What are the initial management recommendations for bursitis in children?

Initial Management of Bursitis in Children

The initial management of bursitis in children should begin with nonsteroidal anti-inflammatory drugs (NSAIDs), which are strongly recommended as first-line therapy over no treatment. 1

Diagnosis and Initial Approach

• Bursitis in children presents as localized pain, swelling, and tenderness over affected bursae, commonly involving the prepatellar, olecranon, trochanteric, and retrocalcaneal areas 2, 3
• Differentiate between septic and non-septic bursitis through clinical evaluation and, when indicated, aspiration with fluid analysis 4
• Consider underlying conditions such as juvenile idiopathic arthritis (JIA) with enthesitis or sacroiliitis that may present with bursal inflammation 1

First-Line Management

• NSAIDs are strongly recommended as initial therapy with very low-quality evidence supporting this recommendation 1
• Implement relative rest and activity modification to reduce mechanical stress on the affected bursa 2, 3
• Apply ice to reduce inflammation and pain, especially in acute cases 2, 5
• Consider compression and elevation when appropriate to minimize swelling 2

Additional Conservative Measures

• Physical therapy is conditionally recommended for children who have or are at risk for functional limitations 1
• Ultrasound therapy may be beneficial in some cases, particularly for calcific bursitis 6
• Avoid prolonged pressure on the affected area and modify activities that exacerbate symptoms 3

Management of Refractory Cases

• For bursitis that persists despite NSAID therapy, a limited course of oral glucocorticoids (<3 months) may be conditionally recommended as bridging therapy 1
  • This is particularly useful in cases with high disease activity, limited mobility, or significant symptoms 1
• For septic bursitis, oral antibiotics and possible repeated aspiration are indicated 3, 4

Cautions and Considerations

• Intrabursal corticosteroid injections should be used cautiously in children, as recent literature has shown potential adverse effects compared to non-invasive management 5
• Surgical intervention is rarely needed in children and should be reserved for recalcitrant cases that fail conservative management 3
• Monitor for signs of infection, which would necessitate a different treatment approach including antibiotics 4

Special Considerations for Underlying Inflammatory Conditions

• If bursitis is associated with juvenile idiopathic arthritis with enthesitis:
  • NSAIDs remain first-line therapy 1
  • For persistent symptoms despite NSAIDs, tumor necrosis factor inhibitors (TNFi) are conditionally recommended over methotrexate or sulfasalazine 1
  • Physical therapy is conditionally recommended for those with functional limitations 1