What is the treatment for bursitis?

Treatment of Bursitis

The first-line treatment for bursitis should include rest, ice application, NSAIDs (such as naproxen), and activity modification to reduce pressure on the affected area. 1, 2

Initial Conservative Management

• Rest and Activity Modification: Reduce pressure on the affected joint and avoid activities that worsen symptoms 1
• Ice Application: Apply for 10-minute periods through a wet towel 1
• NSAIDs: Naproxen is recommended at an initial dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed (not exceeding 1250 mg on first day and 1000 mg daily thereafter) 2
• Elevation of the affected area when possible 3
• Compression may help reduce swelling 3

Treatment Based on Type of Bursitis

Non-Septic Bursitis

1. Acute Traumatic/Hemorrhagic Bursitis:

   • Conservative treatment with RICE (rest, ice, compression, elevation) 3
   • Aspiration may shorten symptom duration in severe cases 3

2. Chronic Microtraumatic Bursitis:

   • Address underlying mechanical causes 1
   • Avoid bursal aspiration due to risk of iatrogenic infection 3
   • Physical therapy including:
     • Progressive range-of-motion exercises
     • Strengthening exercises
     • Joint mobilization techniques 1

Septic Bursitis

1. Diagnostic Approach:

   • Bursal aspiration with fluid analysis (cell count, Gram stain, cultures, crystal analysis) 1, 3
   • Ultrasound to confirm bursal fluid collection and guide aspiration 1

2. Treatment:

   • Immediate empiric antibiotics targeting Staphylococcus aureus after aspiration 1, 4
   • First-line options: oral Cephalexin/Dicloxacillin or IV Cefazolin/Nafcillin 1
   • Continue antibiotics for at least 14 days 1
   • May require repeated aspirations 4
   • Consider hospitalization for patients with systemic symptoms or immunocompromised status 3

Inflammatory Bursitis (e.g., gout, rheumatoid arthritis)

• Treat the underlying condition 3
• Consider intrabursal corticosteroid injections 3

Adjunctive Therapies

• Physical Therapy Modalities:

  • Ultrasound therapy 5
  • Electrical stimulation 6
  • Strengthening exercises for surrounding muscles 1

• Corticosteroid Injections:

  • May be considered for prepatellar and olecranon bursitis 7
  • Should be used cautiously as a short-term bridging option due to potential complications 1
  • Avoid in retrocalcaneal bursitis as it may adversely affect Achilles tendon 7

Surgical Management

• Reserved for refractory cases that fail conservative management 1, 7
• Consider for recurrent septic bursitis not responsive to antibiotics 3

Prevention of Recurrence

• Address underlying mechanical factors 1
• Use protective padding over susceptible areas 1
• Correct biomechanical abnormalities 1
• Modify activities that cause repetitive trauma 1
• Ensure complete healing before returning to normal activities 1

Common Pitfalls and Caveats

1. Misdiagnosis: Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology 7

2. Inappropriate Corticosteroid Use:

   • Avoid intrabursal corticosteroid injections if infection is suspected 3
   • Limited high-quality evidence for benefit in microtraumatic bursitis 3

3. Inadequate Treatment of Septic Bursitis:

   • Recovery can take months 4
   • Insufficient antibiotic duration may lead to recurrence 1

4. Overhead Pulleys: Avoid using overhead pulleys for shoulder bursitis as they encourage uncontrolled abduction 8