Subacromial Bursitis: Overview and Evidence Summary

Condition Overview

Subacromial bursitis is a painful shoulder condition arising from irritation or inflammation of the subacromial–subdeltoid bursa, one of the largest bursae in the body and a crucial interface for smooth shoulder movement. This bursa sits between the rotator cuff tendons—primarily the supraspinatus—and the overlying acromion and deltoid muscle. Its purpose is simple yet essential: it reduces friction so the humeral head can glide freely beneath the acromion during elevation, rotation, and functional tasks.

When the subacromial bursa becomes irritated, the entire mechanics of the shoulder begin to unravel. Patients often describe a sharp, catching pain when lifting the arm or reaching overhead, alongside a dull ache that lingers at rest. Some experience burning or throbbing discomfort that radiates down the lateral upper arm. Night pain is particularly common because lying on the affected side compresses the bursa, increasing irritation at a time when joint fluid dynamics naturally slow.

Subacromial bursitis rarely appears in isolation. It almost always coexists with other contributors—rotator cuff tendinopathy, scapular dyskinesis, poor postural control, reduced thoracic mobility, capsular tightness, or altered humeral head translation. Sometimes these processes stem from decades of accumulated microtrauma; sometimes they emerge abruptly following overload, trauma, or repetitive overhead work. The bursa becomes the “victim” rather than the original problem.

In younger individuals, subacromial bursitis commonly results from mechanical overload—repetitive throwing, swimming, weightlifting, painting ceilings, or sudden increases in activity. In older adults, bursitis is more often associated with degenerative changes in the rotator cuff or acromion, or generalized age-related tissue sensitivity.

The encouraging truth is that subacromial bursitis responds exceptionally well to structured, thoughtful rehabilitation. By restoring balanced muscle function, improving scapular mechanics, addressing capsular tightness, and managing load intelligently, most individuals regain comfortable motion and reduce pain significantly—even if imaging shows bursitis alongside degenerative findings.

Summary of Current Evidence for Subacromial Bursitis

Evidence-Based Management Discussion

Biomechanics and Why the Bursa Becomes Irritated

The subacromial bursa exists primarily to allow smooth, almost frictionless motion between the humeral head and the structures above it. During normal elevation, the humeral head remains centered while the scapula upwardly rotates, posteriorly tilts, and externally rotates—all orchestrated by a symphony of rotator cuff, scapular stabilizers, and thoracic mobility.

When any element of this symphony falters, the bursa pays the price.

Common Drivers of Bursal Irritation

• Excessive superior migration of the humeral head, often due to rotator cuff weakness or fatigue.

• Reduced scapular upward rotation, limiting subacromial space.

• Thoracic kyphosis, altering glenoid position and forcing the shoulder to elevate inefficiently.

• Posterior capsule tightness, shifting humeral head mechanics and increasing compression during elevation.

• Repetitive overhead loading, particularly in sports or occupations.

• Sudden spikes in training volume—a common cause in recreational athletes.

The bursa, richly innervated and highly reactive, becomes inflamed when repeatedly compressed. Once sensitized, even subtle movements that previously caused no issue suddenly become painful.

Clinical Presentation: Why Everyday Tasks Become Difficult

Subacromial bursitis produces a distinctive pattern of pain: discomfort during mid-range elevation (the “painful arc”), weakness secondary to pain inhibition, and night pain that disrupts sleep. Tasks such as reaching into cupboards, washing hair, fastening seatbelts, or lifting objects away from the body often evoke sharp discomfort.

Unlike rotator cuff tears, strength may be near normal when pain is minimal; the limitation is usually sensitivity, not structural failure. Patients often unconsciously modify movement, elevating the shoulder using the upper trapezius or side-bending the trunk to avoid compressing the bursa. Over time, these compensations become habitual and perpetuate dysfunction.

Exercise Therapy

Exercise is the cornerstone of treatment because bursitis rarely resolves without addressing its mechanical drivers. A well-sequenced program improves space within the subacromial region, restores neuromuscular control, and reduces strain on irritated tissues.

Early Phase: Calming Symptoms and Improving Basic Mechanics

The initial aim is to reduce irritation while restoring movement quality. Patients benefit from:

• Gentle active motion that avoids painful arcs

• Low-load rotator cuff activation exercises

• Scapular setting and awareness drills

• Thoracic extension and mobility work

Controlling posture—especially reducing rounded shoulders and thoracic flexion—is essential for relieving pressure on the subacromial region.

Middle Phase: Strengthening and Coordinating the Shoulder Complex

Once symptoms stabilize, loading becomes more deliberate. The evidence strongly supports:

• Strengthening the external rotators and subscapularis

• Improving serratus anterior and lower trapezius function

• Restoring balanced scapular upward rotation

• Gradually increasing resistance during elevation

Exercises must be progressed gradually to avoid flare-ups; tendons and bursae respond best to controlled, predictable loads.

Late Phase: Preparing for Real-World or Athletic Function

At this stage, treatment becomes increasingly functional:

• Movement patterns such as reaching, lifting, and pressing are retrained

• Sport- or occupation-specific drills are integrated

• Eccentric and dynamic control exercises help prevent recurrence

The focus shifts from merely reducing pain to building capacity and resilience that withstands daily and recreational demands.

Manual Therapy

Manual therapy provides short-term symptom relief and enhances movement quality, creating a window for more effective exercise. Evidence suggests that mobilizing the glenohumeral and acromioclavicular joints, releasing myofascial tension in the deltoid or posterior cuff, and improving thoracic mobility can reduce the mechanical stress on the subacromial space.

Importantly, manual therapy is not a cure. It is an adjunct that accelerates progress when paired with structured rehabilitation.

Pain Management and Injections

NSAIDs can temporarily reduce symptoms during acute flares. Subacromial corticosteroid injections often provide significant short-term relief, particularly for night pain. However, injections do not address underlying biomechanical issues, and repeated use may weaken surrounding tissues. The most successful long-term outcomes come from combining injections (if used at all) with targeted exercise.

PRP and other biologics currently lack strong evidence for isolated bursitis, though research continues.

Surgical Considerations

Surgery is rarely required for bursitis in isolation. Historically, subacromial decompression (acromioplasty) was widely performed, but recent evidence shows minimal benefit over conservative care for many patients. Surgery may be considered when bursitis coexists with significant rotator cuff pathology or structural impingement that has not responded to comprehensive rehabilitation.

Clinical Considerations for Therapists

Therapists have a central role in guiding recovery:

• Educating patients about the reversible nature of bursitis

• Reinforcing that imaging findings of “bursitis” do not dictate prognosis

• Teaching movement strategies that reduce superior humeral head translation

• Addressing compensatory patterns to prevent recurrence

• Grading exposure back to meaningful activities

Success hinges on patience, consistency, and restoring the natural rhythm of scapulohumeral motion.

References

Lewis, J., et al. “Management of Shoulder Impingement and Related Disorders.” British Journal of Sports Medicine, 2015.

Seitz, A., et al. “Mechanisms of Subacromial Pain: Scapular Dyskinesis and Biomechanical Contributors.” Sports Health, 2011.

Koester, M., et al. “Efficacy of Subacromial Corticosteroid Injection.” Journal of Bone & Joint Surgery, 2007 and updates.

Khan, K., et al. “Tendon and Bursa Adaptation to Mechanical Loading.” Clinical Sports Medicine, 2016.

Littlewood, C. “Exercise Therapy for Shoulder Pain: Evidence and Application.” Journal of Shoulder and Elbow Surgery, 2012.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.