Bursitis

Candice Reyes Yuvienco, M.D., RH.M.S.U.S.

Basic Information

Definition

Bursitis is an inflammation or reaction of a bursa, which is a thin-walled, synovial-lined sac. Bursae function as cushions to reduce friction while also facilitating movement of tendons and muscles over bony prominences. Olecranon bursitis and prepatellar bursitis are the most common, usually due to chronic microtrauma from repetitive pressure or activity.

Synonyms

Student’s elbow, miner’s elbow, draftsman’s elbow (olecranon bursitis)
Housemaid’s knee, carpet-layer’s knee (prepatellar bursitis)
Weaver’s bottom (ischial gluteal bursitis)
Baker’s cyst (gastrocnemius-semimembranosus bursa)
Pump bumps (subcutaneous calcaneal bursitis)
Pes anserine bursitis (goose’s foot, insertion of conjoined tendon into medial knee)

ICD-10CM CODES
M75.80	Other shoulder lesions, unspecified shoulder
M70.20	Olecranon bursitis, unspecified elbow
M70.60	Trochanteric bursitis, unspecified hip
M70.70	Other bursitis of hip, unspecified hip
M76.899	Other specified enthesopathies of unspecified lower limb, excluding foot
M70.40	Prepatellar bursitis, unspecified knee
M71.20	Synovial cyst of popliteal space [Baker], unspecified knee
M77.50	Other enthesopathy of unspecified foot

Physical Findings & Clinical Presentation

Local swelling, tenderness, erythema, warmth over the site of bursa
Pain with active joint movement or on compression at rest
Range of motion may be markedly limited in septic arthritis, whereas ROM is relatively preserved in nonseptic bursitis
Subacromial/subdeltoid bursitis and trochanteric bursitis may also be found in polymyalgia rheumatica (PMR), thus can present with symptoms of PMR

Etiology

Acute traumatic
Chronic microtrauma from repetitive activity or pressure
Infection (septic bursitis)—spread from contiguous skin or soft tissue infection (Staphylococcus aureus causative in >80%)
Crystal diseases (e.g., gout, pseudogout)
Systemic inflammatory arthritis, particularly rheumatoid arthritis
Bleeding (from diathesis, anticoagulation, or trauma)

Diagnosis

Differential Diagnosis

Acute monoarthritis caused by septic arthritis or crystal arthritis (gout, pseudogout)
Tendinitis, tenosynovitis
Cellulitis

Workup

Bursal fluid aspiration: send for Gram stain, culture and sensitivity, cell count, and crystal analysis

Imaging Studies

Plain radiography can rule out foreign body penetration and other bone or joint problems such as fracture (Fig. E1)

FIG.E1

A, Bursae around the knee. B, Markedly swollen prepatellar bursa.

From Scudieri G, [ed]: Sports medicine principles of primary care, St Louis, 1997, Mosby.
MRI to define soft tissue involvement
Musculoskeletal ultrasound to visualize superficial and deep bursae; assess inflammatory activity with Doppler and directly guide aspiration/injection

Treatment

Nonpharmacologic Therapy

Avoid direct pressure or repetitive irritation
Joint protection (e.g., kneeling pads, compression wraps)
Rest, ice, elevation for acute phase
Physical therapy
Activity modification

Acute General Rx

Septic:
1. Appropriate antibiotic coverage and drainage. If MSSA, use nafcillin or oxacillin 2 g IV q4h or dicloxacillin 500 mg PO qid. If MRSA, use vancomycin 15 to 20 mg/kg IV q8-12h or linezolid 600 mg PO bid.
2. Serial aspirations of purulent fluid or surgical drainage may be indicated.
Nonseptic:
1. Aspiration of bursal fluid or blood from acute trauma
2. Nonpharmacologic therapy
3. Traumatic bursitis may respond well to aspiration and corticosteroid injection
4. Inflammatory arthritis such as gout or RA: treat underlying condition with specific therapies and with systemic antiinflammatory medications for active disease; can consider intrabursal injection of steroids

Chronic Rx

Aspiration and drainage of fluid can provide symptomatic improvement if large fluid collection, followed by compression dressing to prevent fluid reaccumulation
Steroid injection into nonseptic bursa if inflammatory, recurrent, or persistently symptomatic (40 mg triamcinolone mixed with 1 to 3 ml lidocaine, depending on size of bursa)
Oral NSAIDs, over-the-counter analgesics

Disposition

Conservative nonsurgical treatment is effective in most cases. Surgical drainage may be indicated for loculated bursitis or if septic. Recurrent bursitis affecting function may require open or endoscopic bursectomy.

Referral

Orthopedic consultation may be needed as part of treatment of septic bursitis, particularly if nonresponsive to appropriate antibiotic therapy, for bursectomy in those with significantly enlarged bursa, or for persistent or recurrent bursitis that interferes with daily function.

Pearls & Considerations

Bursae in patients with RA are not usually the sole site of active flare. Therefore, in patients with RA, acute bursitis should be considered septic bursitis until proven otherwise.

Comments

Scapulothoracic bursitis is under-recognized and undertreated. It results from friction between superomedial angle of scapula and adjacent second and third ribs. Crepitus, snapping, and tenderness are suggestive findings; it can also cause chest wall pain.
Do not incise and drain sterile bursae because chronic draining sinus tract may develop and risk iatrogenic septic bursitis.
In bursitis caused by infectious or systemic inflammatory disorders, the leukocytosis in bursal fluid may be substantially less intense than the elevations in the joint fluid.
Investigate crystal-induced bursitis for underlying metabolic or hematologic diseases (hemochromatosis, hyperparathyroidism [calcium pyrophosphate deposition disease]), and for hyperuricemia (gout).

Ferri – Bursitis