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bursitis
Etiology:
1) repetitive motion activities
2) bursitis generally arises from overuse
3) repetitive microtrauma
a) areas exposed to constant pressure & rubbing may develop a chronic low-grade bursitis
b) commonly affected bursae
1] prepatellar
2] olecranon
3] retrocalcaneal
4] pes anserine
5] trochanter
4) acute trauma may precipitate a hemorrhagic bursitis
5) septic bursitis
a) overlying cellulitis
b) direct puncture wounds
c) lacerations
d) hematogenous spread
e) > 90% are due to Staphylococcus aureus
6) gout/pseudogout may result in crystal-induced bursitis
7) rheumatoid arthritis may be associated with bursitis
Pathology:
- tenosynovitis & calcium apatite deposition commonly coexist
Clinical manifestations:
1) active range of motion may be painful
- passive range of motion is not painful [3]
2) insidious onset of aching type pain
3) pain tends to be localized, rarely with radiation
4) pain intensity is generally low grade to moderate
5) septic bursitis may be extremely painful
6) repetitive activity exacerbates the pain, rest tends to relieve the pain
7) localized tenderness to palpation over the affected bursae
8) swelling is generally present, but may be difficult to detect if bursa lies deep
9) erythema & warmth may be present, but should raise suspicion of infection
10) joint range of motion is generally not impaired
11) common sites of bursitis:
a) olecranon bursitis
b) prepatellar bursitis
c) retrocalcaneal bursitis
d) pes anserine bursitis
e) trochanteric bursitis
f) subacromial bursitis
g) iliopectineal bursitis
h) ischial bursitis (weaver's bottom)
Laboratory:
1) generally no laboratory testing is indicated
2) if infection suspected, joint aspiration, cell count, gram stain & culture
3) septic bursitis generally does not produce high WBC counts as observed in synovial fluid obtained with septic arthritis
4) Staphylococci are most common etiologic agents of septic bursitis
5) if gout/pseudogout is suspected, joint aspiration with cell count & crystal analysis
Radiology: generally not indicated
Differential diagnosis:
1) consider infectious etiology
2) intra-articular effusion
3) stress fracture, pathologic fracture
4) degenerative joint disease (DJD)
5) gout/pseudogout
6) rheumatoid arthritis
Management:
1) goal of treatment is to alleviate pain & restore function
2) remove offending agent/ stop offending activity
3) ice massage
4) compression wrap to reduce swelling seen with hemorrhagic bursitis
5) NSAIDs
a) use full anti-inflammatory dose
b) ibuprofen 600-800 mg TID
c) indomethacin 25-50 mg TID
6) site-specific stretching activity
7) physical therapy
a) ultrasound
b) phonophoresis
8) refractory symptoms
a) further activity restriction & splinting
b) intrabursal injection with long-acting corticosteroid local anesthetic combination
1] hydrocortisone 25-50 mg (25 or 50 mg/mL) with 1-2 mL of 1% lidocaine
2] methylprednisolone acetate 40 mg (40 mg/mL) with 1-2 mL of 1% lidocaine
9) chronic cases with soft tissue thickening & calcification may require surgical excision
10) septic bursitis (most commonly Staphylococcus aureus)
a) empiric antibiotic therapy with beta-lactamase resistant antibiotic
1] dicloxacillin 250 mg PO QID
2] cephalexin (Keflex) 500 mg PO QID
b) severe infection may require surgical drainage with intravenous antibiotics (nafcillin 2 g IV every 4 hours)
Related
bursa
Specific
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
General
enthesopathy (enthesitis)
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders,
Philadelphia, 1996, pg 673-74
- Medical Knowledge Self Assessment Program (MKSAP) 11, 16.
American College of Physicians, Philadelphia 1998, 2012
- Geriatric Review Syllabus, 7th edition
Parada JT et al (eds)
American Geriatrics Society, 2010
- National Institute of Arthritis and Muscluloskeletal and Skin Diseases (NIAMS)
Bursitis
https://www.niams.nih.gov/health-topics/bursitis