcomes and prevent chronic shoulder disability.

Pathophysiology

The subacromial bursa acts as a lubricating sac to facilitate smooth gliding between the rotator cuff tendons and the overlying acromion. Repetitive overhead activities, poor scapular kinematics, rotator cuff weakness, or direct trauma cause bursal inflammation through mechanical irritation and microtrauma. Inflammatory mediators accumulate within the bursa, thickening the synovial lining and reducing available subacromial space, leading to further mechanical impingement and pain with arm elevation.

Patient Education

Modifying aggravating overhead activities while maintaining pain-free movement patterns is crucial; progressive strengthening of the rotator cuff and scapular stabilizers addresses underlying biomechanical dysfunction and prevents recurrence.

Typical Presentation

Site

Anterolateral shoulder, localized to the subacromial space; pain may radiate to the lateral upper arm

Quality

Dull, aching, or sharp mechanical pain worsened by specific movements; may feel like catching or pinching sensation

Intensity

Mild to moderate (3-7/10) with acute flare-ups potentially reaching severe levels (7-9/10); typically worse in morning and with activity

Aggravating

Overhead reaching, throwing, swimming, painting, sleeping on affected side, cross-body adduction, repetitive lifting

Relieving

Rest, NSAIDs, ice application, gentle pendulum exercises, scapular support, avoiding provocative positions

Associated

Reduced active range of motion (especially abduction 60-120 degrees), weak rotator cuff on manual testing, positive Neer impingement sign, possible scapular dyskinesis, night pain disrupting sleep

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neer Impingement Sign

Procedure

Patient seated or standing. Stabilise the scapula with one hand and, with the arm internally rotated (thumb down), passively raise it forwards to full flexion.

Positive Finding

Reproduction of the familiar anterior or lateral shoulder pain near the end of range.

Sensitivity / Specificity

72%/60%

Reference: Hegedus EJ et al., Br J Sports Med 2012; PMID 22773322

Interpretation

Supports a subacromial pain source, which includes the bursa. It does not separate bursitis from cuff tendinopathy; in practice they often occur together. Neer sign pooled figures (72%/60%) are from Hegedus (2012) meta-analysis; original description Neer 1972.

Sources

No accuracy study

Hawkins-Kennedy Impingement Test

Procedure

Patient seated or standing. Raise the arm to 90° of forward flexion with the elbow bent to 90°, support the elbow, then turn the forearm down to internally rotate the shoulder.

Positive Finding

Reproduction of the familiar anterolateral shoulder pain.

Interpretation

Supports a subacromial pain source but does not isolate the bursa. Pooled sensitivity/specificity for the Hawkins–Kennedy test vary widely across studies (Hegedus 2012); no single confirmed pair is shown. Original description: Hawkins & Kennedy 1980 (Am J Sports Med, not JBJS).

Sources

No accuracy study

Painful Arc Sign

Procedure

Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where pain appears and disappears.

Positive Finding

Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.

Interpretation

A mid-range painful arc supports a subacromial source, including bursitis, but does not separate it from cuff problems. ('Cocking test' is not a recognised alternative name.) Park (2005) reported the painful arc at ~74% sensitivity, but a matched specificity varied by severity; shown Not verified pending a single confirmed pair.

Sources

No accuracy study

Subacromial Space Palpation

Procedure

Patient seated. Palpate just below the anterolateral edge of the acromion, first with the arm at the side and then with the arm passively extended.

Positive Finding

Tenderness below the acromion that reproduces the familiar pain.

Interpretation

Supports a subacromial source. The bursa and the cuff tendon lie together and cannot be separated by palpation.

Sources

No accuracy study

Resisted Abduction Test

Procedure

Patient seated, arm at the side or slightly abducted. Ask the patient to push the arm out to the side against your resistance; compare sides.

Positive Finding

Pain with resisted abduction, or weakness.

Interpretation

Pain on loading fits rotator cuff involvement, which commonly accompanies bursitis. Clear weakness raises concern for a tear.

Sources

No accuracy study

Empty Can Test (Supraspinatus Strength)

Procedure

Patient standing. Arms elevated to 90° in the scapular plane, elbows straight, thumbs pointing down. Apply a downward force while the patient resists; compare sides.

Positive Finding

Pain or weakness compared with the other side.

Interpretation

Loads supraspinatus and compresses the overlying bursa, so pain cannot separate the two. Weakness points more towards a tear. Itoi (1999, Am J Sports Med — not JSES) compared the empty-can and full-can tests by diagnostic accuracy (~70–75%), not a sensitivity/specificity pair.

Sources

⚠ Red Flags

  • •Sudden onset with severe unremitting pain unresponsive to conservative care lasting >6 weeks
  • •Neurovascular symptoms (numbness, tingling, discoloration, temperature changes)
  • •History of trauma with suspicion of rotator cuff tear (positive drop arm test)
  • •Signs of systemic infection (fever, constitutional symptoms, rapidly worsening swelling)
  • •Inability to actively lift arm from side with negative rotator cuff strength testing
  • •Imaging findings suggesting full-thickness rotator cuff tear requiring surgical intervention

⚡ Yellow Flags

  • •High baseline anxiety or catastrophizing about shoulder injury and prognosis
  • •Significant work demands involving overhead activities with poor ergonomic support
  • •Poor compliance with prescribed exercise program or negative beliefs about activity
  • •Multiple previous shoulder injuries suggesting chronic pain cycle
  • •Depression or low mood affecting motivation for rehabilitation
  • •Lack of social support for activity modification and recovery

Osteopathic Techniques

Exercise is the first-line treatment, and most add-ons may not beat exercise alone. Manual therapy can be added for a small, mostly short-term drop in pain; the evidence is low quality.

Region

Upper and mid thoracic spine

Technique

Articulation, thoracic
Grade B
Moderate evidence: supported by at least one good study
Reviews found thoracic mobilisation reduced pain and disability in shoulder impingement. Thrust manipulation (HVLA) did not show the same effect.

Rationale

Gentle, rhythmic mobilisation of a stiff upper back. Reviews found it reduced shoulder pain and disability in impingement.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of restricted thoracic segments within their passive range, with no thrust. The patient is seated, side-lying or prone. For neck problems the upper thoracic segments (T1–T6) are the usual focus.

Evidence in Subacromial Bursitis

A 2026 meta-analysis of 12 studies found thoracic Maitland mobilisation improved pain and disability in subacromial impingement more than control, while thrust (HVLA) techniques showed no significant effect. A 2025 meta-analysis of 10 trials found thoracic manual therapy reduced pain and disability, including versus placebo. An earlier 2018 review found a single session was no better than placebo straight after treatment.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)
Grade C
Limited evidence: indirect or low-quality support only
Manual therapy eased pain a little more than placebo or exercise alone, with low-quality evidence. The best placebo-controlled trial found no clinically important difference.

Rationale

Graded mobilisation of the shoulder through its range. Adds a small, short-term pain benefit to exercise.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Subacromial Bursitis

A 2015 meta-analysis of 21 trials found manual therapy cut pain by about 1 point out of 10 versus placebo or when added to exercise; its effect on function was unclear. A 2017 meta-analysis found it beat placebo and, added to exercise, helped only at the shortest follow-up (very low quality). A 2016 Cochrane review found the one high-quality trial of manual therapy plus exercise versus placebo showed no clinically important difference. These trials tested shoulder mobilisation in general, not the Spencer sequence.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular muscles
Grade C
Limited evidence: indirect or low-quality support only
Massage helped pain, function and range in the short term versus no treatment (low-quality evidence). Added to exercise, it gave no extra benefit in a trial.

Rationale

Eases tension in the rotator cuff and shoulder blade muscles. Short-term help; it adds little to exercise.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Subacromial Bursitis

A 2014 meta-analysis found low-quality evidence that soft tissue massage improved pain, function and range of motion in non-specific shoulder pain in the short term, versus no treatment. A 2015 trial of 80 patients found adding massage to exercise gave no extra benefit; at 12 weeks exercise alone did slightly better for pain. A 2025 review found trigger point manual therapy matched other passive treatments for pain in rotator cuff related shoulder pain, with slightly better function.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracic
Grade C
Limited evidence: indirect or low-quality support only
Thoracic MET beat placebo for pain and disability in shoulder impingement, up to 1 year. This is one trial of 75 patients.

Rationale

Low-force, patient-powered upper-back technique. Beat placebo for pain and disability in one impingement trial.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Subacromial Bursitis

A 2022 placebo-controlled trial of 75 patients aged 40 or over with shoulder impingement, run in an osteopathic practice, found 4 weekly sessions of MET to the thoracic spine improved pain and disability more than placebo at discharge, 6 and 12 months. MET plus soft tissue massage improved disability but not pain.

Rehabilitation Exercises

Pendulum Circles

Range of MotionBeginner

Cross-Body Shoulder Stretch

StretchingBeginner

Sleeper Stretch for Infraspinatus

StretchingBeginner

Supine External Rotation with Resistance Band

StrengtheningBeginner

Standing Internal Rotation with Resistance Band

StrengtheningBeginner

Prone Horizontal Abduction at 90 Degrees

PosturalIntermediate

Side-Lying External Rotation

StrengtheningIntermediate

Y-T-W Raises (Wall or Prone)

PosturalIntermediate

Quadruped Shoulder Stabilization (Bird Dog Variation)

BalanceIntermediate

Prone Horizontal Abduction with External Rotation (90/90)

StrengtheningAdvanced

Standing Cable External Rotation at 0 Degrees Abduction

PosturalAdvanced

Controlled Overhead Reaching Pattern with Progressive Load

CardiovascularAdvanced

Referral Criteria

  • •Failure to improve after 4-6 weeks of consistent conservative management with manual therapy and exercise
  • •Positive imaging findings (MRI/ultrasound) confirming full-thickness rotator cuff tear or significant subacromial narrowing
  • •Persistent severe night pain preventing sleep despite treatment
  • •Signs of neurological compromise or vascular insufficiency
  • •Acute trauma with immediate inability to move shoulder suggesting acute rotator cuff injury
  • •Suspicion of other pathology (AC joint osteoarthritis, calcific tendinopathy, labral pathology)
  • •Patient preference for corticosteroid injection as adjunctive intervention
  • •Functional demands requiring surgical intervention for return to occupation or sport