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Saturday, August 16, 2025

Bursitis


Introduction

Bursitis is a common musculoskeletal disorder characterized by inflammation of a bursa, which is a small synovial fluid–filled sac that provides cushioning and reduces friction between tendons, muscles, bones, and joints. When the bursa becomes inflamed, it leads to pain, swelling, and restricted mobility. Bursitis most frequently affects large joints such as the shoulder, elbow, hip, and knee, although any bursa in the body can be affected.

While bursitis is often self-limiting, recurrent or chronic forms can significantly impair daily activities and quality of life. A combination of conservative management, pharmacological therapy, and, in some cases, interventional procedures is required to control symptoms and prevent recurrence.

Anatomy and Function of Bursae

Bursae are thin, fluid-filled sacs lined with synovial membrane and located at sites where friction occurs between moving structures such as tendons and bones. They act as cushions that reduce mechanical stress during movement.

  • Subacromial bursa – located in the shoulder beneath the acromion, commonly affected in shoulder bursitis.

  • Olecranon bursa – found at the posterior aspect of the elbow, commonly affected in students or workers (“student’s elbow”).

  • Trochanteric bursa – located at the outer hip, frequently involved in hip bursitis.

  • Prepatellar bursa – at the front of the knee, often inflamed in individuals who kneel frequently (“housemaid’s knee”).

  • Retrocalcaneal bursa – at the heel, often inflamed in athletes or runners.

Etiology and Risk Factors

Bursitis can result from multiple causes, often multifactorial:

1. Mechanical Causes

  • Repetitive motion or overuse: Athletes, musicians, and manual laborers often develop bursitis due to repetitive stress.

  • Prolonged pressure: Frequent kneeling (carpet layers, gardeners) or leaning on elbows can cause prepatellar or olecranon bursitis.

2. Trauma

  • Direct injury: A fall or blow to the joint can cause acute bursitis.

  • Microtrauma: Accumulated small injuries over time can lead to chronic inflammation.

3. Inflammatory Disorders

  • Rheumatoid arthritis

  • Gout (uric acid crystal deposition in bursae)

  • Pseudogout (calcium pyrophosphate crystal deposition)

4. Infectious Causes

  • Septic bursitis: Occurs when bacteria (commonly Staphylococcus aureus) invade the bursa, usually after trauma or penetrating wounds.

5. Other Risk Factors

  • Age (more common in middle-aged and older adults)

  • Obesity (increased pressure on weight-bearing joints)

  • Poor posture and musculoskeletal imbalances

Clinical Presentation

Symptoms

  • Localized pain over the affected bursa

  • Swelling, warmth, and tenderness

  • Reduced range of motion in the affected joint

  • Pain worsens with movement or direct pressure

Signs

  • Visible swelling or fluid accumulation

  • Erythema (redness) in septic bursitis

  • Crepitus or stiffness in chronic bursitis

Common Types of Bursitis

  1. Subacromial bursitis (shoulder bursitis): Pain with overhead arm movement, often associated with rotator cuff pathology.

  2. Olecranon bursitis: Swelling at the tip of the elbow, may be painless unless infected.

  3. Trochanteric bursitis: Lateral hip pain, worse when lying on the affected side or climbing stairs.

  4. Prepatellar bursitis: Knee swelling anteriorly, common in professions with frequent kneeling.

  5. Retrocalcaneal bursitis: Heel pain, especially in athletes and runners.

Diagnostic Evaluation

Clinical Examination

Diagnosis is usually clinical, based on history and examination.

Imaging

  • Ultrasound: Useful for detecting fluid in bursae.

  • MRI: Indicated in refractory cases to evaluate associated tendinopathy.

  • X-rays: May rule out bone abnormalities.

Laboratory Studies

  • Bursal aspiration: Performed if septic bursitis is suspected. Fluid is analyzed for cell count, crystals, and culture.

  • Blood tests: ESR, CRP, and WBC count may be elevated in infection or inflammatory bursitis.

Management of Bursitis

Management depends on etiology (traumatic, inflammatory, or infectious).

1. General Conservative Measures

  • Rest: Avoid repetitive activities or pressure on the affected area.

  • Ice therapy: 15–20 minutes several times daily to reduce inflammation.

  • Elevation: For lower limb bursitis to reduce swelling.

  • Protective padding: For knees and elbows.

  • Physical therapy: Stretching, strengthening, and postural correction.

2. Pharmacological Management

a. Analgesics and NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy.

  • Ibuprofen: 400–800 mg orally every 6–8 hours (maximum 3200 mg/day).

  • Naproxen: 250–500 mg orally twice daily (maximum 1500 mg/day).

  • Diclofenac: 50 mg orally two to three times daily; topical diclofenac gel may also be used.

  • Celecoxib (COX-2 inhibitor): 200 mg orally once daily or 100 mg twice daily for patients intolerant to nonselective NSAIDs.

b. Corticosteroid Injections

For persistent, severe bursitis not responding to NSAIDs.

  • Triamcinolone acetonide: 10–40 mg injected directly into the affected bursa.

  • Methylprednisolone acetate: 20–40 mg intra-bursal injection.

  • Hydrocortisone acetate: 25–50 mg injected into the bursa.

Note: Injections should not be repeated too frequently to avoid tendon weakening.

c. Antibiotics (for septic bursitis)

Empirical treatment typically targets Staphylococcus aureus and Streptococcus.

  • Dicloxacillin: 500 mg orally every 6 hours.

  • Cephalexin: 500 mg orally every 6 hours.

  • Clindamycin: 300–450 mg orally every 6–8 hours (for penicillin-allergic patients).

  • Trimethoprim-sulfamethoxazole (TMP-SMX): 1 double-strength tablet (160/800 mg) orally twice daily for MRSA coverage.

  • Vancomycin: 15–20 mg/kg IV every 8–12 hours for severe MRSA infections.

Duration: 10–14 days for oral antibiotics; IV antibiotics may be required for severe cases.

d. Colchicine

In crystal-induced bursitis (gout, pseudogout).

  • Colchicine: 0.6 mg orally once or twice daily.

3. Interventional and Surgical Options

  • Aspiration: Removal of fluid from the bursa can provide relief and allow analysis.

  • Bursectomy: Surgical removal of the bursa in chronic or recurrent bursitis resistant to conservative treatment.

  • Arthroscopic techniques: Less invasive, quicker recovery.

Prognosis

Most cases of bursitis resolve with conservative management and pharmacological therapy. Chronic or recurrent cases require lifestyle modifications, physical therapy, and occasionally surgical intervention. Septic bursitis requires prompt antibiotic therapy to prevent systemic complications.

Prevention

  • Avoid repetitive stress and prolonged pressure on joints.

  • Use protective equipment such as knee pads or elbow pads.

  • Maintain healthy body weight to reduce joint stress.

  • Perform regular stretching and strengthening exercises.

  • Manage underlying systemic inflammatory conditions.

Complications

  • Chronic bursitis with recurrent pain and swelling

  • Septic bursitis leading to cellulitis or systemic infection

  • Tendon rupture after repeated corticosteroid injections

  • Reduced joint mobility


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