Shoulder Bursitis and Impingement

rotator-cuff-shoulder-impingementThe rotator cuff is made up of 4 muscles that attach to the ball of the ball and socket joint known as the shoulder. There is a space between the rotator cuff and the bone that lies directly above it. On top of the muscle is a bursa that allows the muscles to glide against the bone easily. When the bursa becomes inflamed it is called bursitis.

shoulder-4-muscles

Here is the shoulder with its 4 muscles.

shoulder-anatomy-acromion

When you lift your arm overhead, there is a tendency for the rotator cuff to get pinched against the acromion, which is the bone above it. It is also part of your scapula or wing blade. As we can see there are different shapes of acromion ranging from Type 1 to Type 3.

shoulder-acromion-types

Some research has shown that a severe bone spur can dig into the rotator cuff.

If someone has a Type 3 acromion, research has shown that over time the bone can rub against the rotator cuff and dig into it. Also if you landed on your shoulder at some point in your illustrious career of sporting activities, then there is a chance that the acromion impacted against your cuff and bursa. This can develop into a partial tear of your cuff or bursitis, where there is bleeding and swelling in the bursa.

shoulder-tears

The bursa which used to be smooth becomes thickened and swollen, and turns into a substance that looks like cotton candy.

shoulder-tears-cotton-candy

This is what a bursitis can look like:

shoulder-bursitis

The rotator cuff, acromion, and bursa will then rub against one another, causing a painful condition known as impingement. Each time the arm is raised, the tendons and bursa rub against the bone leading to inflammation.
Impingement may become a serious problem for some people and disturb their normal activities. This is when treatment is needed.

Treatment is usually in the form of physical therapy exercises to strengthen the cuff, decrease the risk of bursitis becoming worse. If no relief is seen, then a one-time cortisone injection into the bursa can be very effective. If these don’t work then shaving the acromion and removing the bursitis is often very helpful for this shoulder pain. The diagram below shows a shaver flattening out the acromion and its spur.

acromion-spur-shaving

shouder-bone-spur-impingement

So with all this how do we prevent it from happening? First and foremost don’t get born with a Type 3 acromion:) If you can’t control that, then here are some tips.

In CrossFit with overhead maneuvers we have to be aware of the scapula and its rotation. Rotating the scapula back and pinching the shoulder blades together with overhead lifts is helpful. Locking the scapula helps to rotate the acromion posteriorly away from the cuff. This then prevents the acromion from digging in and decreases the chances of impingement.

Mat is rotated and locked in as seen here:

crossfit-shoulder-rotated-locked-in

I would say if you have shoulder pain, that isn’t going away the most important thing is not to push through it. Modify your workouts and allow things to quiet down. Listen to your body and get it checked out because your body and your shoulders are trying to tell you something. Pushing through pain when your shoulders are talking is not beneficial. To prevent bursitis, keep your EARS open and your SHOULDERS back.

9 Comments

  1. I have a type II slap tear, surgeon is recommending cortisone shot for now, would that just mask pain and not fix problem?
    I laid off overhead lifting, push-ups, burpees, pull-ups for 2 weeks started to incorporate again and no luck.
    Doing snatches is fine, but regular presses, push-ups burpees causes pain. I don’t want a temporary fix.
    Your input is appreciated.

    • Cortisone can help if there is inflammation in the tissues such as bursitis. It does not help a SLAP heal but sometimes can make it feel better. If it feels better from overuse and things quiet down, then you may avoid a surgery.

  2. I’ve been doing CrossFit for three years now and still have a hard time convincing people that I just can’t do overhead stuff. I had a PRP injection on my shoulder a year ago to try to jump start healing to a torn rotator cuff and it did not get any better. I have shoulder impingement, but this explanation of the different types of an acromion is new news to me and really seems to me that I have a Type 3. If I lay flat on the ground and put my arms straight back overhead, I can’t get the back of my hands closer than several inches from the ground. I has always felt like there are bones in the way of from reaching such a position. On snatches I can do virtually no weight unless I rotate the palms of my hands outward away from my body while holding the bar. It does something a little different with the shoulders that allows me to do a little weight overhead–but even then it is quite minimal. (I can’t even do a squat snatch; I have to first do a power snatch, then switch my grip at the top to my hands facing out, and then squat down. And my PR for this method is #75.)

    Does all this info seem to be indications of a severe type of type 3 acromion? Got any suggestions? It seems to me that the only solution that would really work would be shaving down the acromion. I did have x-rays taken of my shoulders in the last year and the doctor said everything looks structurally sound. I doubt, however, that he was looking for what type of acromion I have. My next step is to get a hold of those X-rays and ask about that. Anything else to look for?

    • I would go get reevaluated sometimes another exam can pick up on other things like biceps or rotator cuff issues

  3. I am one of those that fell into the type 3 acromium hook over time. I spent most of the year after The Open not doing any overhead presses to full extension (only up to where bicep was parallel to the floor) letting everything settle down. It never really did and was presenting other problems, especially when sleeping.

    Had the Subacromial Decompression surgery in December on a Friday. Was back at the gym on Monday doing the Assault bike only letting my ROM go as far as possible without pain. By end of the week, I had full ROM on the bike. By time I went back, I had full ROM with minimal issues.

  4. After the one time cortisone injection, how much time is needed before resuming exercise?
    Is there evidence that the injection weakens connective tissue (or is that an urban myth)?

    • Direct injection in to a tendon can weaken the tendon. Most injections avoid direct injection. Not an urban myth. Everyone is different regarding recommnedations on when to resume activity with the injected body part. I usually tell my patients 48 hours.

  5. As always you need to check with your surgeon and get the green light. If you were my patient everything has to be light and not cause strain on the other side. Running that distance is too soon. Good luck and check with your surgeon.

  6. I had rotator cuff surgery 10/21 and want to start one armed workouts again. Should I go light with good arm or is it ok to go heavier? Also I was hoping to run a 5K at the end of the month but I am thinking it may be too early to expect this???????

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About Me

Dr. Sean Rockett is an Orthopedic Surgeon specializing in Sports Medicine. His group is Orthopedics New England with offices in Dedham, Natick and Newton, Massachusetts. Dr. Rockett is a CrossFit Level 1 Trainer and has been a CrossFitter at CrossFit New England since 2007. Dr. Rockett is on the Medical Team for the CrossFit Games and the Northeast Regionals.

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