Bursitis
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More Specific Terms
- iliopectineal bursitis
- ischial bursitis ('weaver's bottom')
- olecranon bursitis
- pes anserine bursitis
- prepatellar bursitis ('housemaid's knee')
- retrocalcaneal bursitis
- septic bursitis
- subacromial bursitis
- trochanteric 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 [3]
- 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:
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
- 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
Additional Terms
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 673-74
- Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
- Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
- Bursitis: NIH Institute and Center Resources [1]
