Causes and Treatment of Periscapular Bursitis

Periscapular bursitis is a possible cause of upper back pain. The scapula, also called the shoulder blade, is an important bone that shifts its position with the upper body and shoulder movement. The motion of the scapula on the upper back is critical to the normal function of the shoulder and the spine. When movements of the shoulder blade are abnormal, significant inflammation and pain can result.

Normal Function of the Scapula

The scapula is also called the shoulder blade. The bone is a triangular-shaped bone that sits on the outside of the rib cage on your upper back. You have one scapular bone on each side of your body. The outer (lateral) side of the scapula contains the socket of the shoulder joint (called the glenoid), while the rest of the bone serves as attachment points for many of the shoulder and back muscles. 

As you move your arm forward and back, the scapula shifts on the rib cage. This scapular movement (called scapulothoracic motion) is critical to the normal function of the upper extremity and the shoulder joint. When the scapula does not glide in a coordinated motion, the function of the torso and shoulder joint can be problematic.

The Scapular Bursa

A bursa is a fluid-filled sac within the body that allows for smooth motion between structures. You have important bursae scattered around your body including in the shoulder joint, on the outside of your hip, and in front of the kneecap. These bursae allow gliding movements between bones and tendons. When a bursa becomes inflamed and irritated, these normal movements can become painful.

In the upper back, there are several bursae around the scapula. Two of these bursa sacs are between the bones and the serratus anterior muscle, an important muscle that controls scapular movement on the chest wall. One of the bursa sacs is located on the upper corner of the scapula (not far from the spine at the base of the neck), and the other is located at the bottom corner of the scapula (in the mid-back). Either or both of these bursa sacs can be involved in periscapular bursitis.

In addition, a number of other minor bursae have been described around the scapula and the surrounding tendons, but these two seem to be the primary culprits in people with periscapular bursitis.

Inflammation of the Bursa

When these bursae become inflamed and irritated, the condition called bursitis is the result. Bursitis occurs when there are swelling and thickening of the bursa. When bursitis near the scapula occurs, movements of the muscles and shoulder blade can lead to discomfort. The most common symptoms in people diagnosed with periscapular bursitis include:

• Pain
• Grinding sensations (crepitus)
• Snapping with movement
• Tenderness directly over the scapular bursa
• Abnormal scapular mechanics

When examined, people with bursitis of the scapula may display abnormal movements of the shoulder blade. This can lead to a finding called "winging" of the scapula, where the shoulder blade is not held tightly to the rib cage and protrudes out abnormally. People with winging of the scapula typically have abnormal mechanics of the shoulder joint, because the positioning of the shoulder can be altered.

Causes of periscapular bursitis can be varied. Most common is simply an overuse syndrome where a specific activity is causing irritation to the scapular bursa. These may include sports or work-related activities that result from repetitive use. Traumatic injuries can also cause periscapular bursitis when a specific injury caused inflammation or irritation to the bursa.

Lastly, there are some conditions where abnormal anatomy or growths can cause irritation to the bursa. One of the most common is a benign bone growth called an osteochondroma. These benign bone growths can cause projections off the scapula that lead to irritation of the bursa.

Treatment of Bursitis

Treatment of scapular bursitis always begins with simple steps. Most people with this condition can find relief with a few simple treatments. Fortunately, invasive treatments are seldom needed to correct the problem, and it's very unusual for someone who treats this condition to have ongoing symptoms of discomfort. Treatment steps include:

• Rest: The first, and often most important, step in the management of periscapular bursitis is to rest the irritated bursa and allow the inflammation to settle down. This usually takes a few weeks and can be accomplished by modifying any specific activity (such as a sport or work-related activity) that seems to aggravate the condition.
• Ice: Reduction of inflammation and controlling pain are helpful steps in the management of this condition. Ice is a useful tool to accomplish both of these tasks. Knowing how to properly ice an injury can help you manage the pain and swelling associated with bursitis.
• Anti-Inflammatory Medications: Non-steroidal anti-inflammatory medications are also very useful treatments to control the inflammation from bursitis. In people who may need surgical treatment, successful treatment with a cortisone shot is a sign that surgery is more likely to be effective. In general, people taking these medications should use them regularly for a few weeks to help block the inflammatory response. Before taking any medication, you should confirm with your healthcare provider that it is safe for you to use these medications.
• Physical Therapy: Physical therapy is actually one of the most useful treatments for periscapular bursitis. There are two reasons that therapy is beneficial. First, therapy can help limit the symptoms of inflammation of the bursa. Second, physical therapy can be very effective at improving scapular mechanics so the problem doesn't become ongoing and recurrent. Abnormal movement of the scapula on the rib cage can not only lead to the development of bursitis, but it may lead to the recurrence of the problem if these abnormal mechanics are not addressed.
• Cortisone Injections: Cortisone injections can be very helpful to deliver a powerful anti-inflammatory dose directly to the site of inflammation. Cortisone injections should be limited in terms of how many injections are offered to an individual, but in limited doses can be very helpful. In people who may need surgical treatment, successful treatment with a cortisone shot is a sign that surgery is more likely to be effective. However, cortisone shots should only be performed once the diagnosis is confirmed.

As stated, surgery is seldom necessary but can be effective in the few individuals who fail to find relief with the aforementioned treatments. Surgery is most often used for individuals who have abnormal scapular anatomy, such as bone growths or tumors, causing direct irritation to the bursa.