AUTHOR AND EDITOR INFORMATION

Section 1 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

INTRODUCTION

Section 2 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

Bursae are saclike structures between skin and bone or between tendons, ligaments, and bone. They are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures. Bursitis occurs when the synovial lining becomes thickened and produces excessive fluid, leading to localized swelling and pain.^{1, 2, 3}

(Also see the eMedicine Emergency Medicine article Bursitis and the Medscape article Greater Trochanteric Bursitis.)

Problem

Bursitis is defined as inflammation of a bursa. A bursa is a lubricating sac of synovial fluid that minimizes friction between moving parts of an extremity. Most people have approximately 160 bursae in the body.

In bursitis, a bursa, which is not normally palpable, becomes swollen, tender, and painful. Pain is aggravated by movement of the specific joint, tendon, or both.

There are three stages of bursitis: acute, recurrent, and chronic.⁴ During the acute phase of bursitis, local inflammation occurs and the synovial fluid is thickened, which results in painful movement. Chronic bursitis leads to continual pain and can cause weakening of overlying ligaments and tendons and, ultimately, rupture of the tendons. Because of the possible adverse effects of chronic bursitis on overlying structures, bursitis and tendinitis may occur together; the differential diagnosis should include both of these diagnoses.

Frequency

Bursitis accounts for 0.4% of all visits to primary care clinics. The incidence of bursitis is higher in athletes, with an incidence of up to 10% in runners.

The most common locations of bursitis are the subdeltoid, olecranon, ischial, trochanteric, and prepatellar bursae. Approximately 85% of cases of septic superficial bursitis occur in men.

Etiology

Bursitis has many causes, such as autoimmune disorders, crystal deposition (gout or pseudogout), infectious diseases, traumatic events, and hemorrhagic disorders, as well as being secondary to overuse. Repetitive injury within the bursa results in local vasodilatation and increased vascular permeability, which stimulate the inflammatory cascade.

Systemic diseases such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic pulmonary osteoarthropathy, and idiopathic hypereosinophilic syndrome have also been associated with bursitis.

In addition, bursitis and other soft-tissue disorders have been associated with generalized hypermobility. Some rheumatic conditions, such as gout, can predispose patients to bursitis.

Infectious bursitis is most common in superficial bursae. Staphylococcus aureus is the most common causative organism and is present in 80% of cases of septic bursitis. However, many other organisms have been implicated in septic bursitis, including bacterial, mycobacterial, and fungal microbes. Factors predisposing individuals to infection include diabetes mellitus, steroid therapy, uremia, alcoholism, and trauma. Septic bursitis most commonly occurs secondary to traumatic injury or cellulitis in overlying skin.

Pathophysiology

Varying degrees of local inflammation occur in bursitis. The synovial cells increase in thickness and may undergo villous hyperplasia. Granulation tissue and fibrous tissue may form. The bursa becomes filled with fluid, which is often rich in fibrin, and the fluid can become hemorrhagic.

Clinical

Patients with bursitis have a history of pain with motion and at rest; swelling; and, often, decreased range of motion of the affected joint.

On physical examination, patients have tenderness at the site of the inflamed bursa. If the bursa is superficial, physical examination findings are significant for localized tenderness, warmth, edema, and erythema of the skin. Joint motion is preserved in septic bursitis; other types of bursitis are associated with limited range of motion. Reduced active range of motion with preserved passive range of motion is suggestive of bursitis, but the differential diagnosis includes tendinitis and muscle injury. A decrease in both active and passive range of motion is more suggestive of other musculoskeletal disorders.

Patients with septic bursitis may have fever, bursal warmth, tenderness that is more severe than in nonseptic bursitis, and associated cellulitis.

In patients with chronic bursitis, the affected limb may show disuse atrophy and weakness. Tendons may also be weakened and tender.

INDICATIONS

Section 3 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

Surgery is not required in most cases of bursitis. Surgical procedures that can be used to treat chronic bursitis, which is refractory to more conservative treatment, are aspiration, incision and drainage, excision of chronically inflamed bursae, and removal of underlying bony prominences.

RELEVANT ANATOMY

Section 4 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

There are 2 types of bursae: constant and adventitial. Both types can be involved in acute or chronic bursitis.

• Constant bursae
  • Form during embryologic development
  • Lined with endothelial cells
  • Located between tendon and bone or skin
  • Contain synovial cells that secrete a lubricating fluid rich in collagen and proteoglycans
• Adventitial bursae
  • Form later in life in response to repeated trauma or constant friction and pressure
  • Lack endothelial cells
  • Do not contain synovial fluid
  • Examples include those that develop over a bunion and osteochondroma

Upper-Extremity Bursae

There are approximately 160 bursae in the human body, all of which can become injured. Three upper-extremity bursae most commonly affected are the subacromial, subscapular, and olecranon bursae.⁵

Subacromial bursitis

The subacromial bursa is a synovial-lined sac that separates the superior surface of the supraspinatus tendon from the overlying coracoacromial arch and the deltoid muscle. This bursa facilitates movement of the supraspinatus tendon and becomes inflamed secondary to repetitive overuse injury of the supraspinatus tendon. Subacromial bursitis is often coexistent with supraspinatus tendinitis and partial- or complete-thickness tears of the supraspinatus tendon.⁶

Subscapular bursitis

Subscapular bursae are found between the anterior surface of the scapula and the posterior chest wall. The 2 commonly affected bursae are located superomedially between the serratus anterior muscle and the chest wall. These bursae become inflamed as a result of abnormal bony structures or soft-tissue changes that affect the movement of the scapula over the posterior chest wall.

Olecranon bursitis

There are 2 olecranon bursae that can become inflamed: one lies between the tendon of the triceps muscle and the posterior ligament of the elbow and the olecranon; the other is more superficial, lying between the attachment of the triceps to the olecranon and the skin. The more superficial bursa is predisposed to direct trauma or cumulative microtrauma from activities requiring frequent elbow motion (eg, swimming, skiing, gymnastics, weight lifting). This type of bursitis is often recurrent.⁷

Lower-Extremity Bursae

Several lower-extremity bursae can also be affected; the most common ones are in the hip, the knee, and the ankle.^{8, 9, 10}

Ischiogluteal bursitis

The ischiogluteal bursa lies deep to the gluteus maximus over the ischial tuberosity. Inflammation of this bursa is associated with sedentary occupations and is caused by direct stress on the bursa, giving it the nickname weaver's bottom. Patients have pain with sitting and walking and have localized tenderness over the ischial tuberosity. Physical examination is often significant for pain with passive hip flexion and resisted hip extension.

Greater trochanter bursitis

There are up to 3 bursae associated with the greater trochanter. Bursitis of the greater trochanter is common in overweight, middle-aged women, and it is associated with acute trauma, overuse, and mechanical factors. The clinical presentation is of deep, aching lateral hip pain that may radiate into the buttocks or lateral knee. Pain is worse with activity and stretching and may be worse at night. Patients have severe tenderness to palpation over the greater trochanter. On physical examination, pain also occurs with resisted hip abduction and external rotation.^{11, 12}

Bursitis of the knee

The knee has 11 associated bursae, of which 4 are commonly involved: medial collateral ligament bursa, the pes anserine, prepatellar, and Baker's cyst (popliteal bursitis).⁹

• Medial collateral ligament bursitis

  The medial collateral ligament bursa is most commonly injured secondary to a twisting injury with external tibial rotation. Medial joint line pain occurs and may limit knee extension. This may be confused with a meniscal tear on physical examination.

• Pes anserine bursitis

  Pes anserine bursitis occurs behind the medial hamstring, under the insertion site of the sartorius, gracilis, and semitendinous muscles on the medial flare of the tibia just below the tibial plateau. This condition is not usually associated with overuse but may occur in patients with medial compartmental osteoarthritis. Clinically, patients complain of pain and tenderness over the anteromedial knee that is worse with knee flexion. This condition may be confused with medial meniscal pathology.^{13, 14}

• Prepatellar bursitis

  Prepatellar bursitis, also known as housemaid's knee, occurs anteriorly over the patella. It is associated with trauma or with chronic, repetitive kneeling. This bursa is also a common site for septic bursitis, and this diagnosis should be considered when there is skin injury, erythema, warmth, or severe tenderness over the patella. In patients with septic prepatellar bursitis, the patella is not palpable and knee flexion is painful.

• Baker's cyst (popliteal bursitis)

  Popliteal bursae, or Baker's cysts, occur in the posterior joint capsule of the knee, with associated local swelling and pain with walking, jumping, and squatting. MRI or ultrasound can differentiate an isolated bursitis from intra-articular injury (also see the eMedicine Radiology article Baker Cyst).

Retrocalcaneal bursitis

The most commonly inflamed bursa in the ankle is the retrocalcaneal bursa, which is anterior to the Achilles tendon and posterior to the calcaneus. Bursitis in this region is commonly caused by local trauma associated with poorly designed shoes. Patients complain of posterolateral heel pain and may have a posterior heel prominence, often called a "pump bump," as well as local swelling and tenderness over the Achilles tendon. Pain is increased by squeezing the bursa from side to side and anterior to the Achilles. A heel lift and open-back shoes help alleviate pressure.

WORKUP

Section 5 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

Lab Studies

• Erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor (RF)
• • The ESR, ANA, and RF tests should all be ordered in cases in which autoimmune disease is suspected, because these inflammatory disorders can trigger bursitis.
• Fluid analysis
• • The joint should be aspirated and fluid sent for analysis to rule out infectious or rheumatic causes. Bursal fluid should be drawn for uric acid crystal determination, cell count with differential, Gram stain, and culture. Nonseptic bursitis has cell counts less than 2000, with a predominance of mononuclear cells. Septic bursitis has cell counts greater than 70,000, with a predominance of polymorphonuclear cells. Gram stain and culture are done to identify any pathogens.

Imaging Studies

• Radiographs
• • Plain radiographs may be useful in identifying osteophytes or other underlying bony pathology that may be triggering the bursal inflammation. They may also show joint effusions.
• Bone scan
• • Bone scan is not a sensitive test of bursitis, but it may be done in cases in which the diagnosis is unclear, to rule out other causes of pain.
• MRI and CT scan
• • MRI and CT are usually not necessary because of the common clinical presentation of bursitis. MRI is useful to delineate the anatomy of the entire joint and is a very sensitive test for identification of bursitis. MRI is also helpful in ruling out suspected solid tumors and defining pathology for possible surgical excision.
• Ultrasonography
• • Ultrasonography is a useful modality to obtain further imaging of the bursa when the diagnosis is uncertain, and it is often used to obtain images of popliteal cysts. These bursae are often discovered incidentally when lower-extremity Doppler studies are done to rule out deep vein thrombosis. Ultrasound studies distinguish solid from cystic masses and are helpful in detecting Baker's cysts (popliteal bursitis) when there are extensive joint deformities.^{7, 15}

TREATMENT

Section 6 of 7  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

Medical therapy

The PRICEMM eponym can be used for pain control. Patients should let pain be their guide with regard to activities.

• Protect - with padding, braces, changes in technique
• Rest - avoid activities that exacerbate pain
• Ice - cryotherapy can relieve pain and decrease inflammation
• Compression - elastic dressings can ease pain, as in olecranon bursitis
• Elevation - raise affected limb above level of heart
• Modalities - electrical stimulation, ultrasound, phonophoresis
• Medications - nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, corticosteroid injection

Corticosteroid injection can be helpful if the patient does not respond to other treatment. A 1.5- to 4-inch 20-gauge spinal needle may be used as a probe to determine the points of maximal tenderness in the affected bursa. A mix of corticosteroid and local anesthetic is injected into each tender site. An injection of 20 mg or less of corticosteroid should be used per lesion, and no more than a total of 40 mg of corticosteroid should be used.^{6, 11, 16}

In cases in which septic bursitis is suspected, the bursa should be aspirated. The skin over the bursa is sterilized, and the area is anesthetized with lidocaine using a 27-gauge needle. A 20- or 22-gauge needle is then introduced sterilely into the bursa. Fluid is aspirated and sent for analysis to look for an infectious organism or crystals.

If bursitis is found to be secondary to infection following aspiration and fluid analysis, treatment should be initiated with antibiotics. Outpatient treatment is effective in 40-50% of patients with mild to moderate infections. A 4-week course is advisable using high doses of sensitivity-directed antibiotics. In more severe cases, hospitalization is required with 1 week of parenteral antibiotics followed by 30 days of oral antibiotics.

Surgical therapy

In general, bursitis is not treated surgically. However, surgical release may be indicated when adhesive bursitis develops, severely limiting joint motion. During surgery, the adhered bursa is removed and the contiguous tissues are released.^{17, 18}

In the upper extremity, subscapular bursitis can be caused by bony exostoses, and surgery may be needed to reduce these structures. In addition, the association of subacromial bursitis with rotator cuff impingement and tears is high, and surgical repair of the tear may be indicated.

In the lower extremity, Baker's cysts (popliteal bursitis) are often removed surgically. Before open excision, arthroscopy should be performed to evaluate for intra-articular conditions. Most cysts are approached posteromedially through a hockey-stick incision.

Follow-up

Most patients respond well to conservative management. Patients who do not respond to nonoperative treatment or who have signs of tendinous or ligamentous injury require further evaluation.

REFERENCES

Section 7 of 7

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Workup
• Treatment
• References

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2. DeLee JC, Drez D. Imaging effusions, cysts, and ganglia. In: DeLee JC, Drez D, Miller MD, eds. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, Pa: WB Saunders;. 2003: 1646-8.
3. Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention. 3rd ed. Baltimore, Md: Williams and Wilkins;. 1996.
4. Reilly JP, Nicholas JA. The chronically inflamed bursa. Clin Sports Med. Apr 1987;6(2):345-70. [Medline].
5. Salzman KL, Lillegard WA, Butcher JD. Upper extremity bursitis. Am Fam Physician. Nov 1 1997;56(7):1797-806, 1811-2. [Medline].
6. Chen MJ, Lew HL, Hsu TC, Tsai WC, Lin WC, Tang SF. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil. Jan 2006;85(1):31-5. [Medline].
7. Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. Dec 2006;27(6):568-71. [Medline].
8. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. May 15 1996;53(7):2317-24. [Medline].
9. Keplinger FS, Gupta N. Knee bursitis. In: Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. Philadelphia, Pa: Hanley & Belfus;2002: 340-4.
10. McAfee JH, Smith DL. Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med. Nov 1988;149(5):607-10. [Medline].
11. Brinks A, van Rijn RM, Bohnen AM, Slee GL, Verhaar JA, Koes BW. Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice. BMC Musculoskelet Disord. Sep 19 2007;8(1):95. [Medline].
12. Alvarez-Nemegyei J, Canoso JJ. Evidence-Based Soft Tissue Rheumatology: III: Trochanteric Bursitis. J Clin Rheumatol. Jun 2004;10(3):123-124. [Medline].
13. Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. Apr 2007;13(2):63-5. [Medline].
14. Alvarez-Nemegyei J, Canoso JJ. Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis. J Clin Rheumatol. Aug 2004;10(4):205-206. [Medline].
15. Tsai YH, Huang TJ, Hsu WH, Huang KC, Li YY, Peng KT. Detection of subacromial bursa thickening by sonography in shoulder impingement syndrome. Chang Gung Med J. Mar-Apr 2007;30(2):135-41. [Medline].
16. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006;(4):CD006189. [Medline].
17. Baker CL Jr, Massie RV, Hurt WG, Savory CG. Arthroscopic bursectomy for recalcitrant trochanteric bursitis. Arthroscopy. Aug 2007;23(8):827-32. [Medline].
18. Baums MH, Spahn G, Nozaki M, Steckel H, Schultz W, Klinger HM. Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis. Knee Surg Sports Traumatol Arthrosc. May 2007;15(5):638-44. [Medline].

Article Last Updated: Oct 30, 2007