What is the empirical treatment for bursitis and tendinosis?

Empirical Treatment of Bursitis and Tendinosis

The empirical treatment of bursitis and tendinosis should begin with NSAIDs such as naproxen (500 mg twice daily), activity modification, and physical therapy, with corticosteroid injections reserved for cases that don't respond to initial management. 1, 2

Initial Assessment and Treatment Approach

Aseptic Bursitis Treatment:

• First-line treatment:

  • NSAIDs (naproxen 500 mg twice daily) 1, 2
  • Activity modification to reduce pressure on affected area 3, 1
  • Ice application for acute symptoms 3
  • Open-backed shoes for heel bursitis 3
  • Orthoses or heel lifts for appropriate cases 3

• Second-line treatment (if no improvement in 6-8 weeks):

  • Corticosteroid injections (avoid injecting directly into tendons) 3, 1
  • Immobilization with cast or fixed-ankle walker-type device for refractory cases 3

Septic Bursitis Treatment:

• Aspiration of bursal fluid for diagnosis (cell count, Gram stain, culture) 1
• Empiric antibiotics targeting Staphylococcus aureus 1
• Mild cases: Oral antibiotics for 7-10 days with follow-up in 48-72 hours 1
• Moderate to severe cases: Hospitalization and parenteral antibiotics 1

Treatment by Specific Condition

Tendinosis:

• Progressive rehabilitation exercises in three phases 1:

  1. Initial phase (0-4 weeks): Pain control and protected range of motion
  2. Intermediate phase (4-8 weeks): Progressive strengthening exercises
  3. Advanced phase (8-12 weeks): Sport-specific or occupation-specific training

• NSAIDs are strongly recommended as first-line treatment (naproxen 500 mg twice daily) 1, 2

• Stretching exercises, particularly for Achilles tendinosis 3

• Weight loss if indicated 3

Insertional Achilles Tendinitis:

• Open-backed shoes to reduce pressure 3
• Heel lifts or orthoses 3
• NSAIDs 3
• Decreased activity 3
• Stretching exercises 3
• Important: Local corticosteroid injections are NOT recommended for Achilles tendinitis 3

Bursitis Associated with Haglund's Deformity:

• Open-backed shoes 3
• Orthoses and accommodative padding 3
• NSAIDs 3
• Corticosteroid injections (avoiding the Achilles tendon) 3
• Physical therapy 3

When to Consider Surgical Intervention

Surgical consultation should be considered if:

• Pain persists despite 3-6 months of well-managed conservative treatment 1
• Functional limitations significantly impact quality of life 1
• Recurrent or persistent infection 1
• Loculated fluid collections 1

For plantar fasciitis, surgery (plantar fasciotomy) may be considered after 2-3 months of failed conservative treatment 3.

For bursitis associated with Haglund's deformity, surgical options include resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 3.

Follow-up and Monitoring

• For septic bursitis: Follow-up 48-72 hours after starting antibiotics, then weekly until resolution 1
• For aseptic bursitis: Follow-up 1-2 weeks after initial treatment 1
• Regular follow-up at 2,6, and 12 weeks to assess healing and function 1

Important Caveats and Pitfalls

1. Avoid corticosteroid injections into the Achilles tendon as they may adversely affect its biomechanical properties 3, 4

2. Differentiate between septic and aseptic bursitis - septic bursitis requires more aggressive treatment with antibiotics 1

3. Consider alternative diagnoses if no improvement occurs after appropriate treatment duration 3

4. Limit corticosteroid injections to 2-3 injections with 4-6 weeks between injections to avoid tendon weakening 1

5. For retrocalcaneal bursitis, surgical outcomes may be less favorable (71% success) compared to tendon/sheath involvement (92% success) 5