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Bursitis

by Joseph J. Biundo, MD

Bursitis is acute or chronic inflammation of a bursa. The cause is usually unknown, but trauma, repetitive or acute, may contribute, as may infection and crystal-induced disease. Symptoms include pain (particularly with motion or pressure), swelling, and tenderness. Diagnosis is usually clinical; however, ultrasonography may be needed to evaluate deep bursae. Diagnosis of infection and crystal-induced disease requires analysis of bursal fluid. Treatment includes splinting, NSAIDs, sometimes corticosteroid injections, and treatment of the underlying cause.

Bursae are fluid-filled sac-like cavities or potential cavities that are located where friction occurs (eg, where tendons or muscles pass over bony prominences). Bursae minimize friction between moving parts and facilitate movement. Some communicate with joints.

Bursitis may occur in the shoulder (subacromial or subdeltoid bursitis), particularly in patients with rotator cuff tendinitis, which is usually the primary lesion in the shoulder. Other commonly affected bursae include olecranon (miner's or barfly’s elbow), prepatellar (housemaid’s knee), suprapatellar, retrocalcaneal, iliopectineal (iliopsoas), ischial (tailor’s or weaver’s bottom), greater trochanteric, pes anserine, and first metatarsal head (bunion) bursae. Occasionally, bursitis causes inflammation in a communicating joint.

Etiology

Bursitis may be caused by the following:

  • Injury

  • Chronic overuse

  • Inflammatory arthritis (eg, gout, RA)

  • Acute or chronic infection (eg, pyogenic organisms, particularly Staphylococcus aureus)

Idiopathic and traumatic causes are by far the most common. Acute bursitis may follow unusual exercise or strain and usually causes bursal effusion. The olecranon and prepatellar bursae are the bursas most often infected.

Chronic bursitis may develop after previous attacks of bursitis or repeated trauma. The bursal wall is thickened, with proliferation of its synovial lining; bursal adhesions, villus formation, tags, and chalky deposits may develop.

Symptoms and Signs

Acute bursitis causes pain, particularly when the bursa is compressed or stretched during motion. Swelling, sometimes with other signs of inflammation, is common if the bursa is superficial (eg, prepatellar, olecranon). Swelling may be more prominent than pain in olecranon bursitis. Crystal- or bacterial-induced bursitis is usually accompanied by erythema, pitting edema, pain, and warmth in the area over the bursa.

Chronic bursitis may last for several months and may recur frequently. Bouts may last a few days to several weeks. If inflammation persists near a joint, the joint’s range of motion may be limited. Prolonged limitation of motion may lead to muscle atrophy.

Diagnosis

  • Clinical evaluation

  • Ultrasonography or MRI for deep bursitis

  • Aspiration for suspected infection or crystal-induced bursitis

Superficial bursitis should be suspected in patients with swelling or signs of inflammation over bursae. Deep bursitis is suspected in patients with unexplained pain worsened by motion in a location compatible with bursitis. Usually, bursitis can be diagnosed clinically. Ultrasonography or MRI can help confirm the diagnosis when deep bursae are not readily accessible for inspection, palpation, or aspiration. These tests are done to confirm a suspected diagnosis or exclude other possibilities. These imaging techniques increase the accuracy of identifying the involved structures.

If bursal swelling is particularly painful, red, or warm or if the olecranon or prepatellar bursa is affected, infection and crystal-induced disease should be excluded by bursal aspiration. After a local anesthetic is injected, fluid is withdrawn from the bursa using sterile techniques; analysis includes cell count, Gram stain and culture, and microscopic search for crystals. Gram stain, although helpful, may not be specific, and WBC counts in infected bursae are usually lower than those in septic joints. Urate crystals are easily seen with polarized light, but the apatite crystals typical of calcific tendinitis appear only as shiny chunks that are not birefringent. X-rays should be taken if bursitis is persistent or if calcification is suspected.

Acute bursitis should be distinguished from hemorrhage into a bursa, which should be considered particularly when a patient taking warfarin develops acute bursitis. Hemorrhagic bursitis can cause similar manifestations because blood is inflammatory. Fluid in traumatic bursitis is serosanguinous. Cellulitis can cause signs of inflammation but does not normally cause bursal effusion; cellulitis overlying the bursa is a relative contraindication to bursal puncture through the cellulitis, but if septic bursitis is strongly suspected, aspiration must occasionally be done.

Treatment

  • Rest

  • High-dose NSAIDs

  • Treatment of crystal-induced disease or infection

Crystal-induced disease (see Crystal-Induced Arthritides) or infection should be treated if present. For infection, choice of antibiotic is determined by results of Gram stain and culture. Empiric antibiotics effective against S. aureus should be given. Infectious bursitis requires drainage or excision in addition to antibiotics.

Acute nonseptic bursitis is treated with temporary rest or immobilization and high-dose NSAIDs and sometimes with other analgesics. Voluntary movement should be increased as pain subsides. Pendulum exercises are helpful for the shoulder joint.

If oral drugs and rest are inadequate, aspiration and intrabursal injection of depot corticosteroids 0.5 to 1 mL (eg, triamcinolone acetonide 40 mg/mL) are the treatment of choice. About 1 mL of local anesthetic (eg, 2% lidocaine) can be injected before the corticosteroid injection. The same needle is used; it is kept in place and the syringes are changed. Dose and volume of the corticosteroid may vary according to the size of the bursa. Infrequently, a flare-up occurs within several hours of injection of a depot corticosteroid; the flare-up is probably a synovitis in reaction to crystals in the injection. It usually lasts 24 h and responds to cold compresses plus analgesics. Oral corticosteroids (eg, prednisone) can be used to treat the primary problem if a local injection is not feasible.

Chronic bursitis is treated the same as acute bursitis, except that splinting and rest are less likely to help, and range-of-motion exercises are especially important. Rarely, the bursa needs to be excised.

Key Points

  • The usual causes of bursitis are injury and overuse, but infection and crystal-induced disease are possible.

  • Withdraw bursal fluid to diagnose bacterial or crystal-induced bursitis when the olecranon or prepatellar bursa is affected or when there is warmth, redness, tenderness, and pitting edema.

  • Treat most cases with rest, high-dose NSAIDs, and sometimes intrabursal corticosteroid injection.

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  • COUMADIN
  • XYLOCAINE
  • KENALOG
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