What is the best treatment approach for a patient diagnosed with bursitis?

Treatment of Bursitis

Start with conservative management including rest, ice application (10-minute periods through wet towel), NSAIDs, and activity modification as first-line therapy for all bursitis cases, progressing to corticosteroid injections or surgical intervention only when conservative measures fail. 1

Initial Conservative Management

First-line treatment consists of:

• Rest and activity modification to reduce pressure 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, with naproxen being FDA-approved specifically for bursitis at an initial dose of 500 mg followed by 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

The American Academy of Family Physicians emphasizes this stepwise approach, with progression to invasive treatments only if symptoms persist after conservative measures 1. Most patients respond to this initial management strategy 4, 5.

When Conservative Treatment Fails

Evaluate treatment response at 2-4 weeks:

• If sufficient response occurs, continue conservative management and re-evaluate at 12 weeks 1
• If insufficient response at 2-4 weeks or later, consider advancing to corticosteroid injection or alternative NSAIDs 1

Corticosteroid Injection Guidelines

Location-specific injection recommendations:

• Prepatellar and olecranon bursitis: Corticosteroid injections may be considered 1, 5
• Trochanteric bursitis: Ultrasound-guided bursal injection with lidocaine or combined with corticosteroid (e.g., 24 mg betamethasone with 1% lidocaine) is beneficial for persistent symptoms 1, 6
• Retrocalcaneal bursitis: AVOID corticosteroid injections due to risk of Achilles tendon rupture - this is a critical contraindication with high-strength evidence 1

Critical Diagnostic Consideration Before Treatment

Rule out septic bursitis before initiating standard treatment:

• Septic bursitis requires bursal aspiration with Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 4
• If septic bursitis is confirmed, antibiotics effective against Staphylococcus aureus are the initial treatment, with outpatient management for non-acutely ill patients and hospitalization with IV antibiotics for acutely ill patients 4
• Do not perform bursal aspiration for chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 4

Alternative Analgesics

If NSAIDs are insufficient, contraindicated, or poorly tolerated, consider paracetamol or opioids for pain control 1.

Surgical Intervention

Reserve surgery for recalcitrant cases:

• For heel bursitis: resection of prominent posterior superior calcaneus and inflamed bursa 1
• For trochanteric bursitis: iliotibial band release, subgluteal bursectomy, or trochanteric reduction osteotomy in rare intractable cases 6
• For other locations: surgical excision may be required for chronic refractory bursitis 5, 7

Immobilization with cast or fixed-ankle walker may be necessary for heel bursitis before considering surgery 1.

Common Pitfalls to Avoid

• Never inject corticosteroids into retrocalcaneal bursa - high risk of Achilles tendon rupture 1
• Do not aspirate chronic microtraumatic bursitis - increases infection risk 4
• Do not combine naproxen with aspirin - aspirin increases naproxen excretion without additional benefit 3
• Consider systemic rheumatic disease if multiple symptomatic bursae are present 1