bursitis

Etiology

• repetitive motion activities
• bursitis generally arises from overuse
• repetitive microtrauma
  • areas exposed to constant pressure & rubbing may develop a chronic low-grade bursitis
  • commonly affected bursae
    • prepatellar
    • olecranon
    • retrocalcaneal
    • pes anserine
    • trochanter
• acute trauma may precipitate a hemorrhagic bursitis
• septic bursitis
  • overlying cellulitis
  • direct puncture wounds
  • lacerations
  • hematogenous spread
  • > 90% are due to Staphylococcus aureus
• gout/pseudogout may result in crystal-induced bursitis
• rheumatoid arthritis may be associated with bursitis

Pathology

• tenosynovitis & calcium apatite deposition commonly coexist

Clinical manifestations

• active range of motion may be painful
  • passive range of motion is not painful
• insidious onset of aching type pain
• pain tends to be localized, rarely with radiation
• pain intensity is generally low grade to moderate
• septic bursitis may be extremely painful
• repetitive activity exacerbates the pain, rest tends to relieve the pain
• localized tenderness to palpation over the affected bursae
• swelling is generally present, but may be difficult to detect if bursa lies deep
• erythema & warmth may be present, but should raise suspicion of infection
• joint range of motion is generally not impaired
• common sites of bursitis:
  • olecranon bursitis
  • prepatellar bursitis
  • retrocalcaneal bursitis
  • pes anserine bursitis
  • trochanteric bursitis
  • subacromial bursitis
  • iliopectineal bursitis
  • ischial bursitis (weaver's bottom)

Laboratory

• generally no laboratory testing is indicated
• if infection suspected, joint aspiration, cell count, gram stain & culture
• septic bursitis generally does not produce high WBC counts as observed in synovial fluid obtained with septic arthritis
• Staphylococci are most common etiologic agents of septic bursitis
• if gout/pseudogout is suspected, joint aspiration with cell count & crystal analysis

Radiology

generally not indicated

Differential diagnosis

• consider infectious etiology
• intra-articular effusion
• stress fracture, pathologic fracture
• degenerative joint disease (DJD)
• gout/pseudogout
• rheumatoid arthritis

Management

• goal of treatment is to alleviate pain & restore function
• remove offending agent/ stop offending activity
• ice massage
• compression wrap to reduce swelling seen with hemorrhagic bursitis
• NSAIDs
  • use full anti-inflammatory dose
  • ibuprofen 600-800 mg TID
  • indomethacin 25-50 mg TID
• site-specific stretching activity
• physical therapy
  • ultrasound
  • phonophoresis
• refractory symptoms
  • further activity restriction & splinting
  • intrabursal injection with long-acting corticosteroid local anesthetic combination
    • hydrocortisone 25-50 mg (25 or 50 mg/mL) with 1-2 mL of 1% lidocaine
    • methylprednisolone acetate 40 mg (40 mg/mL) with 1-2 mL of 1% lidocaine
• chronic cases with soft tissue thickening & calcification may require surgical excision
• septic bursitis (most commonly Staphylococcus aureus)
  • empiric antibiotic therapy with beta-lactamase resistant antibiotic
    • dicloxacillin 250 mg PO QID
    • cephalexin (Keflex) 500 mg PO QID
  • severe infection may require surgical drainage with intravenous antibiotics (nafcillin 2 g IV every 4 hours)

More general terms

• enthesopathy (enthesitis)

More specific terms

• iliopectineal bursitis
• ischial bursitis ('weaver's bottom')
• ischiogluteal bursitis
• olecranon bursitis
• pes anserine bursitis
• prepatellar bursitis ('housemaid's knee')
• retrocalcaneal bursitis
• septic bursitis
• subacromial bursitis
• trochanteric bursitis

Additional terms

• bursa

Patient information

bursitis patient information