Highlights & Basics
- The acute or chronic inflammation of a bursa.
- A bursa is a sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer. There are >150 bursae in the body and these can be deep (e.g., the subacromial bursa) or superficial (e.g., the olecranon bursa).
- In bursitis there is thickening and proliferation of the synovial lining, bursal adhesions, villus formation, tags, and deposition of chalky deposits. This may result from repetitive stress, infection, autoimmune disease, or trauma.
- Key diagnostic findings are localized pain and tenderness over a bursa and swelling if superficially sited.
- Treatment for nonseptic bursitis involves modified physical activity, rest, and analgesia. Corticosteroid injections are reserved for those cases that do not respond to conservative management. Bursal excision is a last resort.
- The first-line treatment for septic bursitis is aspiration and antibiotic therapy. Surgical debridement and lavage may be required.
Quick Reference
History & Exam
Key Factors
pain at site of bursa
tenderness to palpation at site of bursa
decreased active range of motion
Other Factors
low-grade temperature (septic bursitis)
swelling
erythema (septic bursitis)
warmth of overlying skin (septic bursitis)
painful arc on shoulder abduction (subacromial)
lateral hip pain (trochanteric)
pain at the extremes of hip rotation, abduction, or adduction (trochanteric)
pain of contraction of the hip abductors against resistance (trochanteric)
pseudoradiculopathy: pain radiating down the lateral aspect of the thigh (trochanteric)
impalpable patella (prepatellar)
palpable bump over heel (retrocalcaneal)
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Other Tests to consider
Gram stain and culture of fluid aspirate
crystal analysis
x-ray of affected region
MRI
Treatment Options
acute
nonseptic bursitis
conservative management and analgesia
corticosteroid injection
surgery
septic bursitis
antibiotic therapy and aspiration of the bursa
conservative management and analgesia
surgical debridement and lavage
antibiotic therapy
conservative management and analgesia
Definition
Classifications
Anatomic classification
- Prepatellar bursitis ("housemaid's knee")
- Infrapatellar bursitis ("clergyman's knee")
- Anserine bursitis (anserine refers to the classic appearance of a swollen bursa being restrained by the 3 tendons overlying it - sartorius, gracilis, and semitendinosus - creating the impression of a goose's foot)
- Olecranon bursitis ("student's elbow")
- Retrocalcaneal bursitis
- Trochanteric bursitis
- Subacromial (subdeltoid) bursitis.
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
- Repetitive injury or acute trauma: any repetitive pattern of movement that puts pressure on a bursa, such as compression of the subacromial bursa under the coracoacromial arch. An alteration in gait pattern caused by lower limb discrepancy or iliotibial band contracture may affect the stresses on the subtrochanteric bursa. Certain professions have been thought to be more at risk of certain types of bursitis due to repetitive action in their daily work; this led to the colloquial naming of "clergyman's knee" and "student's elbow" for infrapatellar and olecranon bursitis, respectively. Poorly fitting footwear can cause retrocalcaneal bursitis by exerting excessive pressure on the heel.
- Crystal deposition secondary to gout or pseudogout: crystal arthropathy can result in crystal deposition within the bursa and subsequent inflammation of the synovial lining, resulting in bursitis. Bursitis can also be the first presenting feature of a crystal arthropathy.
- Autoimmune disease: e.g., rheumatoid arthritis has been associated with bursitis.
- Infection, acute or chronic: may follow a penetrating injury from a foreign body.
- Osteoarthritis of the hip: has been implicated as a cause of trochanteric bursitis through osteophyte deposition, but this remains unproven.
Pathophysiology
Images
Diagnostic Approach
History and exam
- Pain at the extremes of rotation, abduction, or adduction
- Pain of contraction of the hip abductors against resistance
- Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh.
Investigations
Risk Factors
History & Exam
Tests
Differential Diagnosis
Medial meniscopathy
Differentiating Signs/Symptoms
- May be confused with anserine bursitis.
- McMurray test: usually positive in meniscal disease and negative in bursitis. Patient lies supine; leg is rotated on the thigh with the knee fully flexed. The physician grasps the patient's foot. The leg is flexed to 90° while the foot is maintained first in full internal rotation and then rotated in full external rotation. A click occurs and the patient feels pain if a meniscal tear is present.
- Apley grind test: usually positive in meniscal disease and negative in bursitis. Patient lies prone; foot is rotated externally, and knee flexed to 90°. Foot rotated internally and knee extended. The tibia is then compressed into the knee joint while externally rotating the foot. If this increases the pain, test is positive, indicating meniscal damage.
- Bounce home test: usually positive in meniscal disease and negative in bursitis. With the patient lying supine, the surgeon grasps the foot and completely flexes the knee. The knee is then passively allowed to extend. The knee should extend completely or bounce home into extension with a sharp endpoint. Test is positive when full extension cannot be attained.
Differentiating Tests
- MRI: shows a meniscal tear, communicating with its superior and/or inferior surfaces or inner margin, on >1 slice. Meniscal subluxation is defined as protrusion over the edge of the tibial plateau seen at the level of the body of the meniscus.
Medial compartment osteoarthritis
Differentiating Signs/Symptoms
- May be confused with anserine bursitis.
- Medial knee osteoarthritis is defined as pain or stiffness for most days of the preceding month and osteophytes at the medial joint margin of the tibiofemoral joint.
Differentiating Tests
- Weight-bearing radiographs of the knees: shows medial joint space narrowing, osteophytes, subchondral bone cysts, and sclerosis.
Baker cyst
Differentiating Signs/Symptoms
- May be confused with anserine bursitis.
- Often asymptomatic. The cyst may rupture or leak, causing swelling and pain in the popliteal region.
Differentiating Tests
- Ultrasound scan: demonstrates a fluid-filled cystic mass in the popliteal region.
- MRI: shows an oval-shaped, fluid-filled, well-defined mass posterior to the knee joint.
Medial collateral ligament damage
Differentiating Signs/Symptoms
- May be confused with anserine bursitis.
- Valgus stress test is usually positive in medial collateral ligament disease and negative in bursitis. The patient lies supine. The physician places one hand on the lateral aspect of the knee joint and the other hand on the medial aspect of the distal tibia. A valgus stress is applied with the leg flexed to 30°. If the knee joint abducts more than the uninjured leg, the test is positive.
Differentiating Tests
- MRI scan: shows increased signal within the ligament itself without an associated knee joint effusion (unless there is another injury such as an associated ACL tear or patellar dislocation).
Soft tissue infection
Differentiating Signs/Symptoms
- Clinically similar to any bursitis, with pain, erythema, and swelling. May have spreading cellulitis.
Differentiating Tests
- MRI: a reticulated pattern of abnormal signal intensity in the subcutaneous tissue on both T1-weighted and fluid-sensitive sequences. When intravenous contrast is administered, the subcutaneous tissues will have a reticulated pattern of enhancement. Noninfective edema may have similar signal characteristics but without enhancement.
- X-ray/CT: fasciitis is an infection of the deep or superficial fascia. Soft-tissue gas is a suggestive feature of necrotizing fasciitis.
Local bone tissue tumors
Differentiating Signs/Symptoms
- Can be clinically similar to any local bursitis, with pain, swelling, and erythema.
Differentiating Tests
- X-ray: abnormal bone mass can be readily identified. Further imaging may not be required.
- MRI: useful to delineate anatomic boundaries and may demonstrate soft-tissue involvement.
- Bone scan: normally shows increased uptake, although some tumors show decreased uptake. Done in combination with x-ray or MRI.
Spinal stenosis
Differentiating Signs/Symptoms
- May be confused with subtrochanteric bursitis.
- Neurogenic claudication: pain extending from the back into the buttocks and thigh, and sometimes into the lower leg. The pain is exacerbated by lumbar extension and improves with lumbar flexion.
- A sensory or motor deficit is present in about half of patients with symptomatic lumbar stenosis.
- Romberg maneuver: patient stands with eyes closed and is observed for imbalance. This may reveal a wide-based gait and unsteadiness, reflecting involvement of proprioceptive fibers in the posterior columns.
Differentiating Tests
- X-ray: narrowing may occur in the central spinal canal, in the area under the facet joints (subarticular stenosis), or more laterally, in the neural foramina. Can demonstrate the extent of disk-space narrowing, end-plate sclerosis, and facet-joint hypertrophy. The neural foramina may reveal osteophytes, suggesting foraminal stenosis.
- MRI/CT: can confirm the presence of spinal stenosis, as a reduction in the cross-sectional area of the central canal and neural foramina.
Lumbar radiculopathy
Differentiating Signs/Symptoms
- May be confused with subtrochanteric bursitis.
- A sharp or dull, burning pain in the back, radiating into the leg (sciatica).
- Pain is exacerbated by bending forward or sitting and relieved by lying down and sometimes by walking. Typical presentation is pain and sensory loss.
- Lasegue, Wasserman, and Valsalva tests are usually positive in lumbar radiculopathy and negative in bursitis.
- Lasegue test: usually positive in lumbar radiculopathy and negative in bursitis. With the patient lying supine, the surgeon flexes the leg to 90° at the hip and knee. The knee is slowly extended, which produces radiating pain.
- Wasserman test: usually positive in lumbar radiculopathy and negative in bursitis. The patient lies prone and the physician slowly extends the hip. Accentuation of pain in the anterior thigh suggests a high lumbar (L2, L3) radiculopathy.
- Valsalva test: usually positive in lumbar radiculopathy and negative in bursitis. This maneuver increases intrathecal pressure, which accentuates radicular pain in the presence of spinal nerve compression and inflammation.
Differentiating Tests
- MRI: reveals structure of the lumbosacral spine and nerve roots. Imaging results need to be interpreted in the context of clinical symptoms and signs.
- Needle electromyography: can diagnose compressive and noncompressive radiculopathies and provides a measure of severity of radiculopathic disease.
Osteoarthritis of the hip
Differentiating Signs/Symptoms
- May be confused with subtrochanteric bursitis.
- Hip pain or stiffness in the groin and hip region on most days of the preceding month.
- Often a loss of internal rotation initially.
Differentiating Tests
- X-ray: shows femoral or acetabular osteophytes and/or axial joint space narrowing.
Differentiating Signs/Symptoms
- May be confused with subtrochanteric bursitis.
- Hip pain and/or stiffness in the groin and hip region.
Differentiating Tests
- X-ray: can demonstrate advanced stages of osteonecrosis characterized by sclerosis, lucency, and flattening of the femoral head.
- MRI: shows subchondral lesions of variable signal intensity outlined by a low-signal rim on T1-weighted images along the anterosuperior aspect of the femoral head. A more specific sign is the double-line sign (an outer low-intensity rim and an inner high-intensity band) on T2-weighted images.
Stress fracture of the hip
Differentiating Signs/Symptoms
- May be confused with subtrochanteric bursitis.
- Hip pain and/or stiffness in the groin and hip region.
Differentiating Tests
- X-ray: may demonstrate a stress fracture, but this is often missed on plain films.
- MRI: is the most sensitive modality to detect and characterize stress fracture of the hip.
Rotator cuff tendinopathy
Differentiating Signs/Symptoms
- Clinically indistinguishable from subacromial bursitis. Many patients with a rotator cuff tendinopathy have a subacromial bursitis as well.
Differentiating Tests
- MRI: shows an increased signal within the tendon of the rotator cuff.
Rotator cuff lesions
Differentiating Signs/Symptoms
- Often clinically indistinguishable from subacromial bursitis. Many patients with rotator cuff tendinopathy have an associated subacromial (subdeltoid) bursitis. Usually, weakness accompanies pain. Pain with preserved strength is more suggestive of bursitis or tendinopathy.
Differentiating Tests
- MRI: shows an interruption of the signal within the tendon of the rotator cuff.
Calcific tendinopathy of the rotator cuff or Achilles tendon
Differentiating Signs/Symptoms
- Clinically indistinguishable from subacromial/retrocalcaneal bursitis.
Differentiating Tests
- X-ray: may show presence of a calcific deposit within the tendon of the rotator cuff or Achilles tendon.
- Ultrasound: can detect calcifications in the Achilles tendon as hyperechoic areas casting acoustic shadowing.
- MRI: demonstrates presence of a calcific deposit within the tendon.
Differentiating Signs/Symptoms
- Often clinically indistinguishable from subacromial bursitis.
- O'Brien test: a positive result suggests an SLAP lesion. The arm is flexed to 90° with the elbow extended. The arm is adducted by 10° and the thumb pointed toward the floor. Downward pressure is applied by the examiner. The palm is then supinated and the procedure repeated. The test is considered positive if pain is elicited with the first maneuver and reduced or eliminated on supination.
- Speed test: a positive result suggests an SLAP lesion. The patient flexes his/her shoulder against resistance while the elbow is extended and forearm supinated. The test is positive when pain is localized to the bicipital groove.[15]
Differentiating Tests
- MRI: shows the presence of increased signal within the labrum extending to its surface. If contrast is used, it may be taken up into the labrum.
Differentiating Signs/Symptoms
- Clinically indistinguishable from subacromial bursitis but often associated with an injury to the subscapularis, which might be detected with the belly-press test or the lift-off test.
- Belly-press test: the patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation. If subscapularis is impaired, the elbow drops back behind the trunk.
- Lift-off test: patients with subscapularis rupture will be unable to lift the dorsum of their hand off their back.
Differentiating Tests
- MRI: shows the presence of a subluxated long head of the biceps tendon.
Tendinopathy of the long head of the biceps tendon
Differentiating Signs/Symptoms
- Clinically indistinguishable from subacromial bursitis.
Differentiating Tests
- MRI: shows the presence of increased signal within the long head of the biceps tendon.
Differentiating Signs/Symptoms
- May be confused with, or exist along with, retrocalcaneal bursitis.
- The pain generally emanates from the posterior aspect of the heel and is aggravated by active or passive motion.
Differentiating Tests
- Lateral x-ray: prominent posteriosuperior calcaneal process. The ossification is in the most proximal extent of the insertion of the tendon or as a spur off the superior portion of the calcaneus.
- Haglund syndrome is a triad of insertional tendinopathy of the Achilles tendon, retrocalcaneal bursitis, and Haglund deformity.
Tendinopathy of the main body of the Achilles tendon
Differentiating Signs/Symptoms
- May be confused with retrocalcaneal bursitis.
- Pain and swelling is localized around the tendon.
Differentiating Tests
- Ultrasound: most commonly focal or diffuse thickening of the Achilles tendon with focal hypoechoic areas.
- MRI: features include morphologic findings of a fusiform tendon shape, anteroposterior tendon thickening, and convex bulging of the anterior tendon margin. Areas of increased signal within the tendon on T2-weighted sequences are thought to represent more severe areas of collagen disruption and partial tearing.
Differentiating Signs/Symptoms
- May be confused with retrocalcaneal bursitis.
- Pain at the heel, which frequently occurs before or during the peak growth spurt.
Differentiating Tests
- Lateral x-ray of the ankle: may show avulsion of the calcaneal apophysis. Can be normal despite significant apophysitis.
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Anterior elbow pain or proximal volar forearm pain. May occur with repetitive pronation and gripping activities.
- Tinel sign over the anterior cubital fossa may be present.
- Sensory deficits in the radial three and a half digits of the hand on the affected side may be present.
Differentiating Tests
- Electromyography: can help to delineate the severity of damage to the median nerve.
Lateral epicondylitis (tennis elbow)
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Tenderness to palpation over the origin of the extensor carpi radialis brevis tendon.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Tenderness at the lateral epicondyle and distally at the site of the arcade of Frohse. Often pain reproducible with resisted supination and extension of the middle finger.
Differentiating Tests
- Clinical diagnosis.
Medial epicondylitis (golfer's elbow)
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Tenderness to palpation just anterior to the medial epicondyle.
- Resisted wrist flexion and forearm pronation while the patient's elbow is in extension reproduces symptoms.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Valgus stress of the elbow reproduces the symptoms.
Differentiating Tests
- MRI and CT arthrography are both 100% sensitive for diagnosing complete tears.
Differentiating Signs/Symptoms
- May be confused with olecranon bursitis.
- Flexion at the elbow may reproduce or exacerbate symptoms. May have tenderness over the ulnar nerve posterior to the medial epicondyle. Tinel sign is often positive in this location.
Differentiating Tests
- X-ray of elbow: can detect osteophytes in the cubital tunnel.
- EMG may help to localize the lesion.
Differentiating Signs/Symptoms
- Lateral pivot shift test evaluates the lateral collateral ligament complex. Patient lies down and arm is internally rotated and supinated; the elbow is flexed as axial and valgus pressure is applied. Very uncomfortable in an awake patient.
Differentiating Tests
- X-ray elbow: may show fractures, loose bodies, or osteochondritis dessicans.
- MRI may reveal injury to the lateral collateral ligament complex.
Criteria
- Pain at the extremes of rotation, abduction, or adduction
- Pain of contraction of the hip abductors against resistance
- Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh.
Treatment Approach
Conservative management
Corticosteroid injections
Surgery
Treatment of septic bursitis
Treatment Options
nonseptic bursitis
conservative management and analgesia
Primary Options
- acetaminophen
325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
- acetaminophen
Secondary Options
- diclofenac topical
apply to the affected area(s) up to four times daily when required
- diclofenac topical
Tertiary Options
- ibuprofen
200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
- ibuprofen
- diclofenac potassium
50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
- diclofenac potassium
Comments
- Conservative management involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
- Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
- Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen. In patients with olecranon bursitis there is a risk of recurrence. Because treatments like aspiration and aspiration with steroid injection can cause complications, compression bandaging and a short course of NSAIDs may offer the most appropriate balance of safety and efficacy.[16]
corticosteroid injection
Primary Options
- methylprednisolone acetate
40 mg injected into bursa as a single dose every 1-5 weeks when required
and
- lidocaine
10 mg injected into bursa as a single dose every 1-5 weeks when required
- methylprednisolone acetate
Comments
- Corticosteroid injection is reserved for patients who have not settled with conservative management. This is a high-risk procedure in retrocalcaneal bursitis due to the risk of tendon rupture. In 36 women with trochanteric bursitis, an excellent response was reported in two-thirds and improvement was reported in the remaining third.[12] Injectable corticosteroid may be combined with local anesthetic for additional benefit, and the 2 agents may be mixed in the same syringe.
surgery
Comments
- Surgery to remove the affected bursa is reserved for those cases refractory to conservative management. This may be undertaken in combination with another procedure such as subacromial decompression or resection of Haglund deformity. This may be an open procedure or an endoscopic procedure.Image
septic bursitis
antibiotic therapy and aspiration of the bursa
Primary Options
- dicloxacillin
125-250 mg orally every 6 hours
- dicloxacillin
- cefazolin
500-1500 mg intravenously/intramuscularly every 6-8 hours
- cefazolin
- oxacillin
500-1000 mg intravenously/intramuscularly every 6-8 hours
- oxacillin
Secondary Options
- clarithromycin
500 mg orally every 12 hours
- clarithromycin
- erythromycin lactobionate
500 mg intravenously every 12 hours
- erythromycin lactobionate
Tertiary Options
- vancomycin
1 g intravenously every 12 hours
- vancomycin
Comments
- Aspiration of the bursa provides fluid for culture to direct antimicrobial therapy and reduces the bacterial load. Repeat aspiration may be required.
- Initial antimicrobial therapy should cover staphylococci and streptococci.
- Cefazolin or penicillinase-resistant penicillin, such as oxacillin, is appropriate for the initial management in most patients. Gram staining and culture from bursal fluid aspirate will direct specific antibiotic therapy.[14]
- Duration of antibiotics is patient and region dependent and can be from 1 to 4 weeks.
- Oral antibiotics are usually sufficient for a systemically well patient. If patient is systemically unwell, immunosuppressed, or requiring surgery for drainage, intravenous therapy would be recommended initially. If patient is allergic to penicillin, erythromycin and clarithromycin are oral alternatives with a similar spectrum of activity, although some bacterial species may be resistant. In the case of resistance, inpatient treatment with intravenous vancomycin is recommended. Vancomycin is the preferred antibiotic for confirmed MRSA septic bursitis.
conservative management and analgesia
Primary Options
- acetaminophen
325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
- acetaminophen
Secondary Options
- diclofenac topical
apply to the affected area(s) up to four times daily when required
- diclofenac topical
Tertiary Options
- ibuprofen
200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
- ibuprofen
- diclofenac potassium
50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
- diclofenac potassium
Comments
- Supportive management with activity modification and analgesia is offered alongside antibiotic therapy and following aspiration. This involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
- Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
- Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen.
surgical debridement and lavage
Comments
- May be required if needle aspiration has not adequately drained the bursa, if an abscess is present, or if a sinus has formed. The aim is to drain the bursa and reduce the bacterial load.
antibiotic therapy
Primary Options
- dicloxacillin
125-250 mg orally every 6 hours
- dicloxacillin
- cefazolin
500-1500 mg intravenously/intramuscularly every 6-8 hours
- cefazolin
- oxacillin
500-1000 mg intravenously/intramuscularly every 6-8 hours
- oxacillin
Secondary Options
- clarithromycin
500 mg orally every 12 hours
- clarithromycin
- erythromycin lactobionate
500 mg intravenously every 12 hours
- erythromycin lactobionate
Tertiary Options
- vancomycin
1 g intravenously every 12 hours
- vancomycin
Comments
- Initial antimicrobial therapy should cover staphylococci and streptococci.
- Cefazolin or penicillinase-resistant penicillin, such as oxacillin, is appropriate for the initial management in most patients. Gram staining and culture from bursal fluid aspirate will direct specific antibiotic therapy.[14]
- Duration of antibiotics is patient and region dependent and can be from 1 to 4 weeks.
- Oral antibiotics are usually sufficient for a systemically well patient. If patient is systemically unwell, immunosuppressed, or requiring surgery for drainage, intravenous therapy would be recommended initially. If patient is allergic to penicillin, erythromycin and clarithromycin are oral alternatives with a similar spectrum of activity, although some bacterial species may be resistant. In the case of resistance, inpatient treatment with intravenous vancomycin is recommended. Vancomycin is the preferred antibiotic for confirmed MRSA septic bursitis.
conservative management and analgesia
Primary Options
- acetaminophen
325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
- acetaminophen
Secondary Options
- diclofenac topical
apply to the affected area(s) up to four times daily when required
- diclofenac topical
Tertiary Options
- ibuprofen
200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
- ibuprofen
- diclofenac potassium
50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
- diclofenac potassium
Comments
- Conservative management involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
- Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
- Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen.
Emerging Tx
Extracorporeal shock wave therapy
Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007 Apr;13(2):63-5.[Abstract]
Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: trochanteric bursitis. J Clin Rheumatol. 2004 Jun;10(3):123-4.[Abstract]
Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology. Part I: subacromial impingement syndrome. J Clin Rheumatol. 2003 Jun;9(3):193-199.[Abstract]
1. Kozlov DB, Sonin AH. Iliopsoas bursitis: diagnosis by MRI. J Comput Assist Tomogr. 1998 Jul-Aug;22(4):625-628.[Abstract]
2. Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. 2005 Mar;55(512):199-204.[Abstract][Full Text]
3. Gomez-Rodriguez N, Mendez-Garcia MJ, Ferreiro-Seoane JL, et al. Infectious bursitis: study of 40 cases in the pre-patellar and olecranon regions [in Spanish]. Enferm Infec Microbiol Clin. 1997 May;15(5):237-42.[Abstract]
4. Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007 Apr;13(2):63-5.[Abstract]
5. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: trochanteric bursitis. J Clin Rheumatol. 2004 Jun;10(3):123-4.[Abstract]
6. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology IV: anserine bursitis. J Clin Rheumatol. 2004 Aug;10(4):205-6.[Abstract]
7. Silva F, Adams T, Feinstein J, et al. Trochanteric bursitis: refuting the myth of inflammation. J Clin Rheumatol. 2008 Apr;14(2):82-86.[Abstract]
8. Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med. 2006 May;73(5):465-71.[Abstract]
9. Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician. 2002 May 1;65(9):1805-11.[Abstract][Full Text]
10. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology. Part I: subacromial impingement syndrome. J Clin Rheumatol. 2003 Jun;9(3):193-199.[Abstract]
11. Longo UG, Franceschi F, Ruzzini L, et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med. 2008 Mar;36(3):533-38.[Abstract]
12. Ege Rasmussen KJ, Fano N. Trochanteric bursitis: treatment by corticosteroid injection. Scand J Rheumatol. 1985;14(4):417-20.[Abstract]
13. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomized, controlled trial. J Bone Joint Surg Am. 2008 Jan;90(1):52-61.[Abstract]
14. Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005 Dec;19(4):991-1005.[Abstract]
15. Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part II: laxity, instability, and superior labral anterior and posterior (SLAP) lesions. Am J Sports Med. 2003 Mar-Apr;31(2):301-7.[Abstract]
16. Kim JY, Chung SW, Kim JH, et al. A randomized trial among compression plus nonsteroidal antiinflammatory drugs, aspiration, and aspiration with steroid injection for nonseptic olecranon bursitis. Clin Orthop Relat Res. 2016 Mar;474(3):776-83.[Abstract][Full Text]
17. Koester MC, Dunn WR, Kuhn JE, et al. The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: a systematic review. J Am Acad Orthop Surg. 2007 Jan;15(1):3-11.[Abstract]
18. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016.[Abstract][Full Text]
19. Smith DL, McAfee JH, Lucas LM, et al. Treatment of nonseptic olecranon bursitis: a controlled, blinded prospective trial. Arch Intern Med. 1989 Nov;149(11):2527-30.[Abstract]
20. Shbeeb MI, O'Duffy JD, Michet CJ, et al. Evaluation of glucocorticoid injection for the treatment of trochanteric bursitis. J Rheumatol. 1996 Dec;23(12):2104-06.[Abstract]
21. Kelly BT, Williams RJ 3rd, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med. 2003 Nov-Dec;31(6):1020-37.[Abstract]
22. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011 Sep;21(5):447-53.[Abstract]
23. Krishna Sayana M, Maffulli N. Insertional Achilles tendinopathy. Foot Ankle Clin. 2005 Jun;10(2):309-320.[Abstract]
24. Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012 Feb;28(2):283-93.[Abstract]
25. McAfee JH, Smith DL. Olecranon and prepatellar bursitis: diagnosis and treatment. West J Med. 1988 Nov;149(5):607-10.[Abstract][Full Text]
26. Rompe JD, Furia J, Weil L, et al. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull. 2007;81-82:183-208. [Abstract][Full Text]