What is the management and treatment for bursitis?

Management and Treatment for Bursitis

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

Types and Presentation of Bursitis

• Bursitis is inflammation of a bursa, a fluid-filled sac that reduces friction between tissues of the body 2
• Common locations include:
  • Olecranon (elbow) and prepatellar (knee) bursae - most common 2
  • Superficial infrapatellar and calcaneal bursae 2
  • Trochanteric (hip) and retrocalcaneal (heel) bursae 3
• Causes include:
  • Chronic microtrauma (most common) - e.g., kneeling, repetitive pressure 2
  • Acute trauma or hemorrhage 2
  • Inflammatory disorders (gout, rheumatoid arthritis) 2
  • Infection (septic bursitis) 2

Initial Assessment

• Focus on distinguishing infectious from non-infectious causes 2
• Key diagnostic elements:
  • Location of pain and tenderness 1
  • Presence of swelling, redness, or warmth 2
  • Aggravating and relieving factors 1
• For heel bursitis (Haglund's deformity):
  • Pain is typically aggravated by pressure from shoes 1
  • Relief occurs when walking barefoot 1
  • Tenderness lateral to the Achilles tendon 1
• Consider diagnostic studies if infection is suspected:
  • Ultrasonography to distinguish bursitis from cellulitis 2
  • Blood tests (WBC count, inflammatory markers) 2
  • Bursal aspiration with fluid analysis if septic bursitis is suspected 2

Treatment Algorithm

Step 1: Conservative Management (First-Line)

• Rest and activity modification to reduce pressure on affected area 1, 2
• Ice application for 10-minute periods through a wet towel 1
• NSAIDs for pain and inflammation 1, 4
  • Naproxen is FDA-approved for bursitis at a recommended dose of 500 mg initially, followed by 250 mg every 6-8 hours as needed 4
• Specific measures based on location:
  • For heel bursitis: open-backed shoes, orthoses, accommodative padding 1
  • For olecranon/prepatellar bursitis: padding and protection from further trauma 2, 5

Step 2: Intermediate Interventions (If No Improvement After 6-8 Weeks)

• Physical therapy and stretching exercises 1
• Corticosteroid injections for certain types of bursitis 1
  • Effective for prepatellar and olecranon bursitis 3
  • For heel bursitis (Haglund's deformity): inject into bursa but avoid the Achilles tendon 1
  • Avoid in retrocalcaneal bursitis as it may adversely affect Achilles tendon properties 3
• Aspiration may be considered for:
  • Acute traumatic/hemorrhagic bursitis to shorten symptom duration 2
  • Diagnostic purposes when infection is suspected 2
  • Note: Aspiration of microtraumatic bursitis generally not recommended due to risk of iatrogenic infection 2

Step 3: Advanced Interventions (For Refractory Cases)

• Immobilization with cast or fixed-ankle walker-type device for heel bursitis 1
• Referral to specialist (podiatric foot and ankle surgeon for heel bursitis) 1
• Surgical intervention for recalcitrant cases 1, 3
  • For heel bursitis: resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1
  • For trochanteric bursitis: surgical intervention may be required if refractory 3
  • For olecranon bursitis: arthroscopic or open excision may be considered 6

Special Considerations

Septic Bursitis

• Requires prompt treatment with antibiotics effective against Staphylococcus aureus 2
• Outpatient antibiotics for non-acutely ill patients; hospitalization with IV antibiotics for acutely ill patients 2
• Surgery may be necessary for cases not responsive to antibiotics or for recurrent infections 2

Inflammatory Bursitis

• Address underlying condition (e.g., gout, rheumatoid arthritis) 2
• Intrabursal corticosteroid injections are often used 2

Treatment Duration and Follow-up

• For heel bursitis: continue initial treatments until symptoms resolve if improvement occurs within 6-8 weeks 1
• If no improvement occurs after the initial treatment period, reassess diagnosis and consider more aggressive interventions 1
• For chronic conditions, long-term management may be necessary to prevent recurrence 7

Pitfalls and Caveats

• Avoid corticosteroid injections into the Achilles tendon when treating heel bursitis 1
• Distinguish bursitis from other conditions like tendinitis, arthritis, or fractures 3
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• Consider the presence of multiple symptomatic bursae as a potential indicator of systemic rheumatic disease 1