para>Bursitis is less common in children. á
EPIDEMIOLOGY
Predominant age á
- 15 to 50 years (most common in skeletally mature)
- Traumatic bursitis is more likely in patients <35 years of age.
Incidence
- Bursitis: 32/1,000 per year (1)
- Approximately 1 in 31; 3.2% or 8.7 million people in the United States impacted annually (1)
- Trochanteric pain: 1.8/1,000 per year
ETIOLOGY AND PATHOPHYSIOLOGY
- Trauma: acute or chronic
- Repetitive movement: Upper extremity bursitis, in particular, is usually the result of repetitive microtrauma.
- Infections: most commonly Staphylococcus aureus
- Systemic disease: rheumatoid disease, tuberculosis, pancreatitis, lupus
- Crystal deposition: gout and pseudogout
RISK FACTORS
- Individuals who engage in repetitive motion and/or vigorous training
- Prolonged pressure on particular bursae (e.g., "clergyman's knee"Ł and "student's elbow"Ł)
- Sudden increase in level of activity
- Leg length discrepancy and Trendelenburg gait increase risk for trochanteric bursitis.
- Anabolic steroid use increases risk of bursitis due to increased training, estrogen suppression causing increased inflammation, and muscle stiffness.
GENERAL PREVENTION
- Appropriate warmup and cool-down maneuvers
- Frequent breaks between repetitive activities
- Use of protective gear (e.g., knee and elbow pads)
- Maintain fitness and general health.
COMMONLY ASSOCIATED CONDITIONS
- Tendinitis
- Sprains, strains
- Associated stress fractures
- Muscular tightness and physical deconditioning
DIAGNOSIS
HISTORY
- Pain in the affected region, usually gradual in onset; can be rapid if due to trauma
- Decreased ROM or stiffness of the affected region
- Recent changes in recreational or occupational activity
- History of prior injury
- Subacromial bursitis: repetitive overhead activities, pain with overhead activity
- Trochanteric bursitis: recent increase in running or lower extremity exercise
- Prepatellar bursitis: fall on patella, prolonged kneeling or running
- Olecranon bursitis: leaning on elbows, trauma, decreased ROM at the elbow
- Radiohumeral bursitis: repetitive forearm pronation (medial epicondylitis/golfer's elbow) or supination (lateral epicondylitis/tennis elbow) and pain with opening jars, wringing out hair or opening doors
PHYSICAL EXAM
- Pain and point tenderness of affected area
- Decreased ROM of affected region (particularly shoulder)
- Erythema
- Swelling
- Crepitus
- Point tenderness
DIFFERENTIAL DIAGNOSIS
- Septic arthritis; Lyme disease
- Osteoarthritis
- Gout, pseudogout
- Rheumatic disorders
- Tendinitis, strains, and sprains
- Fractures and contusions
- Cellulitis
DIAGNOSTIC TESTS & INTERPRETATION
Consider ECG (if left shoulder pain suggests cardiac pain). á
Initial Tests (lab, imaging)
- The diagnosis of bursitis is typically clinical.
- The following tests help differentiate soft tissue disease from rheumatic and connective tissue disease (but are not necessary for routine diagnosis):
- CBC with differential
- ESR
- Serum protein electrophoresis
- Rheumatoid factor
- Anti-CCP
- ANA
- Joint fluid analysis
- Calcific deposits may be seen on plain radiograph.
- MRI may help if diagnosis is unclear.
- Ultrasound useful for direct visualization and to guide injection (2)[B]
Diagnostic Procedures/Other
- Aspiration: particularly to rule out infection or crystalline disease
- Fluid analysis, Gram stain, cell count, culture, and examination for presence of crystals
- White blood cell (WBC) 2,000 to 5,000/╬╝L implies inflammatory cause; >5,000/╬╝L implies infectious cause. Noninflammatory fluid contains <2,000 WBCs/╬╝L.
- If the Gram stain and culture indicate infection, treat with appropriate antibiotics.
Test Interpretation
- Acute bursitis (early inflammation), bursa is distended with watery or mucoid fluid.
- Infection: purulent fluid on aspiration
- Chronic bursitis
- Bursal wall is thickened and inner surface is shaggy and trabeculated.
- Bursal space is filled with granular, brown, inspissated blood with gritty, calcific precipitations.
TREATMENT
Outpatient; refer only difficult cases á
GENERAL MEASURES
- Goal is to reduce pain and irritation and prevent recurrence.
- Conservative therapy consists of PRICE therapy (protection-rest-ice-compression-elevation). Compression is particularly helpful.
- Bursa aspiration (particularly if suspicion for infection)
- Corticosteroid injection if infectious etiology ruled out
- Treat any underlying infection.
- Treat underlying causes such as overtraining, poor body mechanics, repetitive trauma, or tight or deconditioned muscles.
- For prepatellar bursitis resulting from trauma, have patient wear knee pads during prolonged kneeling.
MEDICATION
First Line
- NSAIDs or aspirin (2)[B]
- Antibiotic therapy if infection present; cover for staphylococcal and streptococcal species (most common)
Second Line
- Systemic steroids provide limited short-term benefit (3)[B].
- Injectable corticosteroids once infection ruled out (2,4)[B]. Local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis; however, steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon (2,5)[B].
- US guidance for bursa injections increases anatomic accuracy and effectiveness of therapy (4)[B].
ADDITIONAL THERAPIES
- Low-energy shock wave therapy (SWT) (6)[A]
- Platelet-rich plasma (PRP) (7)[B]
- Physical therapy to correct biomechanical abnormalities and strengthen surrounding musculature
- Dry needling (8)[B]
SURGERY/OTHER PROCEDURES
- Surgical excision in severe cases unresponsive to conservative treatments
- Outpatient arthroscopic bursectomy under local anaesthesia is an effective procedure for the treatment of posttraumatic prepatellar bursitis after failed conservative treatments (9)[B].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Rest and elevation of affected extremity á
Patient Monitoring
- Discontinue NSAIDs as soon as possible to avoid side effects.
- Some patients may require repeated injections (limit to no more than 3) of a corticosteroid and lidocaine (2)[C].
DIET
Consider dietary changes if bursitis is directly related to obesity/crystalline deposition. á
PROGNOSIS
- Most bouts of bursitis heal uneventfully.
- Repetitive bouts may lead to chronic bursitis, necessitating repeated joint/bursal aspirations or (rarely) surgical excision of involved bursa.
- Although multiple aspirations may not be curative, they can provide significant symptom relief while awaiting a more definitive treatment (i.e., surgery).
COMPLICATIONS
- Septic bursitis may extend to nearby joint.
- Acute bursitis leading to chronic pain, limitation of motion, and dysfunction
REFERENCES
11 Centers for Disease Control and Prevention. National health interview survey. http://www.cdc.gov/nchs/nhis.htm. Accessed 2014.22 Bambach áSF, Lobo áCM, Badyine áI, et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg. 2014;134(3):359-370.33 Buchbinder áR, Hoving áJL, Green áS, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2004;63(11):1460-1469.44 Wu áT. Ultrasound-guided versus blind subacromial-subdeltoid bursa injections in adults with shoulder pain: a systematic review and meta-analysis [published online ahead of print May 20, 2015]. Semin Arthritis Rheum.55 Vallone áG, Vittorio áT. Complete Achilles tendon rupture after local infiltration of corticosteroids in treatment of deep retrocalcaneal bursitis. J Ultrasound. 2014;17(2):165-167.66 Chen áCY, Hu áCC, Weng áPW, et al. Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis. J Shoulder Elbow Surg. 2014;23(12):1843-1851.77 Rowicki áK, P┼éomi┼äski áJ, Bachta áA. Evaluation of the effectiveness of platelet rich plasma in treatment of chronic pes anserinus pain syndrome. Ortop Traumatol Rehabil. 2014;16(3):307-318.88 Clewley áD, Flynn áTW, Koppenhaver áS. Trigger point dry needling as an adjunct treatment for patient with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. 2014;44(2):92-101.99 Huang áYC, Yeh áWL. Endoscopic treatment of prepatellar bursitis. Int Orthop. 2011;35(3):355-358.
ADDITIONAL READING
- Aaron áDL, Patel áA, Kayiaros áS, et al. Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011;19(6):359-367.
- Finlay áK, Friedman áL. Ultrasonography of the lower extremity. Orthop Clin North Am. 2006;37(3):245-275.
- Gasparre áG, Fusaro áI, Galletti áS, et al. Effectiveness of ultrasound-guided injections combined with shoulder exercises in the treatment of subacromial adhesive bursitis. Musculoskelet Surg. 2012;96(Suppl 1):S57-S61.
- Hsieh áLF, Hsu áWC, Lin áYJ, et al. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc. 2013;45(12):2205-2213.
- Hsu áWK, Mishra áA, Rodeo áSR, et al. Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment. J Am Acad Orthop Surg. 2013;21(12):739-748.
- Lustenberger áDP, Ng áVY, Best áTM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447-453.
- Wiegerinck áJI, Kok áAC, van Dijk áCN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012;28(2):283-293.
- Williams áBS, Cohen áSP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-1670.
SEE ALSO
- Tendinopathy
- Video: Olecranon Bursitis Aspiration
CODES
ICD10
- M71.9 Bursopathy, unspecified
- M75.50 Bursitis of unspecified shoulder
- M70.20 Olecranon bursitis, unspecified elbow
- M70.40 Prepatellar bursitis, unspecified knee
- M75.52 Bursitis of left shoulder
- M70.42 Prepatellar bursitis, left knee
- M70.61 Trochanteric bursitis, right hip
- M70.62 Trochanteric bursitis, left hip
- M70.41 Prepatellar bursitis, right knee
- M75.51 Bursitis of right shoulder
- M70.60 Trochanteric bursitis, unspecified hip
ICD9
- 727.3 Other bursitis
- 726.10 Disorders of bursae and tendons in shoulder region, unspecified
- 726.33 Olecranon bursitis
- 726.65 Prepatellar bursitis
- 726.61 Pes anserinus tendinitis or bursitis
- 726.5 Enthesopathy of hip region
SNOMED
- Bursitis (disorder)
- Subdeltoid bursitis
- inflammation of bursa of olecranon (disorder)
- Prepatellar bursitis
- Pes anserinus tendinitis and bursitis (disorder)
- trochanteric bursitis (disorder)
CLINICAL PEARLS
- PRICE is recommended as conservative therapy for bursitis:
- Protect (protective gear or padding)
- Rest affected area.
- Ice inflamed bursa.
- Compress (with Ace wrap or neoprene sleeve)
- Elevate joint.
- Treat underlying cause of the bursitis. Rehabilitation to restore biomechanics and strengthen surrounding musculature helps to prevent recurrence.