BURSITIS

BURSITIS - John Herbert Stevenson, MD; Christopher Lutryzkowski, MD; Peter L. Hoth, MD
BASICS
DESCRIPTION
• A bursa is a sac that is formed or found in areas subject to friction, such as locations where tendons pass over bony landmarks. Most common sites are subdeltoid, olecranon, prepatellar, trochanteric, radiohumeral. They essentially lubricate the region with synovial fluid.
• Large bursae usually communicate with joints and are responsible for retaining the synovial fluid in place.
• Bursae are fluid-filled sacs that serve as a cushion between tendons and bones.
• Bywaters, an English rheumatologist, found at least 78 bursae symmetrically placed on each side of the body.
• System(s) Affected: Musculoskeletal
ALERT
Pediatric Considerations
Bursitis less common in the pediatric population.
GENERAL PREVENTION
• Appropriate warm-up and cool-down maneuvers, avoidance of overuse, or inadequate rest between workouts
• Range-of-motion exercises
• Maintain high level of fitness and general good health.
EPIDEMIOLOGY
Predominant age
• 15-50 years (most common in skeletally mature)
• Traumatic bursitis more likely in patients 35 years of age
Incidence
• Common
• Trochanteric pain: 1.8 per 1000 per year (6)[B]
RISK FACTORS
Individuals who engage in repetitive and vigorous training or others who suddenly increase their level of activity (e.g., "weekend warriors")
ETIOLOGY
• Bursitis may be acute or chronic.
• Many types of bursitis, including infectious, traumatic, inflammatory, and gouty
• Less often rheumatoid disease or tuberculosis as well as gout and pseudogout
ASSOCIATED CONDITIONS
• Tendinitis
• Sprains, strains
• Associated stress fractures


DIAGNOSIS
SIGNS AND SYMPTOMS
• Pain/tenderness
• Decreased range of motion of affected region (rare except at shoulder)
• Erythema if infection present
• Swelling
• Crepitus sometimes found
TESTS
ECG (if shoulder pain mimics cardiac pain)
Lab
• The following may help in differentiating soft-tissue disease from rheumatic and connective tissue disease
- CBC
- ESR
- Serum protein electrophoresis
- Rheumatoid factor
- Serum uric acid
- Phosphorus
- Alkaline phosphatase
- Blood testing for syphilis
- Joint fluid analysis and culture (when indicated)
• Drugs that may alter lab results
- ESR rate may be increased with coexistent use of methyldopa, methysergide, penicillamine, theophylline, vitamin A.
- ESR may be decreased with coexistent use of quinine, salicylates, and drugs that cause a high glucose level.
Imaging
• MRI may prove beneficial if diagnosis is unclear
• Calcific deposits may be seen on plain radiograph.
• Ultrasound (1)[B]
Diagnostic Procedures/Surgery
• Aspiration of swollen bursa and evaluation of synovial fluid
• The clinician must differentiate infected from inflammatory bursitis. Fluid analysis and culture help make the diagnosis. If the Gram stain and culture yield an infective cause, treat with appropriate antibiotics. If the etiology is inflammatory, give local care.
Pathological Findings
• Acute with early inflammation: Bursa is distended with watery or mucoid fluid.
• Infection: Purulent fluid
• Chronic
- Bursal wall is thickened, and inner surface is shaggy and trabeculated.
- The space is filled with granular, brown, inspissated blood admixed with gritty, calcific precipitations.
- Upper extremity tendonitis and bursitis are usually the result of repetitive microtrauma, probably resulting in disruption of fibers leading to pain, spasm, and disability.
DIFFERENTIAL DIAGNOSIS
• Septic arthritis
• Gout, pseudogout
• Rheumatic disorders
• Osteoarthritis
• Tendinitis, strains, and sprains
• Lyme arthritis
TREATMENT
Outpatient; refer only difficult cases.
GENERAL MEASURES
• Conservative therapy consists of rest, ice, and local care; elevation, gentle compression (often referred to as RICE therapy [rest-ice-compression-elevation]).
• Compression with Ace wrap or neoprene sleeve
• Bursa aspiration
• Corticosteroid injection if infectious etiology ruled out
• Treatment of any underlying infection
Diet
Consider changes if bursitis is directly related to obesity/crystalline deposition.
Activity
Rest and elevation of affected extremity
MEDICATION (DRUGS)
First Line
• NSAIDs or aspirin (2,4,5)[C], (9)[C]
• Antibiotic therapy if infection present; cover for staph and strep species (most common) (8)[B]
• Contraindications: Refer to manufacturer's profile of each drug.
• Precautions: Refer to manufacturer's profile of each drug.
• Significant possible interactions: Refer to manufacturer's profile of each drug.
Second Line
• Injectable corticosteroids once infectious etiology ruled out (2,4,5)[C], 3[B], (9)[B]
• Systemic steroids provide limited short-term benefit (7)[B].
SURGERY
Surgical excision in severe cases unresponsive to conservative treatments (8)[B]
FOLLOW-UP
PROGNOSIS
• Most bouts of bursitis heal without sequelae.
• Repetitive acute bouts may lead to chronic bursitis, necessitating repeated joint/bursal aspirations or eventually surgical excision of involved bursa.
COMPLICATIONS
• Septic bursitis may extend to the nearby joint.
• Acute bursitis may progress to chronic.
• Severe long-range limitation of motion
PATIENT MONITORING
• Discontinue NSAIDs as soon as possible to avoid side effects
• Some patients may require repeated injections (usually no more than 3) of a corticosteroid and lidocaine (2,4,5)[C].
REFERENCES
1. Finlay K, Friedman L. Ultrasonography of the lower extremity. Orthop Clin North Am. 2006;37(3):245-75,v.
2. Talia, Alfred H., Cardone, Dennis. Diagnostic and Therapeutic injection of the shoulder region. Am Fam Phys. 2003;67(6): 1271-1278.
3. Buchbinder R, et. al. Corticosteroid injection for shoulder pain. Cochrane Database Sys Rev. Jan. 1, 2003.
4. Cardone D, Tallia AH. Diagnostic and therapeutic injection of the elbow. Am Fam Phys. 2002;66(11):2097-3100.
5. Cardone D, Tallia AH. Diagnostic and therapeutic injection of the hip and knee. Am Fam Phys. 2003;67(10):2147-2153.
6. Lieviense A, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. xxx;55(512): 199-204.
7. Buchbinder R, et. al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): A randomized, double blind, placebo controlled trial. Ann Rheum Dis. 2004;63(11):1460-1469.
8. Small LN. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005;19(4):991-1005, xi.
9. McFarland EG. Miscellaneous conditions about the elbow in athletes. Clin Sports Med. 2004;23(4):743-763, xi-xii.
MISCELLANEOUS
See also: Tendinitis