What is the treatment for bursitis?

Treatment of Bursitis

The recommended treatment for bursitis begins with conservative measures including rest, ice application, NSAIDs, and activity modification, with progression to more invasive treatments only if symptoms persist. 1

Initial Assessment and First-Line Treatment

• Bursitis treatment should be tailored to the specific location and symptoms, considering pain level and functional limitations 1
• First-line conservative management 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 such as naproxen (starting dose 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed) 2
  • The lowest effective dose of NSAIDs should be used for the shortest duration consistent with treatment goals 2

Treatment Based on Bursitis Type

• For acute traumatic/hemorrhagic bursitis:

  • Conservative treatment with ice, elevation, rest, and analgesics 3
  • Aspiration may shorten the duration of symptoms 3

• For chronic microtraumatic bursitis (e.g., prepatellar or olecranon bursitis):

  • Address the underlying cause (e.g., avoid kneeling for prepatellar bursitis) 3
  • Bursal aspiration is generally not recommended due to risk of iatrogenic septic bursitis 3

• For septic bursitis:

  • Bursal aspiration should be performed and fluid examined using Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 3
  • Antibiotics effective against Staphylococcus aureus are generally the initial treatment 3
  • Outpatient antibiotics may be considered for patients who are not acutely ill 3
  • Patients who are acutely ill should be hospitalized and treated with intravenous antibiotics 3

Intermediate Interventions

• If NSAIDs are insufficient, contraindicated, or poorly tolerated, analgesics such as paracetamol may be considered for pain control 1
• Corticosteroid injections may be considered for certain types of bursitis:
  • Beneficial for prepatellar and olecranon bursitis 1, 4
  • 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 or in combination with a corticosteroid may be beneficial 1

Advanced Interventions

• Immobilization with a cast or fixed-ankle walker-type device may be necessary for heel bursitis 1
• Surgical intervention may be required for recalcitrant cases of bursitis that don't respond to conservative treatment 1, 4
• Surgery options include:
  • Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa for heel bursitis 1
  • Bursectomy for severe, refractory, or chronic/recurrent cases 5

Special Considerations

• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• The presence of multiple symptomatic bursae should be considered as a potential indicator of systemic rheumatic disease 1
• For septic bursitis, surgical intervention is typically reserved for cases not responsive to antibiotics or for recurrent cases 3
• Recovery from septic olecranon bursitis can take months 6
• Elderly patients and those with renal or hepatic impairment may require lower doses of NSAIDs 2

Treatment Algorithm

1. Confirm diagnosis of bursitis through clinical presentation, focusing on location of pain and tenderness, presence of swelling, redness, or warmth 1
2. Rule out septic bursitis through clinical presentation and, if needed, bursal aspiration 3
3. Initiate conservative treatment with rest, ice, NSAIDs, and activity modification 1
4. If symptoms persist after 2-3 weeks of conservative treatment, consider corticosteroid injection for appropriate bursitis types 1, 4
5. For refractory cases not responding to conservative measures and injections, consider referral to a specialist for possible surgical intervention 1, 4