Bursitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
A bursa is a sac that is formed or found in areas subject to friction, such as locations where tendons pass over bony landmarks. Most common sites are subdeltoid, olecranon, prepatellar, trochanteric, and radiohumeral. Bursae essentially lubricate the region with synovial fluid:
- Large bursae usually communicate with joints and are responsible for retaining the synovial fluid in place.
- Bursae are fluid-filled sacs that serve as a cushion between tendons and bones.
- E.G. Bywaters, an English rheumatologist, found at least 78 bursae symmetrically placed on each side of the body.
- System(s) affected: Musculoskeletal
- Bursitis is less common in the pediatric population.
- 15–50 years (most common in skeletally mature)
- Traumatic bursitis more likely in patients < 35 years of age
- Trochanteric pain: 1.8/1,000 per year (1)[B]
Individuals who engage in repetitive and vigorous training or others who suddenly increase their level of activity (e.g., “weekend warriors”)
- Appropriate warm-up and cool-down maneuvers, avoidance of overuse, or inadequate rest between workouts
- Range-of-motion exercises
- Maintain high level of fitness and general good health
- Bursitis may be acute or chronic
- Many types of bursitis, including infectious, traumatic, inflammatory, and gouty
- Less often rheumatoid disease or tuberculosis as well as gout and pseudogout
Commonly Associated Conditions
- Sprains, strains
- Associated stress fractures
- Decreased range of motion of affected region (rare except at shoulder)
- Erythema if infection present
- Crepitus sometimes found
Diagnostic Tests & Interpretation
Consider ECG (if left shoulder pain mimics cardiac pain)
- The following may help in differentiating soft tissue disease from rheumatic and connective tissue disease:
- Serum protein electrophoresis
- Rheumatoid factor
- Serum uric acid
- Alkaline phosphatase
- Blood testing for syphilis
- Joint fluid analysis and culture (when indicated)
- Drugs that may alter lab results:
- ESR rate may be increased with coexistent use of methyldopa, methysergide, penicillamine, theophylline, vitamin A.
- ESR may be decreased with coexistent use of quinine, salicylates, and drugs that cause a high glucose level.
- MRI may prove beneficial if diagnosis is unclear.
- Calcific deposits may be seen on plain radiograph.
- Ultrasound (2)[B]
- Aspiration of swollen bursa and evaluation of synovial fluid; the clinician must differentiate infected from inflammatory bursitis:
- Fluid WBC 2–5,000/uL imply inflammatory, whereas >5,000 imply infectious cause.
- Fluid analysis, Gram-stain, culture, and crystal analysis required to make the diagnosis.
- If the Gram-stain and culture yield an infective cause, treat with appropriate antibiotics. If the etiology is inflammatory, give local care.
- Acute with early inflammation: Bursa is distended with watery or mucoid fluid.
- Infection: Purulent fluid on aspiration
- Bursal wall is thickened, and inner surface is shaggy and trabeculated.
- The space is filled with granular, brown, inspissated blood admixed with gritty, calcific precipitations.
- Upper extremity tendinitis and bursitis are usually the result of repetitive microtrauma, probably resulting in disruption of fibers, leading to pain, spasm, and disability.
- Septic arthritis
- Gout, pseudogout
- Rheumatic disorders
- Tendinitis, strains, and sprains
- Lyme arthritis
Outpatient; refer only difficult cases
- NSAIDs or aspirin (3,4)[C]
- Antibiotic therapy if infection present; cover for staph and strep species (most common) (5)[B]
- Contraindications: Refer to manufacturer’s profile of each drug.
- Precautions: Refer to manufacturer’s profile of each drug.
- Significant possible interactions: Refer to manufacturer’s profile of each drug.
- Injectable corticosteroids once infectious etiology ruled out (3)[C],(4)[B],(6)[C],(7)[B]
- Systemic steroids provide limited short-term benefit (8)[B]
- Conservative therapy consists of rest, ice, and local care; elevation, gentle compression (often referred to as RICE therapy [rest-ice-compression-elevation])
- Compression with Ace wrap or neoprene sleeve
- Bursa aspiration
- Corticosteroid injection if infectious etiology ruled out
- Treatment of any underlying infection
Surgical excision in severe cases unresponsive to conservative treatments (5)[B]
Rest and elevation of affected extremity
- Discontinue NSAIDs as soon as possible to avoid side effects.
- Some patients may require repeated injections (usually no more than 3) of a corticosteroid and lidocaine (3,6)[C].
Consider changes if bursitis is directly related to obesity/crystalline deposition.
- Most bouts of bursitis heal without sequelae.
- Repetitive acute bouts may lead to chronic bursitis, necessitating repeated joint/bursal aspirations or, eventually, surgical excision of involved bursa.
- Septic bursitis may extend to the nearby joint.
- Acute bursitis may progress to chronic.
- Severe long-range limitation of motion
1. Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. 2005;55:199–204.
2. Finlay K, Friedman L. Ultrasonography of the lower extremity. Orthop Clin North Am. 2006;37:245–75, v.
3. Talia AH, Cardone D. Diagnostic and therapeutic injection of the shoulder region. Am Fam Phys. 2003;67(6):1271–8.
4. McFarland EG, Gill HS, Laporte DM, et al. Miscellaneous conditions about the elbow in athletes. Clin Sports Med. 2004;23:743–63, xi–xii.
5. Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005;19:991–1005, xi.
6. Cardone D, Tallia AH. Diagnostic and therapeutic injection of the hip and knee. Am Fam Phys. 2003;67(10):2147–53.
7. Buchbinder R, et al. Corticosteroid injection for shoulder pain. Cochrane Database Sys Rev. 2003;Issue Jan. 1.
8. Buchbinder R, Hoving JL, Green S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis.2004;63:1460–9.
Cardone D, Tallia AH. Diagnostic and therapeutic injection of the elbow. Am Fam Phys. 2002;66(11):2097–3100.
See Also (Topic, Algorithm, Electronic Media Element)
Video: Olecranon Bursitis Aspiration
727.3 Other bursitis disorders
84017003 Bursitis (disorder)
Remember RICE acronym for conservative therapy:
- Rest affected area
- Ice inflammed bursa
- Compression (with Ace wrap or neoprene sleeve)
- Elevate joint