What are the typical X-ray findings in a patient presenting with bursitis?

X-Ray Findings in Bursitis

Plain radiographs are typically normal or show only nonspecific soft-tissue swelling in most cases of bursitis, as X-rays cannot directly visualize the bursa itself or detect inflammation within it. 1

Primary X-Ray Findings

Most Common Finding

• Soft-tissue swelling is the predominant radiographic finding, visible in all cases when bursitis is present, though this is nonspecific and does not confirm the diagnosis 2

Calcifications

• Calcific deposits appear as rounded, amorphous opacities adjacent to bony prominences in approximately 33% of chronic bursitis cases 3, 2
• These calcifications are better visualized on plain films when they are larger, but smaller deposits are frequently missed 3
• Calcific bursitis can occasionally mimic soft tissue sarcomas radiographically, particularly when hemorrhagic 4

Associated Bony Changes

• Osteophyte formation at adjacent bony prominences may be seen in chronic cases 1
• Sclerosis of underlying bone can develop with long-standing inflammation 1
• Erosions or irregular bone surfaces may occur in severe or chronic inflammatory bursitis, though this is uncommon 1

Critical Limitations of X-Ray

Plain radiography is fundamentally limited because bursae are soft-tissue structures that are not directly visible on standard X-rays. 1 The key limitations include:

• Cannot demonstrate the bursa itself or fluid within it 1
• Unable to show bursal wall thickening or synovial proliferation 1
• Cannot differentiate septic from nonseptic bursitis 5
• Misses small calcifications that are clinically significant 3

When X-Rays Are Useful

Plain radiographs serve specific purposes in the evaluation of suspected bursitis:

• Ruling out alternative diagnoses such as fractures, loose bodies, degenerative joint disease, or osteomyelitis 1
• Detecting larger calcifications in chronic calcific bursitis 3
• Identifying bony abnormalities that may be contributing to bursal irritation 1

Superior Imaging Modalities

Ultrasound (Preferred First-Line)

• High-frequency ultrasound (≥10 MHz) is the most effective method for diagnosing bursitis, clearly visualizing fluid collections, bursal wall thickening, and calcifications 3, 6
• Demonstrates calcifications as hyperechoic foci with posterior acoustic shadowing 3
• Can assess for associated inflammation, hyperemia, and synovial thickening in real-time 1, 3
• Allows dynamic assessment during movement to differentiate bursal pathology from other conditions 3

MRI

• Provides detailed soft-tissue characterization when diagnosis remains unclear 1
• Can evaluate extent of inflammation, presence of septations, and associated soft-tissue or bone marrow edema 5, 2
• Useful for preoperative planning or when infection is suspected 1, 5

Common Pitfalls to Avoid

• Do not rely on X-rays alone to diagnose or exclude bursitis, as they will be normal in most acute cases 1
• Do not confuse tendon calcification with bursal calcification on radiographs, as treatment approaches differ 3
• Do not mistake calcific bursitis for a mineralizing soft tissue sarcoma based solely on the presence of calcification on X-ray 4
• Do not overlook the need for ultrasound when clinical suspicion for bursitis is high but X-rays are normal 3, 6