What is the management and treatment for bursitis?

Management and Treatment for Bursitis

The management of bursitis should follow a stepwise approach, starting with conservative measures including rest, ice, NSAIDs, and activity modification, with progression to more invasive treatments only when conservative management fails. 1

Types and Presentation of Bursitis

• Bursitis commonly affects superficial bursae, most frequently the olecranon (elbow) and prepatellar (knee) bursae, but can also occur in the infrapatellar, calcaneal, and trochanteric areas 2
• The condition is typically caused by chronic microtrauma (e.g., kneeling, repetitive pressure), acute trauma, inflammatory disorders, or infection 2
• Symptoms include localized pain, swelling, tenderness, and limited range of motion in the affected area 2, 3

Initial Conservative Management

First-Line Treatments

• Rest and activity modification: Reduce activities that aggravate the bursa 1
• Ice application: Apply for 10-minute periods through a wet towel to reduce inflammation 1
• NSAIDs: Use medications like naproxen (recommended starting dose 500 mg followed by 250 mg every 6-8 hours as needed) for pain and inflammation 4
• Compression and elevation: Particularly helpful for acute traumatic/hemorrhagic bursitis 2

Specific Adaptations Based on Location

• Achilles/retrocalcaneal bursitis: Use open-backed shoes, heel lifts, orthoses, and avoid corticosteroid injections near the Achilles tendon 1
• Haglund's deformity-associated bursitis: Consider accommodative padding and open-backed shoes 1
• Olecranon/prepatellar bursitis: Padding of the affected area to prevent further trauma 3, 5

Second-Line Treatments (If No Improvement After 6-8 Weeks)

• Orthotic devices: Custom orthotics for lower extremity bursitis 1
• Physical therapy: Stretching exercises and modalities like ultrasound 6
• Corticosteroid injections: Consider for chronic, non-septic bursitis, but avoid near the Achilles tendon 1
  • Caution: Steroid injections into retrocalcaneal bursa may adversely affect Achilles tendon properties 3
• Immobilization: Cast or fixed-ankle walker-type device for refractory cases of lower extremity bursitis 1

Management of Septic Bursitis

• Septic bursitis requires prompt diagnosis and treatment to prevent complications 2
• Diagnostic approach: Bursal aspiration with fluid analysis (Gram stain, culture, cell count, crystal analysis) 2
• Antibiotic therapy: Initial coverage for Staphylococcus aureus; outpatient treatment for non-acutely ill patients, intravenous antibiotics for acutely ill patients 2
• Surgical intervention: Reserved for cases not responsive to antibiotics or recurrent infections 2

Third-Line Treatments (For Refractory Cases)

• Surgical intervention: Consider for cases that fail to respond to conservative management after 2-3 months 1
• Arthroscopic procedures: Increasingly used as minimally invasive alternatives to open excision for olecranon bursitis 7
• Open surgical excision: For recalcitrant cases, particularly in trochanteric bursitis 3

Special Considerations

• Inflammatory bursitis (e.g., gout, rheumatoid arthritis): Treat the underlying condition 2
• Neurologic causes: Consider referral for diagnostic testing if neurologic heel pain is suspected 1
• Avoid prolonged immobilization: This can lead to muscle atrophy and deconditioning 1

Common Pitfalls to Avoid

• Misdiagnosis: Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology 3
• Inappropriate corticosteroid use: Avoid injections near the Achilles tendon 1
• Delayed treatment of septic bursitis: Can lead to serious complications including septicemia 2, 5
• Premature return to aggravating activities: Can lead to chronic or recurrent bursitis 6

By following this structured approach to the management of bursitis, most patients will experience significant improvement with conservative measures alone, while those with refractory cases can be appropriately escalated to more invasive interventions when necessary.