What is the management of bursitis?

Management of Bursitis

The management of bursitis should follow a stepped-care approach beginning with conservative measures, including rest, NSAIDs, and activity modification, progressing to corticosteroid injections for refractory cases, with surgical intervention reserved only for persistent cases that fail to respond to conservative treatment.

Diagnosis and Classification

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

• Location-specific bursitis: Common types include prepatellar, olecranon, trochanteric, and retrocalcaneal bursitis 1
• Septic vs. non-septic: Septic bursitis requires different management with antibiotics 2

First-Line Treatment

Non-pharmacological Approaches

• Rest and activity modification: Reduce activities that aggravate the affected bursa
• Local applications: Apply ice or heat to the affected area 3
• Supportive devices:
  • Open-backed shoes for Haglund's deformity-associated bursitis
  • Orthoses or accommodative padding for foot bursitis 3
  • Bracing or joint supports for biomechanical joint pain 3
• Physical therapy:
  • Stretching exercises, particularly for hip bursitis
  • Strengthening of surrounding muscles 3

Pharmacological Approaches

• NSAIDs: First-line pharmacological treatment
  • Use the lowest effective dose for the shortest possible period 3, 4
  • Naproxen is FDA-approved specifically for bursitis 4
  • Consider topical NSAIDs before oral administration, especially for superficial bursitis 3
  • For patients with cardiovascular risk factors, use acetaminophen or non-acetylated salicylates before NSAIDs 3

Second-Line Treatment

Corticosteroid Injections

• Indications: For bursitis that doesn't respond to first-line treatments within 6-8 weeks 3
• Effectiveness: Shown to be effective for most types of bursitis, particularly:
  • Trochanteric bursitis 5, 6
  • Olecranon bursitis 7
• Cautions:
  • Not recommended for Achilles tendon insertional bursitis 3
  • Use with caution in patients with diabetes
  • Limit the number of injections to avoid tissue atrophy

Special Considerations

Septic Bursitis

• Diagnosis: Consider if there is significant erythema, warmth, or systemic symptoms
• Management:
  • Needle aspiration or surgical drainage
  • Antibiotic therapy (typically covering Staphylococcus aureus) 2
  • Blood cultures may be necessary in severe cases 3

Bursitis Associated with Haglund's Deformity

• Initial treatment: Open-backed shoes, orthoses, NSAIDs
• Second-line: Corticosteroid injections (avoiding the Achilles tendon)
• Refractory cases: Consider immobilization with cast or walker-type device
• Surgical options: Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 3

Treatment Algorithm

1. Initial phase (0-6 weeks):

   • Rest and activity modification
   • NSAIDs (topical preferred initially)
   • Physical therapy and supportive devices
   • Local heat/cold applications

2. Intermediate phase (if no improvement after 6-8 weeks):

   • Corticosteroid injection into the affected bursa
   • Continue physical therapy
   • Consider immobilization for acute or refractory cases

3. Advanced phase (persistent symptoms):

   • Referral to specialist (orthopedic surgeon or podiatric surgeon)
   • Consider surgical options for refractory cases:
     • Bursectomy
     • Iliotibial band release (for trochanteric bursitis)
     • Resection of bony prominences (for Haglund's deformity)

Common Pitfalls to Avoid

• Misdiagnosis: Ensure bursitis is correctly diagnosed and not confused with arthritis, tendinitis, or fracture
• Overuse of corticosteroids: Limit injections to avoid tissue atrophy and tendon weakening
• Overlooking septic bursitis: Consider infection in cases with significant inflammation or systemic symptoms
• Prolonged NSAID use: Monitor for gastrointestinal, renal, and cardiovascular side effects with extended NSAID use
• Inadequate follow-up: Ensure appropriate follow-up to assess treatment response and adjust management as needed

Remember that most cases of bursitis respond well to conservative management, and surgical intervention is rarely needed except in persistent cases that fail to respond to appropriate non-surgical treatment.