What are the symptoms, diagnosis, and treatment options for bursitis?

Bursitis: Symptoms, Diagnosis, and Treatment

The most effective approach to managing bursitis involves initial conservative measures including rest, ice application, NSAIDs, and activity modification, followed by aspiration and/or corticosteroid injections for persistent cases, with surgery reserved only for refractory cases. 1

Symptoms

Bursitis presents with characteristic symptoms depending on the affected bursa:

• Cardinal symptoms:

  • Localized pain over the affected bursa
  • Swelling and tenderness
  • Limited range of motion
  • Pain that worsens with movement or pressure
  • Visible swelling or "goose egg" appearance (especially in superficial bursae)

• Signs of infection (septic bursitis): 1

  • Erythema (redness)
  • Warmth
  • Increased tenderness
  • Fluctuant swelling
  • Systemic symptoms (fever, chills)

Common Locations

• Olecranon bursitis: Swelling at the tip of the elbow 2
• Prepatellar bursitis: Swelling at the front of the knee ("housemaid's knee") 2
• Trochanteric bursitis: Pain at the outer hip 3
• Retrocalcaneal bursitis: Pain at the back of the heel 2
• Pes anserine bursitis: Pain at the inner aspect of the knee 4

Diagnosis

1. Clinical examination:

   • Identify location, swelling, tenderness, and range of motion limitations
   • Assess for signs of infection or inflammation
   • Evaluate for underlying conditions (gout, rheumatoid arthritis) 2

2. Imaging: 1

   • Radiographs: First-line imaging to exclude fractures or bony abnormalities
   • Ultrasound: Confirms bursal fluid collection, evaluates bursal wall thickening, and guides aspiration
   • MRI: Reserved for cases with suspected associated conditions or unclear diagnosis

3. Aspiration: 1

   • Essential for definitive diagnosis of suspected infected bursitis
   • Send fluid for:
     • Cell count
     • Gram stain
     • Culture
     • Crystal analysis (to rule out gout)

Treatment Algorithm

1. Initial Conservative Management (1-2 weeks) 1, 5

• RICE protocol:

  • Rest and activity modification to reduce pressure on affected area
  • Ice application for 10-minute periods through a wet towel
  • Compression with elastic bandage if appropriate
  • Elevation when possible

• Medications:

  • NSAIDs (e.g., naproxen 500mg twice daily) 5
  • Acetaminophen for pain relief if NSAIDs are contraindicated

2. For Persistent Symptoms (after 2 weeks of conservative treatment)

• Non-septic bursitis: 1, 3

  • Aspiration may be sufficient
  • Consider corticosteroid injection (with caution)
  • Continue activity modification and NSAIDs

• Septic bursitis: 1, 2

  • Immediate aspiration and empiric antibiotics targeting Staphylococcus aureus
  • First-line oral options: Cephalexin or Dicloxacillin
  • First-line IV options: Cefazolin or Nafcillin/Oxacillin
  • Continue antibiotics for at least 14 days
  • Serial aspirations every 3-5 days if reaccumulation occurs

3. For Refractory Cases

• Persistent non-septic bursitis: 1, 6

  • Consider surgical intervention (bursectomy)
  • Minimally invasive approaches (arthroscopy) may be considered for olecranon bursitis

• Persistent septic bursitis: 1

  • Surgical consultation
  • Consider hospitalization for:
    • Patients with systemic symptoms
    • Immunocompromised patients
    • Surrounding cellulitis or abscess formation

Prevention of Recurrence 1

• Address underlying mechanical factors
• Treat underlying medical conditions
• Use protective padding over susceptible areas
• Correct biomechanical abnormalities
• Modify activities that cause repetitive trauma

Special Considerations

• Corticosteroid injections: Associated with increased complications and should be used cautiously as a short-term bridging option only 1
• Surgical management: Should be reserved for cases that fail conservative management, as nonsurgical approaches are significantly more effective and safer 1
• Chronic microtraumatic bursitis: Aspiration generally not recommended due to risk of iatrogenic infection 2

Pitfalls to Avoid

• Failing to distinguish bursitis from arthritis, fracture, tendinitis, or nerve pathology 7
• Using corticosteroid injections in potentially septic bursitis without prior aspiration and culture 1
• Injecting corticosteroids into the retrocalcaneal bursa, which may adversely affect Achilles tendon biomechanics 7
• Inadequate duration of antibiotics for septic bursitis (minimum 14 days recommended) 1
• Returning to normal activities before complete healing, which increases risk of recurrence 1