What are the management options for bursitis?

Management of Bursitis

The first-line management of bursitis should include conservative measures such as rest, ice, NSAIDs, and appropriate activity modification, with corticosteroid injections reserved for cases that don't respond to initial treatment. 1, 2

Diagnosis and Classification

Before initiating treatment, it's important to identify the type of bursitis:

• Location-based classification:

  • Olecranon (elbow)
  • Prepatellar (knee)
  • Trochanteric (hip)
  • Retrocalcaneal (heel)
  • Ischial (buttock)

• Etiology-based classification:

  • Traumatic/hemorrhagic (acute injury)
  • Microtraumatic (chronic repetitive stress)
  • Inflammatory (associated with gout, rheumatoid arthritis)
  • Septic (infectious)

Treatment Algorithm

Step 1: Conservative Management (First 2-6 weeks)

• Rest and Activity Modification:

  • Avoid activities that aggravate symptoms
  • Prevent ongoing microtrauma to the affected bursa
  • For trochanteric bursitis: avoid lying on affected side

• Ice Application:

  • Apply ice through a wet towel for 10-minute periods
  • Use 3-4 times daily, especially after activity 1

• NSAIDs:

  • Oral NSAIDs (e.g., naproxen) are effective for pain relief and reducing inflammation 2
  • Topical NSAIDs may be considered to avoid systemic side effects 1
  • Use the lowest effective dose for the shortest duration 1

• Physical Therapy:

  • Stretching exercises focused on the affected area
  • For trochanteric bursitis: focus on lower back and sacroiliac joints 3
  • Eccentric strengthening exercises may be beneficial 1

Step 2: For Persistent Symptoms (After 2-6 weeks of conservative treatment)

• Corticosteroid Injection:

  • Highly effective for symptom relief in non-infectious bursitis 1, 3
  • For trochanteric bursitis: injection of betamethasone and lidocaine (or equivalent) 3
  • Caution: Avoid injections into the Achilles tendon area as they may adversely affect tendon biomechanics 4
  • Contraindication: Do not inject if infection is suspected

• Aspiration:

  • Consider for acute traumatic/hemorrhagic bursitis to shorten symptom duration 5
  • Avoid in chronic microtraumatic bursitis due to risk of iatrogenic infection 5
  • Mandatory if septic bursitis is suspected (with fluid analysis)

Step 3: For Refractory Cases (Persistent symptoms despite above measures)

• Immobilization:

  • Cast or fixed-ankle walker-type device for persistent lower extremity bursitis 1
  • Splinting for upper extremity bursitis

• Surgical Intervention:

  • Reserved for cases unresponsive to conservative measures
  • Options include bursectomy, resection of bony prominences, or tendon repair
  • For trochanteric bursitis: iliotibial band release or bursectomy may be considered 3
  • For olecranon bursitis: arthroscopic approaches are increasingly being used 6

Special Considerations

Septic Bursitis

• Requires prompt diagnosis and treatment
• Obtain bursal fluid for Gram stain, culture, cell count, and crystal analysis if infection suspected
• Empiric antibiotics effective against Staphylococcus aureus (most common pathogen) 5
• Hospitalization and IV antibiotics for acutely ill patients

Bursitis Associated with Haglund's Deformity

• Common in women 20-30 years of age
• Treatment includes open-backed shoes, orthoses, NSAIDs, and physical therapy
• If no improvement after 6-8 weeks, consider immobilization or surgical intervention 1

Pitfalls and Caveats

1. Misdiagnosis: Ensure bursitis is distinguished from tendinitis, arthritis, fracture, or nerve pathology 4

2. Inappropriate Steroid Use: Avoid multiple injections as they may lead to tissue atrophy or tendon weakening

3. Overlooking Infection: Always consider septic bursitis, especially with acute onset, significant erythema, or systemic symptoms

4. Inadequate Activity Modification: Failure to address underlying causes (e.g., kneeling, repetitive pressure) will lead to recurrence

5. Premature Return to Activity: Ensure adequate healing before resuming activities that may aggravate the condition

By following this structured approach to bursitis management, most patients will experience significant improvement without requiring surgical intervention.