What is the treatment for bursitis?

Management of Bursitis

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

Initial Assessment and Conservative Management

• Bursitis treatment should be tailored to the specific location (axial, peripheral, entheseal) and current symptoms, considering disease activity, pain level, and functional limitations 2
• First-line treatment includes:
  • Rest and activity modification to reduce pressure on the affected area 1
  • Ice application for 10-minute periods through a wet towel for pain relief 1
  • NSAIDs for pain and inflammation control 1, 3
• For acute bursitis, naproxen is specifically indicated at a recommended starting dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 3
• The initial total daily dose of naproxen should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg 3
• Use the lowest effective NSAID dose for the shortest duration consistent with treatment goals to minimize side effects 3

Intermediate Interventions

• If NSAIDs are insufficient, contraindicated, or poorly tolerated, analgesics such as paracetamol and opioids might be considered for pain control 2
• Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered for certain types of bursitis, such as prepatellar and olecranon bursitis 1, 4
• Caution: Steroid injections should be avoided in retrocalcaneal bursitis as they may adversely affect the biomechanical properties of the Achilles tendon 1, 4
• For trochanteric bursitis, ultrasound-guided bursal injection with lidocaine (as a diagnostic test) or in combination with a corticosteroid may be beneficial 2

Management of Specific Types of Bursitis

• Prepatellar and olecranon bursitis:

  • Conservative management with ice, NSAIDs, and activity modification 4, 5
  • Bursal aspiration may shorten symptom duration in acute traumatic/hemorrhagic bursitis 5
  • Avoid aspiration in chronic microtraumatic bursitis due to risk of iatrogenic infection 5
  • Intrabursal corticosteroid injections may be used, though high-quality evidence for benefit is limited 5, 6

• Trochanteric bursitis:

  • Conservative management as first-line treatment 4, 7
  • Surgical intervention may be required for recalcitrant cases 4

• Septic bursitis:

  • Requires bursal aspiration with fluid examination (Gram stain, culture) 5
  • Antibiotics effective against Staphylococcus aureus are generally the initial treatment 5, 8
  • Outpatient antibiotics for non-acutely ill patients; hospitalization with IV antibiotics for acutely ill patients 5
  • Recovery from septic bursitis can take months 8

Advanced Interventions

• Immobilization with a cast or fixed-ankle walker-type device may be necessary for heel bursitis 1
• Referral to specialists (rheumatologist, orthopedic surgeon, podiatric foot and ankle surgeon) should be considered for:
  • Recalcitrant cases not responding to conservative treatment 1
  • Suspected systemic rheumatic disease (presence of multiple symptomatic bursae) 1
• Surgical intervention may be required for refractory bursitis, such as:
  • Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa for heel bursitis 1
  • Bursectomy for chronic olecranon bursitis unresponsive to conservative measures 6

Prevention and Monitoring

• Disease monitoring should include patient history, clinical parameters, and appropriate testing according to clinical presentation 2
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• Address underlying causes of chronic microtraumatic bursitis to prevent recurrence 5
• The frequency of monitoring should be individualized based on symptoms, severity, and treatment response 2