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Bursitis

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.
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