Topic Editor: Robert Giles, MBBS, BPharm
Review Date: 11/20/2012
Definition 
Bursitis is the acute or chronic inflammation of a bursa. Bursa are thin fluid-filled sacs lined by synovial membrane, and situated between tendons and skin or tendons and bone. Bursa reduce friction and facilitate motion.
Description
- Bursal inflammation is facilitated by repetitive injury, trauma, inflammatory process, infection, prolonged pressure, crystal deposition, or due to complications of systemic disease
- Pathophysiology: Synovial cells generate exudate due to infection or inflammation. This leads to swelling, pain, erythema, and warmth of the affected bursa
- There are nearly 160 bursae in the body. Major bursa are located in the large joints of the shoulder, elbow, knee, ankle, and hip
- Bursitis most commonly occurs at the:
- Ankle/heel (Retrocalcaneal bursitis)
- Elbow (Olecranon bursitis)
- Hip (Trochanteric bursitis)
- Knee (Pre-patellar bursitis)
- Shoulder (Subacromial bursitis)
- Other less common locations of bursitis include
- Knee-medial (Anserine bursitis)
- Hip (Iliopsoas bursitis)
- Hip (Ischiogluteal bursitis)
- Knee (Infra-patellar bursitis)
Epidemiology
Incidence/Prevalence
- Although common, the prevalence of bursitis is unknown
- The incidence of bursitis is greater in athletes, particularly in runners/sprinters, hockey players and rugby players
- Some occupations/ hobbies predispose to bursitis because of associated repetitive stresses (e.g. miners, carpenters, gardeners, and musicians)
Age
- Occurrence has been observed across all age groups, but is more common among older individuals
- Young children are rarely affected
Gender
- Bursitis affects both genders; predominance of location varies by gender
- The majority of septic bursitis cases occur in males
- Anserine (medial knee) bursitis is more common among women who are middle-aged or older
Risk Factors
- Anatomical deformities such as leg length discrepancies, valgus knee deformities
- Autoimmune diseases such as rheumatoid arthritis or ankylosing spondylitis
- Gait abnormalities
- Gout or pseudogout
- Hip osteoarthritis
- Infection in adjacent joints
- Immunosuppression may predispose to septic arthritis (conditions such as alcoholism, diabetes, immunosuppressant or steroid use)
- Occupations, hobbies, or sports causing bursitis due to overuse/stress on the bursa
- Sudden increase in activity
- Trauma / penetrating injury
Etiology
- The exact etiology of bursitis is unknown, however, there are clearly two entities, one inflammatory (overuse, crystal disease, autoimmune) or infectious (septic bursitis)
- Inflammation of bursae can occur due to causes such as:
- Traumatic injury to a bursa
- Repetitive trauma associated with certain occupations or sports
- Crystal deposition diseases (eg gout/ pseudogout)
- Inflammatory autoimmune conditions such as rheumatoid arthritis, rheumatic fever, sarcoidosis, or lupus
- Septic bursitis may occur as a result of wound infection, overlying cellulitis or bacterial intrusion into the bursal space. Staphylococcus species are responsible for the majority of cases (~80%)
- Osteoarthritis: Anserine bursitis and trochanteric bursitis commonly occur in patients with knee and hip osteoarthritis, respectively
[Outline]
History
- Decreased range of motion of the affected joint
- History of recent infection (septic bursitis)
- Localized pain
- Pain may worsen at night and during provocative activities such as climbing stairs or crossing legs
- Stiffness and achiness
- Weakness (chronic bursitis)
Physical findings on examination
- Specific examination findings will vary depending on the location of the inflamed/infected bursa. The following general findings are often present:
- Bursa swelling (especially of superficial bursa)
- Limited active range of motion but normal passive range of motion
- Tenderness to palpation
- Atrophy in patients with chronic bursitis
- Additional examination findings in septic bursitis:
- Erythema (which although common is not a true indicator of sepsis)
- Afebrile or low-grade fever
- Warmth in the region overlying or around the joint
[Outline]
Bursitis is commonly diagnosed based on the clinical presentation. Laboratory investigations may help distinguish septic bursitis from non-septic bursitis. Most blood tests apart from culture have significant overlap in expected results between these diagnostic categories; as such, other blood testing is typically not particularly useful.
Blood test findings
Other laboratory test findings
- Fluid analysis
- Bursal fluid aspirate is helpful in evaluating for infection. In general the WBC count is higher in septic versus non-septic bursitis
- The presence of urate crystals is diagnostic of gout and calcium pyrophosphate crystals diagnostic of pseudogout
- A high white cell count in the bursal fluid is suggestive of infection, gout/pseudogout or rheumatoid arthritis
- Gram staining of bursal fluid can effectively identify bacterial pathogens in 53% to 100% of patients with septic bursitis
- Specific pathogens can often be identified using bacterial cultures, which should be placed in liquid media (blood culture bottle) rather than solid media. Liquid media has superior yield with near 100% yield
Radiographic findings
- Plain radiography
- Plain radiographs are usually normal but may occasionally be helpful if a fracture, foreign body or osteomyelitis is found
- X-rays may reveal calcium deposition in calcific bursitis
- Magnetic resonance imaging (MRI) and computed tomography (CT)
- MRI and CT scans are not usually necessary for the diagnosis of bursitis; however, they may be valuable if the diagnosis is uncertain. They can be used to guide drainage if infection of a deep bursa is suspected. CT/MRI are useful to rule out other conditions such as malignant neoplasms, soft-tissue injuries and synovitis
- Ultrasound
- Ultrasonography is a valuable tool for the diagnosis of bursitis and is useful to guide aspiration of deep bursa
- Ultrasonography can effectively diagnose Baker's cysts (popliteal bursitis)
[Outline]
General treatment items
- Patients with non-septic bursitis should avoid trigger factors. Treatments are primarily symptomatic, and may involve administration of non-steroidal anti-inflammatory drugs (NSAIDs)
- Conservative therapy includes
- Compression with elastic sleeves for pain relief
- Elevating the affected limb above chest level
- Ice packs to reduce swelling and inflammation
- Protective pads and braces
- Resting of the affected area (immobilization using a sling, splint or plaster)
- Restriction of activity
- Warm compresses or heating pads for chronic bursitis
- NSAIDs
- NSAIDs can provide effective pain relief in acute bursitis, but have very little value in chronic bursitis
- NSAIDs should be administered after taking gastrointestinal (GI) and cardiovascular risks into consideration
- Among the many NSAIDs available, ibuprofen, diclofenac, naproxen, and indomethacin are usually preferred
- Acetaminophen is useful for analgesia
- Corticosteroids
- For patients refractory to conservative therapy, a corticosteroid (methylprednisolone) in combination with a local anesthetic (lidocaine) may be injected into the bursal sac to deliver immediate pain relief
- Extended release corticosteroid preparations such as triamcinolone can provide long-term anti-inflammatory effect
- Before administration careful consideration should be given to the potential complications of steroid injections, such as infection risk, including risk of the condition being infectious rather than inflammatory, atrophy, and tendon rupture
- Antibiotics
- Antibiotics with good staphylococci and streptococci coverage are indicated for septic bursitis. The gram stain should help guide antibiotic therapy until cultures are available
- Anti-staphylococcal penicillins are preferred as first line therapy, first and second generation cephalosporins or clindamycin may also be effective
- Mild-moderate cases may be treated on an outpatient basis with dicloxacillin, cephalexin, or clindamycin for 7-10 days
- Absence of adequate response to oral therapy necessitates hospitalization and administration of an intravenous (IV) antibiotic such as nafcillin, oxacillin, cefazolin, or clindamycin
- Vancomycin or linezolid should be used if methicillin-resistant S. aureus (MRSA) is suspected
- IV antibiotics are also preferred in immunocompromised and systemically unwell patients
- Aspiration
- Bursal aspiration is recommended in cases involving septic bursitis
- Percutaneous needle aspiration is sufficient in the majority of cases. Severe cases may require open surgical drainage
- Fluid re-accumulation is often encountered, which necessitates repeated aspiration procedures
- Surgery
- Bursectomy is not routinely indicated. Complete or partial bursectomy is reserved for septic or chronic bursitis unresponsive to antibiotic therapy and aspiration
- Arthroscopic bursectomy is an effective alternative to open bursectomy
- Other modalities
- Other less commonly used treatment modalities which have demonstrated limited success include ultrasound, phonophoresis, iontophoresis, and hydrotherapy
Medications indicated with specific doses
NSAIDs
- Acetaminophen [Oral]
- Diclofenac [Oral]
- Ibuprofen [Oral]
- Indomethacin [Oral]
- Naproxen
Local AnestheticsCorticosteroids- Methylprednisolone [Injectable]
- Triamcinolone [Injectable]
Antibiotics- Cefazolin [IM/IV]
- Cephalexin
- Clindamycin [IM/IV]
- Clindamycin [Oral]
- Dicloxacillin
- Linezolid [IV]
- Nafcillin [IV]
- Oxacillin [IM/IV]
- Vancomycin [IV]
Dietary and Activity restrictions
- Resting the painful joint and avoidance of heavy activity are recommended
- A low purine diet is recommended in bursitis associated with crystalline deposition diseases
Disposition
The majority of bursitis patients respond well to oral therapy and can be treated as an outpatient.
Admission Criteria
- Extensive cellulitis in surrounding area
- Failure of outpatient treatment
- Immunosuppression
- Inability to tolerate oral antibiotics
- Systemically unwell
Discharge Criteria
- Adequate analgesia
- Able to tolerate oral antibiotics or other medications needed
- Not systemically unwell
- Reasonable medical follow-up arranged
[Outline]
Monitoring
- Patients should undergo regular primary care and/or orthopedic follow-up post-discharge to monitor resolution of symptoms
- Patients refractory to nonsurgical treatment or those with evidence of ligament or tendon injury should undergo further assessment
Assessment of therapy
- NSAIDs should be discontinued as soon as possible to avoid risk of treatment-related complications such as GI bleeding or renal toxicity
- Patients should be monitored for complications resulting from corticosteroid therapy such as infection and tendon/fascial rupture
Complications
- Acute bursitis may progress to chronic bursitis
- Septic bursitis may lead to fulminant local or systemic infection
- Long-term decreased range of joint motion
- Spinal epidural abscess secondary to blood borne spread from septic bursitis (rare)
- Tendon tear due to repetitive friction
- Complications from side effects of medications or injectable steroids
Complications of intra-articular corticosteroid injection may include
- Hyperpigmentation
- Perilymphatic atrophy
- Sepsis
- Skin atrophy
- Skin depigmentation
- Tendon rupture
[Outline]
