What is the best treatment for bursitis (inflammation of the bursae)?

From the Guidelines

The best treatment for bursitis typically involves a combination of rest, ice, compression, and elevation (RICE) of the affected area, along with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections directly into the bursa for more severe cases, as recommended by recent guidelines 1. When considering treatment options for bursitis, it's essential to prioritize morbidity, mortality, and quality of life as outcomes. The treatment approach should focus on reducing pain and inflammation, improving joint flexibility, and addressing the underlying cause of the condition.

Initial Treatment

Initial treatment options may include:

• Rest, ice, compression, and elevation (RICE) of the affected area
• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg three times daily) or naproxen (220-500mg twice daily) for 1-2 weeks to reduce pain and inflammation
• Orthoses, accommodative padding, and weight loss (if indicated) as suggested by the American College of Foot and Ankle Surgeons 1

Severe Cases

For more severe cases, a healthcare provider may recommend:

• Corticosteroid injections directly into the bursa to provide more immediate relief, as supported by the 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis 1
• Physical therapy exercises to help strengthen surrounding muscles and improve joint flexibility once acute pain subsides

Special Considerations

If the bursitis is caused by infection (septic bursitis), antibiotics will be necessary, typically a course of cephalexin (500mg four times daily) or clindamycin (300-450mg four times daily) for 7-10 days. In rare cases where conservative treatments fail, surgical removal of the affected bursa (bursectomy) may be considered. Addressing the underlying cause by modifying activities that stress the affected joint is essential for preventing recurrence.

From the Research

Treatment Options for Bursitis

• Nonsurgical management is often the first line of treatment for bursitis, including ice, activity modification, and nonsteroidal anti-inflammatory drugs 2, 3
• Corticosteroid injection may be used in the management of prepatellar and olecranon bursitis, but may adversely affect the biomechanical properties of the Achilles tendon 2
• Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis 2, 4
• Low-energy shock-wave therapy (SWT) has been found to be superior to other nonoperative modalities in some cases 4
• Physiotherapy and combined treatment with corticosteroid injection have been found to be effective in treating chronic subacromial bursitis 5
• Aspiration did not increase the risk of bursal infection for aseptic bursitis, and nonsurgical management is significantly more effective and safer than surgical management 6

Specific Types of Bursitis

• Prepatellar bursitis: local corticosteroid injection may be used in management 2
• Olecranon bursitis: conservative treatment, including ice, rest, anti-inflammatory and analgesic drugs, and occasionally, bursal fluid aspiration, is often effective 3
• Trochanteric bursitis: multiple courses of nonoperative treatment or surgical intervention may be necessary in refractory cases 4
• Subacromial bursitis: combination of corticosteroid subdeltoid injections and physiotherapy may be more effective than either treatment alone 5

Complications and Risks

• Corticosteroid injection is associated with significant risks, including skin atrophy and increased overall complications 6
• Surgical management is less likely to clinically resolve septic or aseptic bursitis and demonstrates higher rates of overall complications 6