What is the recommended treatment for a patient with 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 Approach

The stepwise treatment algorithm prioritizes non-invasive measures first:

• 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
  • 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) 4
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 3, 2

If NSAIDs are contraindicated or poorly tolerated, use paracetamol or opioids for pain control 1

Critical Diagnostic Step: Rule Out Septic Bursitis

Before any treatment, exclude septic bursitis—this requires completely different management with antibiotics rather than corticosteroids. 3, 2, 5

• If infection is suspected: perform bursal aspiration with Gram stain, culture, cell count, glucose measurement, and crystal analysis 5
• Septic bursitis requires antibiotics effective against Staphylococcus aureus (outpatient if not acutely ill; inpatient IV antibiotics if acutely ill) 5

Location-Specific Corticosteroid Injection Guidelines

After 4-6 weeks of failed conservative therapy, consider corticosteroid injection only for specific locations:

Safe for Injection:

• Prepatellar bursitis: corticosteroid injection may be considered 1, 2
• Olecranon bursitis: corticosteroid injection may be considered 1, 2
• Trochanteric bursitis: ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid 1, 2, 6
  • Typical dose: 24 mg betamethasone with 1% lidocaine (or equivalent) 6

NEVER Inject Retrocalcaneal Bursitis:

• Absolutely avoid corticosteroid injection in retrocalcaneal bursitis due to high risk of Achilles tendon rupture 1, 2
• Instead, use immobilization with cast or fixed-ankle walker device 1, 2

Critical Pitfalls to Avoid

• Never inject corticosteroids into a potentially infected bursa—this will worsen infection 2
• Avoid routine aspiration of chronic microtraumatic bursitis—this creates risk of iatrogenic septic bursitis 2, 5
• Do not use intra-articular hyaluronan if concurrent calcium pyrophosphate deposition disease is present—may trigger acute attacks 2

Surgical Intervention

Reserve surgery for recalcitrant cases after exhausting conservative measures:

• Heel bursitis: resection of prominent posterior superior calcaneus and inflamed bursa 1, 2
• Trochanteric bursitis: iliotibial band release, subgluteal bursectomy, or trochanteric reduction osteotomy for intractable symptoms 6
• Refer to orthopedic surgery for surgical candidates or refractory cases 2

When to Suspect Systemic Disease

If multiple bursae are symptomatic simultaneously, consider systemic rheumatic disease and refer to rheumatology 1, 2

Prevention of Recurrence

Address modifiable risk factors to prevent recurrence:

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