Millions of people develop bursitis over the course of their lives, often in the shoulder, elbow, hip, or knees. The editorial team of the Leading Medicine Guide learned more about this and the extent to which bursitis and impingement are related in a conversation with sports and joint surgery specialist Prof. Dr. Sepp Braun.
Bursitis and impingement are common causes of complaints affecting the musculoskeletal and load-bearing system, particularly in the shoulder region. The condition can restrict mobility and cause pain, while targeted diagnostics and modern treatment methods make rapid recovery possible.
The causes of bursitis (Bursitis) are diverse and can generally be divided into acute and chronic triggers.
In acute inflammation, a sudden trauma or injury is usually the main cause. This can occur as a result of an inattentive fall, a strong impact, a sudden overstretching, or a sports injury, for example when throwing overhead in handball, tennis, or during weightlifting.
Accident-related direct trauma, such as a blow to the joint, can also irritate or injure the bursa to such an extent that it acutely swells and becomes painful. In addition, local infections can trigger acute bursitis, for example due to a skin injury through which bacteria enter the bursa and cause an infection.
„Bursitis and impingement are ultimately based on mechanical causes. The bursa in the shoulder, which in anatomical terms are not actually true sacs but rather a thin, gliding layer of tissue, are located above the rotator cuff and beneath the acromion, that is, the roof of the shoulder.
When this tissue layer becomes inflamed, it can cause pain. The inflammation is primarily triggered by mechanical stress. Typically, impingement – that is, the pinching of a muscle or tendon between bony structures – is the main reason for these inflammations. Impingement itself does not describe an independent disease entity but is a consequence of decentration of the shoulder joint, in which the humeral head is not properly centered in the socket.
This can be due to malalignment or instability, either functional, for example due to poor muscular coordination of the rotator cuff, or due to structural damage such as tendon tears. When tendons are damaged or torn, the joint can no longer be held stable, which leads to decentration. As a result, impingement develops, in which structures such as the bursa become irritated and inflamed, which then, for example, triggers pain when lifting or moving the arm“, explains Prof. Dr. Braun, adding about the causes:
„Another cause of impingement is the so-called external impingement, in which bony structures narrow the space and thus irritate the tendons and bursae. A common example is so-called acromial spur formation, which develops through ossification at the bony roof of the shoulder. Anatomical variations such as a broad, laterally overhanging bony portion of the acromion or a change in the scapular position, in which the shoulder blade tilts forward, can also restrict mobility and lead to impingement symptoms. Another frequent change is the so-called lateral ‘acromion downslope,’ in which the acromion tilts downward laterally, which can develop over the course of life due to traction from the deltoid muscle. All of these bony and anatomical factors can be the cause of impingement symptoms; however, impingement itself is never the actual diagnosis but always the consequence of an underlying cause that must first be identified and then treated“.
The bursa subacromialis is a bursa located between the acromioclavicular joint and the tendon of the supraspinatus muscle._ Zameer Hirji, CC BY 3.0
With chronic overuse, repeated movements such as heavy lifting, overhead work, poor posture, or prolonged sitting lead to persistent irritation of the bursa. Especially in occupations that require repetitive movement patterns, chronic bursitis can develop.
Congenital as well as degenerative changes in bones or tendons, such as osteoarthritis in the joint or degenerative tendon changes, can irritate the bursa over a longer period and cause chronic inflammation. It is also important that, in chronic courses, bursa formation is continually stimulated by ongoing microtrauma or unsuitable movement patterns, so that persistent inflammation becomes established.
Impingement in itself is not the actual diagnosis but always a consequence of an underlying problem.
„A good example can be seen in the elbow region. If you spend a lot of time sitting at a desk, the elbows may rest on the edge of the table. In such a posture, a small tissue sac may sometimes form, which does not necessarily cause pain but may present as visible swelling.
There is also a bursa at the elbow, a gliding layer over the tip of the ulna, the elbow bone, which enables the skin to move with each bend of the elbow. Pressure and constant friction against the table cause mechanical irritation there, which can trigger an inflammatory reaction. The tissue swells, and fluid accumulates, causing a doughy swelling.
This reaction is usually not an inflammation in the sense of an infection but a purely mechanical irritation. Only rarely can this bursa become infected, resulting in true bacterial bursitis that must be treated with antibiotics. If the strain persists and irritation recurs repeatedly, the tissue can become chronically inflamed and, in severe cases, may even need to be surgically removed to allow new tissue to develop, as bursae can reform again and again“, says Prof. Dr. Braun, and continues:
„Particularly in overhead sports such as tennis, the risk of shoulder problems should not be underestimated. Repeated overhead movements, such as during serving, often cause problems that are attributable to capsular shortening, decentration of the joint due to specific changes in the joint capsule, and differences in the mobility of joint structures.
These stresses can lead to internal impingement, in which tendons and bursae become irritated and inflamed. It is important to identify the exact cause here in order to counteract it in a targeted manner, because treating only the inflammation provides short-term relief, but the underlying cause remains in the long term.
A sustainable solution always requires a clear diagnosis, because only then can sports-related damage be treated effectively. I am therefore firmly convinced that it is not enough to treat only the acute symptoms, for example through anti-inflammatory measures or symptom relief. The actual cause – biomechanical stress or anatomical change – must be identified and addressed in order to achieve lasting improvement“.
The development of impingement, particularly in the shoulder joint, involves complex biomechanical and pathophysiological processes. Impingement syndrome arises mainly through repeated mechanical stress on the tendons and structures in the so-called subacromial space, which leads to constant irritation and damage to the mucosal lining in this region. A common consequence is recurrent bursitis, which repeatedly flares due to ongoing irritation. The inflammation that arises further increases friction, worsening wear and limiting shoulder mobility.
Various diagnostic methods are used to differentiate between bursitis and impingement syndrome in the shoulder region.
„Diagnostic clarification always begins with a comprehensive, meticulous clinical examination. This is the central element in diagnostics, because only a precise analysis of mobility, restrictions, and pain points can provide a clear picture. It is essential to observe movement patterns dynamically, including scapular motion, in order to detect functional disturbances at an early stage.
It is also important that the patient undresses for the examination, because examining through a T-shirt is not productive; only in this way can the movement and alignment patterns of the shoulder or shoulder joint really be assessed. For complete and accurate diagnosis, imaging procedures are then used: First, X-rays in three planes are very helpful for accurately assessing bony changes and bone structures.
In addition, magnetic resonance imaging (MRI) has become almost indispensable in orthopedic diagnostics today. While MRI images were considered rather secondary in the past, their importance has increased significantly in recent years because they provide very detailed insights into the soft tissues, tendons, ligaments, and structures in the shoulder region and thereby enable targeted treatment planning.
However, one should keep in mind that MRI images should only be reviewed after the clinical examination in order to approach the case with an open and objective mindset. Imaging is ultimately just an additional tool to confirm or refute the clinical diagnosis“, emphasizes Prof. Dr. Braun and continues:
„In addition to X-rays and MRI, ultrasound is also a valuable option for assessing the status of the shoulder. However, it should be noted that ultrasound is highly examiner-dependent, and its quality strongly depends on the device used and the examiner’s experience. Modern high-resolution devices make assessment much easier, but the physician’s expertise plays a decisive role in making optimal use of the potential findings.
I personally use ultrasound frequently, but I consider it far more meaningful to base surgically relevant decisions on the clinical examination and MRI images, as these allow a more comprehensive assessment and provide greater safety in treatment planning. A combination of careful clinical examination and targeted imaging – especially MRI and ultrasound – forms the basis for an accurate diagnosis and sets the course for the right therapy“.
Conservative treatment is usually sufficient when symptoms are mild, inflammation is still limited to local irritation, or symptoms only occur with certain movements.
This includes measures such as rest, protection, physical therapy, anti-inflammatory medications, local injections, or specific exercises for muscle relaxation and posture correction. These approaches often lead to a significant improvement in symptoms, so that surgery is initially not necessary.
„If we are speaking only of functional impingement, without more advanced structural damage, it is clear from the outset that conservative therapy must be initiated first. For me, this is essentially self-evident. However, if I identify larger or multiple tendon injuries of the rotator cuff in a patient, which are also reflected in the examination through loss of function, significant loss of strength, and more severe pain – particularly in active, demanding patients –, it is often advisable to proceed directly with surgery.
In such cases, the conservative path is very unlikely to be successful in the long term, and this approach can significantly shorten the patient’s treatment journey. As for conservative measures, we mainly rely on physiotherapy, supplemented by medication or sometimes injections. I am generally cautious about injections. There are situations where they make sense, for example to bridge acute symptoms and thus make it easier to carry out the actual therapy.
In particular, when pain levels are so high that physiotherapists initially need a lot of time to achieve a less painful condition to allow active training – where the focus is primarily on muscle strengthening rather than massage – injections can be helpful. However, I am cautious because their effect usually lasts only for a short time. Local anesthetic and cortisone are most commonly used. I use them very sparingly because potential side effects can occur both in the joint and in the tendons, and their long-term efficacy is questionable“, states Prof. Dr. Braun, and further explains treatment with autologous plasma:
„There is also the option of working with autologous plasma, or PRP (platelet-rich plasma). I like to use this, for example, in cases of epicondylitis such as tennis or golfer’s elbow, and I have had good experience with it. PRP contains white blood cells that can have anti-inflammatory effects. In the area of the bursa, which is frequently treated with cortisone, I rarely use PRP. I also occasionally use it for partial tendon tears, but only in selected patients – it is not a standard treatment but an option that can be promising in individual cases“.
In chronic problems where conservative measures do not achieve the desired success, minimally invasive surgical treatment – such as shoulder arthroscopy – may be indicated in order to address the underlying causes in a targeted manner, for example by removing bony growths, sources of pain, or by repairing damaged tendons.
„In my practice, I do not operate on isolated impingement. The patient receives good physiotherapy, follows a conservative regimen, and usually does not undergo surgery because it is most often unnecessary. In the past ten years, I have not operated on anyone solely to remove a spur from the acromion; I probably have never done that at all.
If impingement leads to structural damage, for example to the rotator cuff, the rotator cuff is operated on primarily, and the spur is removed in the same procedure. I have never performed an isolated subacromial decompression. This may also be because I rarely see such patients in my specific setting. However, it cannot be ruled out that there are situations where such surgery makes sense, for example in very pronounced spur formation, in order to limit emerging tendon damage.
Most of the time, I see patients only once structural tendon damage is already present. For the postoperative rehabilitation phase after rotator cuff surgery, the rule of thumb ‘two times six weeks’ has proven effective. The first phase consists of six weeks of protection with a very cautious therapy protocol so that the tendon can heal in peace. This is followed by a second, more active phase of another six weeks, during which the tendon is gradually subjected to structural loading and mobility is progressively increased in order to promote complete healing.
Without loading, the tendon cannot heal in a permanently stable manner. After these two six-week periods, the worst is usually over. In the first six weeks, the affected arm is generally not suitable for normal daily activities; in the second six weeks, small household tasks that do not require a large range of motion or greater strength can typically be performed again“, says Prof. Dr. Braun about the course of treatment and recovery.
There are no clear differences between athletes and non-athletes regarding the development of tendon damage in the shoulder – nobody is consciously doing something wrong. However, factors such as posture and regular physical activity are crucial for preventing symptoms. Those who pay attention to an upright posture and stable musculature can help prevent problems.
„Posture is a key factor. Posture is generally important but particularly so for shoulder health. Anyone who spends the entire day in front of a computer or – even worse – slouched with a laptop on their lap, letting the shoulders roll forward and developing a rounded back, places unfavorable stress on the shoulder and rotator cuff.
An upright posture of the upper body with the shoulder blades drawn back can have a preventive effect and help avoid shoulder complaints. Another important aspect is activity. The musculature should be kept as fit as possible, because a certain basic strength is a prerequisite for a joint to function well. As with all joints, regular movement within a non-risky range is highly beneficial for long-term health“, advises Prof. Dr. Braun as prevention.
In addition, it is advisable to avoid repetitive movement patterns at the extremes of range of motion or to modify them through targeted technical and load adjustments. Regular breaks during strenuous activities and conscious posture training can help prevent long-term damage. Learning and maintaining ergonomic movement patterns at work and in sports also help optimally relieve the shoulder and avoid peak loads.
These preventive strategies, combined with targeted training for mobility and stability, help maintain muscular balance in the shoulder joint and thus sustainably reduce the risk of impingement and bursitis. Overall, the earlier and more consistently these measures are implemented, the better the development of chronic symptoms can be prevented.
In clinical practice, very similar basic concepts are applied for all joints – shoulder, knee, elbow, hip, and ankle. This approach makes it possible to diagnose and treat joints in a focused and specialized way. While the underlying principles are comparable, the individual characteristics of each joint can differ significantly.
Many thanks, Prof. Dr. Braun, for these important insights into the treatment of bursitis and impingement!
- Dr. Sepp Braun: leading expert in sports and joint surgery; practicing at the „Gelenkpunkt“ clinic in Innsbruck. Comprehensive training, including at Klinikum rechts der Isar (Technical University of Munich), BG Clinic Murnau, and the University Medical Center Freiburg. One-year fellowship at the Steadman Clinic, Vail, USA – a world-renowned center for sports orthopedics.
- Specializations: arthroscopic and open shoulder surgery, shoulder endoprosthetics, complex sports injuries.
- President of AGA – the largest European professional society for arthroscopy and joint surgery (over 6,000 members).
- Co-founder of the German Arthroscopy Registry (DART) for quality assurance and further development of innovative techniques.
- At the „Gelenkpunkt“ clinic: high level of expertise in minimally invasive surgery, reconstructive joint surgery, and complex joint injuries. Focus on gentle techniques for rapid healing and a quick return to sports and everyday life. Collaboration within an international network of experts to provide state-of-the-art, evidence-based treatment.
- Active in research, with regular publications and development of new technologies to optimize outcomes.
- Highly sought-after specialist worldwide, treating elite and recreational athletes as well as patients of all performance levels.
