What is the treatment for recurrent bursitis and how to prevent its frequent recurrence?

Treatment for Bursitis and Prevention of Recurrence

For acute bursitis, begin with conservative management including rest, ice application (10-minute periods through wet towel), NSAIDs, and activity modification; if symptoms persist after 4-6 weeks of conservative therapy, consider corticosteroid injection for prepatellar and olecranon bursitis (but avoid injection in retrocalcaneal bursitis due to Achilles tendon risk), and address underlying risk factors—particularly repetitive motion, obesity, and metabolic conditions—to prevent recurrence. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

All bursitis should start with conservative measures:

• Rest and activity modification to eliminate pressure or repetitive motion on the affected bursa 1, 2
• Ice application for 10-minute periods through a wet towel for pain relief 1, 2
• NSAIDs for pain and inflammation control as first-line pharmacologic therapy 1, 2, 3
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1

This conservative approach should be maintained for 4-6 weeks before progressing to more invasive interventions. 1, 3

When Conservative Treatment Fails

For prepatellar and olecranon bursitis:

• Corticosteroid injection (20-40 mg methylprednisolone acetate or equivalent) directly into the bursa after aspiration of fluid 4, 3
• The injection technique requires sterile preparation, aspiration of bursal fluid first, then injection of corticosteroid 4
• Repeated injections may be necessary for recurrent or chronic conditions 4

For trochanteric bursitis:

• Ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid 1, 5
• If conservative measures and injection fail, consider surgical options (iliotibial band release, subgluteal bursectomy) 5, 6

For retrocalcaneal (heel) bursitis:

• Do NOT inject corticosteroids as this may damage Achilles tendon biomechanical properties 1, 6
• Consider immobilization with cast or fixed-ankle walker device 1
• Surgical resection of prominent posterior calcaneus may be required for recalcitrant cases 1

Critical Distinction: Septic vs. Non-Septic Bursitis

Before any treatment, rule out septic bursitis:

• If infection suspected (warmth, erythema, fever), perform bursal aspiration with Gram stain, culture, cell count, glucose, and crystal analysis 3
• Septic bursitis requires antibiotics effective against Staphylococcus aureus (most common pathogen), not corticosteroid injection 2, 3
• Outpatient oral antibiotics acceptable if patient not acutely ill; hospitalize with IV antibiotics if systemically ill 3

Never inject corticosteroids into potentially infected bursa—this can worsen infection. 3

Why Bursitis Recurs and Prevention Strategies

Address underlying risk factors to prevent recurrence:

Modifiable Risk Factors

• Repetitive motion/pressure: Occupational or recreational activities causing sustained pressure must be modified 1
• Obesity: Weight reduction decreases mechanical stress on weight-bearing bursae 1
• Metabolic conditions: Control diabetes, treat hyperuricemia (gout), optimize kidney function 1
• Diet: Reduce meat, seafood, and high-fructose foods if crystal-induced bursitis (gout-related) 1
• Medications: Review diuretic use which can cause hyperuricemia 1
• Alcohol: Reduce excess intake contributing to metabolic dysfunction 1

Non-Modifiable Risk Factors to Consider

• Age over 40 years, female sex, and prior joint injury increase risk 1
• Multiple symptomatic bursae may indicate systemic rheumatic disease requiring rheumatology referral 1

Surgical Intervention for Recurrent/Refractory Cases

When medical management fails:

• Arthroscopic bursectomy increasingly preferred over open excision (fewer wound complications) 7
• Open excisional bursectomy allows complete removal of pathological tissue but has higher wound complication rates 7
• Surgery reserved for cases unresponsive to conservative therapy and corticosteroid injections 6, 7

Common Pitfalls to Avoid

• Do not aspirate chronic microtraumatic bursitis routinely—this increases risk of iatrogenic septic bursitis 3
• Do not inject corticosteroids into retrocalcaneal bursa—risk of Achilles tendon rupture 1, 6
• Do not use intra-articular hyaluronan if concurrent calcium pyrophosphate deposition disease—may trigger acute attacks 8
• Do not assume all bursitis is the same—treatment location-specific (heel vs. knee vs. elbow requires different approaches) 1, 6

Monitoring and Follow-Up

• Monitor disease activity, pain level, and functional limitations 1
• Frequency of monitoring should be based on symptom severity and treatment response 1
• If symptoms persist despite appropriate treatment, consider systemic rheumatic disease and refer to rheumatology 1