What is the recommended treatment for a patient with bursitis?

Treatment of Bursitis

Start with conservative management including rest, ice application, NSAIDs, and activity modification for 4-6 weeks before considering more invasive interventions. 1, 2

Initial Conservative Management (First-Line Treatment)

All patients with bursitis should begin with conservative therapy regardless of location:

• Rest and activity modification to eliminate pressure or repetitive motion on the affected bursa for 4-6 weeks 1, 2
• Ice application for 10-minute periods through a wet towel for pain relief 1, 3, 2
• NSAIDs as first-line pharmacologic therapy for pain and inflammation control 1, 3, 2, 4
  • Naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (initial daily dose should not exceed 1250 mg, thereafter not exceeding 1000 mg daily) 4
  • Onset of pain relief typically begins within 1 hour 4
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 3, 2

Location-Specific Treatment Algorithms

Prepatellar and Olecranon Bursitis

If conservative therapy fails after 4-6 weeks:

• Corticosteroid injection may be considered (e.g., 24 mg betamethasone with 1% lidocaine or equivalent) 1, 2, 5
• Critical caveat: Rule out septic bursitis before any injection—never inject corticosteroids into a potentially infected bursa as this can worsen infection 2, 6
• Avoid routine aspiration of chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 2, 6

Trochanteric Bursitis

If conservative therapy fails:

• Ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid 1, 2
• Surgical options (iliotibial band release, subgluteal bursectomy) reserved for intractable cases 5

Retrocalcaneal Bursitis (Heel Bursitis)

CRITICAL WARNING: Never inject corticosteroids into retrocalcaneal bursitis due to high risk of Achilles tendon rupture 1, 2, 7

Treatment progression:

• Conservative management as above 1, 2
• Immobilization with cast or fixed-ankle walker-type device if conservative measures fail 1, 2
• Referral to podiatric foot and ankle surgeon if no improvement within 6-8 weeks 2
• Surgical resection of prominent posterior superior calcaneus and inflamed bursa for recalcitrant cases 1, 2

Septic Bursitis (Requires Different Management)

If infection is suspected (warmth, erythema, fever):

• Bursal aspiration mandatory with Gram stain, culture, cell count, glucose measurement, and crystal analysis 6
• Antibiotics effective against Staphylococcus aureus as initial treatment 6
• Outpatient oral antibiotics for non-acutely ill patients; hospitalization with IV antibiotics for acutely ill patients 6
• Surgery reserved for antibiotic-resistant or recurrent cases 6

Pain Management Alternatives

If NSAIDs are insufficient, contraindicated, or poorly tolerated:

• Consider acetaminophen (paracetamol) or opioids for pain control 8, 1

Prevention of Recurrence

Address modifiable risk factors:

• Reduce repetitive motion and sustained pressure on affected areas 1, 2
• Weight management for obese patients 8, 2
• Dietary modifications: reduce meat, seafood, and high-fructose foods to prevent crystal-induced (gout-related) bursitis 2
• Review and potentially reduce diuretic use and excess alcohol intake 2

When to Refer

Refer to orthopedic surgery for:

• Surgical candidates or refractory cases after appropriate conservative management 2

Refer to rheumatology when:

• Multiple symptomatic bursae present (potential systemic rheumatic disease) 1, 2
• Symptoms persist despite appropriate treatment 2

Common Pitfalls to Avoid

• Never inject corticosteroids into retrocalcaneal bursa—this can cause Achilles tendon rupture 1, 2, 7
• Never inject a potentially infected bursa—corticosteroid injection worsens septic bursitis 2, 6
• Avoid routine aspiration of chronic microtraumatic bursitis—increases risk of iatrogenic infection 2, 6
• Do not use intra-articular hyaluronan if calcium pyrophosphate deposition disease is present—may trigger acute attacks 2