What is the treatment for bursitis?

Treatment of Bursitis

Start with conservative management including rest, ice application (10-minute periods through a wet towel), NSAIDs, and activity modification for 4-6 weeks before considering more invasive interventions. 1, 2

Initial Conservative Management (First-Line for All Types)

The stepwise approach prioritizes non-invasive treatment:

• 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 as first-line pharmacologic therapy for pain and inflammation control 1, 2
  • For acute bursitis and tendonitis: 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 daily thereafter) 3
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1, 4
• Continue conservative therapy for 4-6 weeks before progressing to injections 2

Critical First Step: Rule Out Septic Bursitis

Never inject corticosteroids into a potentially infected bursa as this can worsen infection 2. If infection is suspected based on warmth, erythema, fever, or systemic symptoms, perform bursal aspiration with Gram stain, culture, cell count, and crystal analysis before any treatment 5.

Location-Specific Treatment Algorithms

Prepatellar and Olecranon Bursitis

• After 4-6 weeks of failed conservative therapy, corticosteroid injection may be considered 2
• For chronic microtraumatic bursitis, avoid routine aspiration due to risk of iatrogenic septic bursitis 2, 5
• Corticosteroid injection (e.g., betamethasone 24 mg with 1% lidocaine) can be used for persistent symptoms 6

Trochanteric Bursitis

• Ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid if conservative measures fail 1, 2
• Stretching exercises focused on lower back and sacroiliac joints 6
• Surgical options (iliotibial band release, subgluteal bursectomy) reserved for intractable cases 6

Retrocalcaneal Bursitis (Critical Caveat)

Absolutely avoid corticosteroid injections in retrocalcaneal bursitis due to high risk of Achilles tendon rupture. 1, 2 This is supported by high-strength evidence from the American College of Rheumatology.

• Use analgesics (paracetamol or opioids) if NSAIDs are insufficient 1
• Immobilization with cast or fixed-ankle walker device may be necessary 1, 2
• Refer to podiatric foot and ankle surgeon if no improvement within 6-8 weeks 2
• Surgical resection of prominent posterior calcaneus may be required for recalcitrant cases 1, 2

When to Progress Beyond Conservative Management

Consider corticosteroid injection after 4-6 weeks of failed conservative therapy for prepatellar, olecranon, and trochanteric bursitis only 2. The key distinction is that retrocalcaneal bursitis should never receive steroid injection.

Referral Indications

• Orthopedic surgery referral for surgical candidates or refractory cases after appropriate conservative trial 2
• Rheumatology referral when multiple symptomatic bursae suggest systemic rheumatic disease 1, 2
• Podiatric surgery referral for Haglund's deformity with no improvement after 6-8 weeks 2

Prevention of Recurrence

Address modifiable risk factors to prevent recurrence 2:

• Reduce repetitive motion and sustained pressure on affected areas 1
• Weight reduction in obese patients to decrease mechanical stress 1
• For crystal-induced (gout-related) bursitis: reduce meat, seafood, and high-fructose foods; review diuretic use; limit alcohol intake 1, 2

Common Pitfalls to Avoid

• Never inject steroids into retrocalcaneal bursa - risk of Achilles tendon rupture 1, 2
• Never inject a potentially infected bursa - always aspirate and culture first if septic bursitis suspected 2, 5
• Avoid routine aspiration of chronic microtraumatic bursitis - increases risk of iatrogenic infection 2, 5
• Don't use intra-articular hyaluronan if calcium pyrophosphate deposition disease present - may trigger acute attacks 2