What is the initial management for a patient with non-infectious bursitis?

Initial Management of Non-Infectious Bursitis

Start with conservative therapy: rest, ice application (10-minute periods through a wet towel), NSAIDs, and activity modification to eliminate pressure or repetitive motion on the affected bursa for 4-6 weeks before considering more invasive interventions. 1, 2

First-Line Conservative Management

• Rest and activity modification are essential to reduce mechanical stress on the inflamed bursa, maintained for 4-6 weeks to allow healing while avoiding complete immobilization that could cause muscular atrophy 1, 2
• Ice application should be applied for 10-minute periods through a wet towel to provide pain relief and reduce inflammation 1, 2
• NSAIDs serve as first-line pharmacologic therapy for pain control and inflammation reduction 1, 2, 3
• Analgesics such as acetaminophen or opioids may be considered if NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2

Location-Specific Considerations

For Prepatellar and Olecranon Bursitis:

• Conservative management should be attempted for 4-6 weeks initially 2, 4
• Corticosteroid injection may be considered after failed conservative therapy, but only after ruling out infection 2, 4, 5
• Aspiration of acute traumatic/hemorrhagic bursitis may shorten symptom duration 4
• Avoid routine aspiration of chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 2, 4

For Trochanteric Bursitis:

• Ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid may be beneficial 1, 2
• Conservative measures remain first-line, with injection reserved for refractory cases 5

For Retrocalcaneal Bursitis (Critical Caveat):

• Never inject corticosteroids into the retrocalcaneal bursa due to high risk of Achilles tendon rupture 1, 2, 5
• Immobilization with a cast or fixed-ankle walker device may be necessary 1, 2
• Referral to podiatric foot and ankle surgery is indicated if no improvement occurs within 6-8 weeks 2

NSAID Dosing for Acute Bursitis

For naproxen specifically (when managing acute bursitis):

• Initial dose: 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours 3
• Maximum initial daily dose should not exceed 1250 mg; thereafter, maximum 1000 mg daily 3
• Lower doses should be considered in elderly patients, those with renal/hepatic impairment 3

Critical Diagnostic Requirement Before Treatment

Rule out septic bursitis before any treatment, particularly before corticosteroid injection, as steroids can worsen infection 2, 4. Key distinguishing features include:

• Presence of fever, warmth, erythema, and acute tenderness suggest infection 4
• If infection is suspected, perform bursal aspiration with Gram stain, culture, cell count, glucose measurement, and crystal analysis 4
• Ultrasonography can help distinguish bursitis from cellulitis 4

When to Progress Beyond Conservative Management

After 4-6 weeks of appropriate conservative therapy without improvement:

• Consider corticosteroid injection for prepatellar or olecranon bursitis (never for retrocalcaneal) 2, 5
• Evaluate for underlying systemic inflammatory conditions (gout, rheumatoid arthritis) if multiple bursae are symptomatic 1, 2
• Refer to orthopedic surgery for surgical candidates or refractory cases 2
• Refer to rheumatology when systemic inflammatory disease is suspected 2

Prevention of Recurrence

Address modifiable risk factors to prevent recurrence:

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