What is the recommended initial management for bursitis?

Treatment for Bursitis

Initial Management: Conservative Therapy First

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

First-Line Conservative Approach

• Rest and activity modification to eliminate pressure or repetitive motion on the affected bursa is essential 1, 2
• Ice application for 10-minute periods through a wet towel provides pain relief 1, 2
• NSAIDs serve as first-line pharmacologic therapy for pain and inflammation control 1, 2
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1, 2
• Maintain conservative therapy for 4-6 weeks before progressing to invasive options 2

Critical Diagnostic Step: Rule Out Infection

Before any treatment, you must exclude septic bursitis, as corticosteroid injection can worsen infection. 2, 3

• If infection is suspected, perform bursal aspiration with Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 3
• Septic bursitis requires antibiotics effective against Staphylococcus aureus as initial treatment 3
• Outpatient oral antibiotics may be used for non-acutely ill patients; acutely ill patients require hospitalization with IV antibiotics 3

Location-Specific Treatment Algorithms

Prepatellar and Olecranon Bursitis

• After 4-6 weeks of failed conservative therapy, corticosteroid injection may be considered 2, 4
• Never aspirate chronic microtraumatic bursitis routinely due to risk of iatrogenic septic bursitis 2, 3
• Acute traumatic/hemorrhagic bursitis may benefit from aspiration to shorten symptom duration 3

Trochanteric Bursitis

• Ultrasound-guided bursal injection with lidocaine alone or combined with corticosteroid is the recommended intervention 5, 1, 2
• Conservative measures remain first-line before injection 2

Retrocalcaneal Bursitis (Critical Caveat)

Never inject corticosteroids into retrocalcaneal bursitis due to high risk of Achilles tendon rupture. 1, 2, 6

• Immobilization with a cast or fixed-ankle walker device may be necessary 1, 2
• Pain is typically aggravated by shoe pressure and relieved by walking barefoot 1
• For recalcitrant cases, surgical resection of the prominent posterior superior calcaneus and inflamed bursa may be required 1, 2
• Refer to podiatric foot and ankle surgeon if no improvement within 6-8 weeks of conservative treatment 2

Alternative Pain Management

• If NSAIDs are insufficient, contraindicated, or poorly tolerated, consider analgesics such as paracetamol or opioids for pain control 1, 2

Surgical Intervention

• Reserved for recalcitrant cases unresponsive to conservative management 1, 2, 6
• For septic bursitis, surgery is indicated when antibiotics fail or for recurrent cases 3
• Refer to orthopedic surgery for surgical candidates or refractory cases 2

Prevention of Recurrence

• Address modifiable risk factors: repetitive motion, obesity, metabolic conditions 2
• For crystal-induced (gout-related) bursitis: reduce meat and seafood intake, limit high-fructose foods, review diuretic use, reduce alcohol intake 1, 2
• Monitor disease activity, pain level, and functional limitations regularly 1, 2

Red Flags Requiring Specialist Referral

• Multiple symptomatic bursae suggest systemic rheumatic disease and warrant rheumatology referral 1, 2
• Symptoms persisting despite appropriate treatment require specialist evaluation 2
• Refer to rheumatology when systemic inflammatory disease is suspected as the underlying cause 2