Leg Bursitis: Diagnosis and Treatment
Diagnosis
Leg bursitis is diagnosed primarily through clinical presentation, focusing on location-specific pain patterns, swelling, and tenderness, with imaging reserved for unclear cases or when infection is suspected. 1
Key Diagnostic Features by Location
Heel/Retrocalcaneal Bursitis (Haglund's Deformity):
- Pain aggravated by shoe pressure and relieved when walking barefoot 2
- Tenderness lateral to the Achilles tendon, often with posterior lateral prominence 2
- Most common in women aged 20-30 years, though can occur at any age 2, 1
- Radiographs commonly show the bony prominence 2
Trochanteric Bursitis:
- Pain over the lateral hip with tenderness at the greater trochanter 3
- Symptoms worsen with prolonged standing, climbing stairs, or lying on the affected side 3
Prepatellar and Pes Anserine Bursitis:
- Localized swelling and tenderness at the anterior knee (prepatellar) or medial knee below the joint line (pes anserine) 4, 3
- History of repetitive kneeling or direct trauma is common 4
Distinguishing Septic from Non-Septic Bursitis
Critical distinction: Septic bursitis requires immediate identification and different management 4, 5
Signs suggesting infection:
- Acute onset with marked erythema, warmth, and swelling 4
- Fever or systemic symptoms 4
- History of penetrating trauma or immunocompromise 4
When infection is suspected, bursal aspiration is mandatory with fluid analysis including Gram stain, culture, cell count, glucose, and crystal analysis 4
Imaging Recommendations
- Ultrasonography is useful to distinguish bursitis from cellulitis and can detect bursal fluid 2, 4
- MRI may be used when diagnosis is unclear or to assess surrounding structures 2
- Plain radiographs help identify bony abnormalities (e.g., Haglund's deformity, calcifications) 2
Treatment Algorithm
First-Line Conservative Management (0-6 weeks)
Start with conservative measures for all non-septic bursitis, as most cases respond without invasive intervention. 1, 4, 6
Initial conservative therapy includes:
- Rest and activity modification to reduce pressure on the affected bursa 2, 1, 3
- Ice application for 10-minute periods through a wet towel 1
- NSAIDs for pain and inflammation control 2, 1, 3
- Naproxen: 500 mg initially, then 500 mg every 12 hours or 250 mg every 6-8 hours (maximum 1250 mg first day, then 1000 mg/day thereafter) 7
- Elevation of the affected limb when possible 3
Location-specific modifications:
- Heel bursitis: Open-backed shoes, heel lifts, accommodative padding, avoid corticosteroid injection near Achilles tendon 2, 6
- Trochanteric bursitis: Stretching exercises focused on lower back and sacroiliac joints 8
- Weight loss if indicated for weight-bearing bursae 2, 1
Critical pitfall: Avoid complete immobilization to prevent muscular atrophy and deconditioning 1
Second-Line Treatment (6-8 weeks if no improvement)
If conservative measures fail after 6-8 weeks, consider corticosteroid injection for appropriate locations or refer to specialist. 2, 1, 8
Corticosteroid injection guidelines:
- Appropriate for: Prepatellar, olecranon, and trochanteric bursitis 1, 8, 6
- Contraindicated for: Retrocalcaneal bursitis (risk of Achilles tendon damage) 2, 6
- Technique: Ultrasound-guided injection with lidocaine alone or combined with corticosteroid (e.g., 24 mg betamethasone with 1% lidocaine) 1, 8
Warning: Do not aspirate chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 4
For heel bursitis without improvement:
- Continue initial measures 2
- Add immobilization with cast or fixed-ankle walker-type device 2
- Refer to podiatric foot and ankle surgeon 2
Management of Septic Bursitis
Septic bursitis requires antibiotics effective against Staphylococcus aureus, with hospitalization for acutely ill patients. 4
Treatment approach:
- Outpatient oral antibiotics for patients who are not acutely ill 4
- Hospitalization with IV antibiotics for acutely ill patients 4
- Surgical drainage or bursectomy reserved for cases not responsive to antibiotics or recurrent infections 4, 5
Surgical Intervention (Refractory Cases)
Surgery is reserved for recalcitrant cases failing conservative and injection therapy after several months. 1, 6
Surgical options by location:
- Heel bursitis: Resection of prominent posterior superior calcaneus and inflamed bursa 1
- Trochanteric bursitis: Iliotibial band release, subgluteal bursectomy, or trochanteric reduction osteotomy 8, 6
- Prepatellar/olecranon bursitis: Bursectomy for chronic recurrent cases 5, 6
Special Considerations
Multiple symptomatic bursae should raise suspicion for systemic rheumatic disease (e.g., rheumatoid arthritis, gout) requiring evaluation and treatment of the underlying condition 1, 4
Risk factors to address: