BURSITIS OVERVIEW

A bursa is a sac-like structure that protects soft tissues from injuries that could be caused by pressure from nearby bones. Each bursa produces a lubricating fluid that fills the sac and decreases friction between bones, tendons, and ligaments.

Bursae are located throughout the body. However, certain joints are more subject to increased pressure and repetitive use and are more likely to develop bursitis, in which a bursa becomes inflamed and irritated. These joints include the shoulders, elbows, knees, and feet. Bursa near the hip joint, particularly those on the outer side of the hip and those in the lower buttocks (which are subjected to pressure from sitting), are also prone to bursitis.

BURSITIS CAUSES

Bursitis can develop with the following conditions:

• Prolonged pressure on a bursa
• Arthritis of a nearby joint
• Repetitive movements that cause irritation
• Physical conditions that increase stress on the joints, such as having legs of unequal length
• Injury, such as that resulting from a fall, or the wearing of ill-fitting shoes
• Medical conditions such as gout, rheumatoid arthritis, or pseudogout (see "Patient information: Gout (Beyond the Basics)" and "Patient information: Pseudogout (Beyond the Basics)" and "Patient information: Arthritis (Beyond the Basics)")
• Infection of a bursa (referred to as septic bursitis), which may occur following trauma to the nearby skin or, less often, by spreading through the blood from distant sites

If a bursa becomes septic (infected), the skin in the area around the bursa usually becomes red, warm, and swollen. Excess fluid may also accumulate within an infected bursa. The elbow and the knee are the most common sites of an infected bursa, often as a result of injury to the overlying skin. When redness and swelling are present, urgent medical attention is necessary to determine if an infection is present.

An infected (septic) bursa is treated with antibiotics and with needle drainage of the bursa fluid. Occasionally, if needle drainage is not possible or is not effective, surgical drainage or removal of the bursa may be necessary.

Surgery may also be recommended in some people with uninfected bursitis, including those who have not responded to conservative treatment and those who have had bothersome symptoms of bursitis for more than a year.

BURSITIS SYMPTOMS

Bursitis can cause pain and tenderness, both with motion and at rest. It may be difficult to move the joint due to the pain, and the area may be swollen if the bursa is close to the skin surface.

BURSITIS TESTS

Bursitis can usually be diagnosed based upon your symptoms and upon an examination by a clinician. If you have signs of an infected bursa (swelling, redness, pain), a clinician may use a syringe and needle to remove a sample of fluid from the bursa; the fluid is later examined with a microscope for bacteria and white blood cells.

Imaging tests, such as ultrasound or magnetic resonance imaging (MRI), may be used if your diagnosis is not clear based upon your medical history and physical examination.

Bursitis may be the first sign of gout, pseudogout, or rheumatoid arthritis. If you have bursitis that recurs or that does not respond to treatment, further testing may be recommended to determine if there is an underlying cause. (See "Patient information: Gout (Beyond the Basics)" and "Patient information: Pseudogout (Beyond the Basics)" and "Patient information: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)".)

BURSITIS TREATMENT

Bursitis treatment focuses on relieving inflammation and pain, on treating infection (if needed), and on reducing factors that led to the bursitis.

General measures — During the recovery process, it is important to protect the bursa from further injury, to rest the joint, and to apply ice. Nonsteroidal antiinflammatory drugs (NSAIDs), heat, and steroid injections may also be recommended.

• Protecting the bursa helps to decrease pressure within the bursa sac. Cushioning the affected area, avoiding positions that place pressure on it, and resting the joint help to minimize pressure and to relieve pain.
• You can apply ice in the form of a frozen gel pack or a frozen bag of peas. You can apply ice for 20 minutes several times per day, as needed to reduce pain.
• Nonsteroidal antiinflammatory drugs (NSAIDs), like ibuprofen, indomethacin, or naproxen, may relieve pain and swelling. Prescription strength tablets can make it more convenient to take the relatively high doses of NSAIDs that are needed to control the attack. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
• In some cases, heat treatments may be recommended to relieve pain and stiffness. Heat can be applied to the joints with a hot pack, a hot water bottle, or a heating pad. However, it is important to avoid burning the skin. Hot water bottles should be filled with warm, not boiling, water, and heating pads should be set on a timer and should be used for no more than 20 minutes at a time.
• An injection of a steroid (glucocorticoid) and local anesthetic mixture may be considered in some situations, such as if the pain is persistent or is severe at night or if the area is visibly swollen.

Specific types of bursitis — The features and treatments for specific types of bursitis are discussed in the following sections.

Subacromial (shoulder) bursitis — The subacromial bursa of the shoulder is between the acromion bone and the top of the humerus (upper arm) bone (figure 1). Subacromial bursitis can cause pain at rest and with movement and may also be felt in the deltoid (shoulder) muscle, about 4 inches down the outer arm. Pain may be severe and may interrupt your sleep. You may not be able to fully move your arm away from your body.

Treatment may include use of a temporary arm sling until pain and inflammation subside. NSAIDS are usually recommended. If the pain continues to interfere with your ability to function after a few days, a steroid and local anesthetic injection may be recommended.

Scapulothoracic (upper back) bursitis — Scapulothoracic bursitis causes pain and a popping sensation over the upper back when you shrug your shoulders. It is caused by pressure and friction between the scapula and the second and third ribs. Activities that can aggravate scapulothoracic bursitis include repetitive movements such as working overhead, reaching up and forward, or doing push-ups.

Initial treatment usually includes physical therapy with heat or ultrasound applied to the shoulder blade area to relieve pain. The therapist may recommend a series of stretches to the involved muscles if they are in spasm. In addition, the therapist can help to correct how you sit and stand (your posture), which can contribute to pain.

If physical therapy does not relieve symptoms within a few weeks, your clinician may give you an injection of a local anesthetic and a glucocorticoid (steroid). In rare instances, surgery may be recommended if symptoms persist despite these injections.

Elbow bursitis — The elbow or olecranon bursa, located at the point of the elbow, can develop bursitis as a result of repetitive injury (leaning on the elbow, resting the elbow on the car door during long trips, using the elbow to arise from bed, or using it as part of a job such as laying carpet). Swelling of the bursa is a typical complaint. (See "Patient information: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)".)

Treatment of elbow bursitis usually includes avoiding activities that increase pressure on the bursa and using NSAIDs. Your clinician may recommend draining fluid from the bursa with a needle and syringe, and an injection of steroids may be given if needed. If you have had elbow bursitis previously, try to avoid resting the elbows on arm rests for a prolonged period.

Ischial (pelvic) bursitis — Ischial bursitis is due to inflammation of the bursa overlying the pelvic and hip bones, located in the lower buttocks (figure 2). The most common symptom is pain after prolonged sitting on a hard surface.

Treatment may include a course of NSAIDs and an injection of a steroid and local anesthetic mixture into the area of the ischial bursa. A foam rubber cushion with holes cut for the ischial bones may also be helpful. Stretching and knee to chest exercises should be performed while sitting or lying on the cushion (picture 1 and picture 2 and picture 3).

Hip bursitis — There are two major bursae in the hips. The greater trochanteric bursa, located in the upper outer part of the thigh bone, is more commonly affected than the iliopectineal bursa, located in front of the hip joint (figure 2).

The most common symptoms of trochanteric bursitis are hip pain over the outer thigh and difficulty with walking. The hip pain is usually worsened by activities that increase pressure over the bursa (such as lying on the side) and can cause back pain that travels to the leg. Stretching and strengthening exercises for hip bursitis are provided separately. (See "Patient information: Hip pain (Beyond the Basics)".)

Reducing weightbearing (eg, using temporary crutches, avoiding stairs) can help to reduce the pressure placed on the painful bursa. An injection of glucocorticoids may be recommended if other treatments are not successful.

Knee bursitis — There are two major bursae of the knee.

• Prepatellar bursitis — The prepatellar bursa is located in front of the knee cap (patella) (figure 3). Prepatellar bursitis is a common condition that is related to repetitive pressure on the knee cap, seen in people who kneel frequently. Prepatellar bursitis may also be due to infection or gout. (See "Patient information: Gout (Beyond the Basics)".)
  
  Swelling over the patella (knee cap) is usually visible. The inflammation usually resolves with rest.
• Anserine bursitis — The anserine bursa is over the lower leg bone on the inner aspect of the knee, near a site at which several tendons attach to the bone (figure 4). Anserine bursitis causes pain over the tibia, located just below and to the inside of the knee joint. Anserine bursitis is commonly caused by an abnormal gait (eg, limping) and is common in people with arthritis of the knee. It is also common in women who have a large fat pad over the anserine bursa. Repetitive knee bending such as stair climbing can aggravate anserine bursitis.
  
  Treatment includes eliminating squatting and avoiding repetitive knee bending, crossing of your legs, and other activities that increase pressure on the bursa. Putting a pillow between the knees may reduce pain at night. You can apply ice for 15 minutes every four to six hours to relieve pain. An NSAID may help to reduce pain and swelling. If you continue to have pain after six to eight weeks, you may benefit from a steroid and local anesthetic injection into the bursa. (See "Patient information: Knee pain (Beyond the Basics)".)

Retrocalcaneal (heel) bursitis — Bursae may form at the surface of or beneath the Achilles tendon, which connects the muscles in the calf to the heel bone. Pain from retrocalcaneal bursitis can be chronic and severe. Use of NSAIDs may be recommended to reduce inflammation. To reduce pain, you can cut a “V”-shaped groove into the back of an old shoe, or you can wear shoes without a back. Alternately, you can insert a thick heel pad in the shoe to raise the heel slightly above the back of a shoe.

Glucocorticoid injections are not recommended for heel bursitis because the Achilles tendon may rupture. Surgery is sometimes necessary for permanent relief.

Intermetatarsal (foot) bursitis — With aging, the arches in the feet flatten, and the long bones of the feet (called the metatarsals) can press on the bursae that separate these bones from one another. Tight and narrow shoes contribute to these events. Intermetatarsal bursitis may cause pain in the foot, or pain may travel to the toes. Visible swelling is rare.

Treatment includes use of wider shoes, a rocker bar (a device added to the soles of the shoes to decrease pressure on the metatarsals) (figure 5), and injection of the area with a steroid and local anesthetic combination.

BURSITIS PREVENTION

Many routine activities, such as kneeling, carrying heavy objects, or wearing tight-fitting shoes place stress and pressure on joints and irritate bursal sacs. Small modifications can help to protect the joints and to reduce the risk of bursitis. These include:

• Use cushions and pads to reduce pressure — Some positions, such as kneeling and sitting, significantly increase joint pressure. Avoid staying in one position for too long, and use pads to cushion the joints. For example, a kneeling pad can be used to decrease pressure on the knee, particularly during activities such as gardening; cushioned knee protectors can be worn for other activities on hard surfaces, such as laying carpet. Padded seat cushions help to protect the bony prominences affected by sitting.
• Balance work and rest — Take periodic short breaks from tasks and activities that increase joint pressure or that require repetitive movements. If possible, alternate tasks with activities that use different joints and muscle groups.
• Respect pain — Pain is often a sign that too much stress is being placed on a joint and that an activity should be moderated or avoided. When you notice pain or discomfort, take a break, change the way you perform the activity, or move on to another activity.
• Maintain good posture — Avoid slouching forward when sitting, walking, and standing.
• Maintain strength and range of motion — An exercise program can help to maintain flexibility and strength. If you play sports, perform conditioning exercises year-round to strengthen and maintain the muscles that surround the joints most commonly used in the activity.
• Maintain normal weight — Excess body weight increases the pressure placed on many joints. If you experience recurrent bursitis and are overweight, you should consider a weight loss program. (See "Patient information: Weight loss treatments (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Hip pain in older people (The Basics)
Patient information: Shoulder impingement (The Basics)
Patient information: Knee pain (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Hip pain (Beyond the Basics)
Patient information: Gout (Beyond the Basics)
Patient information: Pseudogout (Beyond the Basics)
Patient information: Arthritis (Beyond the Basics)
Patient information: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient information: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)
Patient information: Knee pain (Beyond the Basics)
Patient information: Weight loss treatments (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Bursitis: An overview of clinical manifestations, diagnosis, and management
Evaluation of elbow pain in adults
Evaluation of the active adult patient with knee pain
Evaluation of the adult with hip pain
Evaluation of the patient with shoulder complaints
Knee bursitis
Overview of running injuries of the lower extremity
Overview of soft tissue rheumatic disorders
Trochanteric bursitis

The following organizations also provide reliable health information.

• National Library of Medicine
  (www.nlm.nih.gov/medlineplus/bursitis.html)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases
  (www.niams.nih.gov/Health_Info/Bursitis/bursitis_ff.asp)
• The Arthritis Foundation
  (www.arthritis.org)

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