Basics
Description
- Bursae are synovial fluid-filled sacs:
- ~150 are located between bones, ligaments, tendons, muscles, and skin.
- They provide lubrication to reduce friction during movement.
- Bursitis is inflammation of a bursa caused by trauma and overuse, infection, crystal deposition, or systemic disease.
- Chronic bursitis can lead to proliferative changes in the bursa.
- Commonly affected sites:
- Shoulder (subacromial)
- Elbow (olecranon): Usually secondary to trauma
- Hip (greater trochanter, ischial, iliopsoas): More common in elderly
- Knee (prepatellar and pes anserine): Secondary to trauma or arthritis
- Foot (calcaneal): Almost always secondary to improperly fitting shoes/heels
Etiology
- Trauma (most common cause):
- Specific traumatic event or repetitive use of associated joints
- Infection: Secondary to direct penetration; may be obvious or microscopic:
- Higher risk with diabetes, chronic alcohol abuse, uremia, gout, immunosuppression
- 90% caused by Staphylococcus spp.
- Crystal deposition: Calcium phosphate, urate
- Systemic disease: Rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis, lupus, rheumatic fever
Diagnosis
Signs and Symptoms
History
- Acute or chronic
- History of trauma, overuse, or prolonged pressure
- Pain with increased activity at respective joint or with pressure
- Functional complaints (e.g., limping)
- History of localized swelling
- Screen for symptoms of systemic disease
- History of gout or pseudogout or rheumatologic disease
- History of recent procedure at bursa (e.g., aspiration, injection, etc.)
Physical Exam
- Tenderness to palpation is minimal to mild in aseptic bursitis.
- Localized pain with movement
- Often reduced active range of motion (ROM) with preserved passive ROM
- Localized swelling, particularly with superficial bursae
- Skin trauma overlying bursa
- Warmth and erythema*
- May be febrile in septic bursitis
*NB: The constellation of erythema, warmth, swelling, and exquisite tenderness are common in septic bursitis.
Essential Workup
- Full assessment of adjacent musculoskeletal structures
- Any suspicion of infection warrants aspiration of bursae (especially olecranon and prepatellar bursae).
- Lateral approach to prevent a needle tract directly over lines of tension of the joint
- Aspiration of hip and other deep bursae may be guided in ED by US or deferred to consultants.
Diagnosis Tests & Interpretation
Lab
- Serum labs:
- Suspected infection: CBC with differential
- Evaluation of related systemic disease (e.g., uric acid level for gout); ESR and CRP in rheumatologic disease
- Send serum glucose if bursal fluid aspiration is done
- Bursal fluid analysis:
- Send fluid for complete cell count with differential, glucose, total protein, crystal determination, Gram stain, and culture.
- Cultures must always be sent.
- Normal fluid: Fluid is clear yellow with 0-200 WBCs, 0 RBCs, low protein, and glucose is same as serum.
- Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.
- Septic bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on Gram stain.
- Rheumatoid and microcrystalline inflammation (aseptic bursitis): Fluid is yellow, sometimes turbid, and has 1,000-40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; microscopic exam for crystals.
Imaging
- Radiographs may demonstrate soft tissue swelling or adjacent chronic arthritic changes or calcium deposits:
- Especially recommended when trauma is involved to rule out fracture or foreign body
- MRI and US may aid in diagnosis of deep bursitis and in defining the extent of septic bursitis.
- CT scans can also help differentiate septic from nonseptic bursitis.
Differential Diagnosis
- Arthritides: Septic, inflammatory, rheumatoid and degenerative joint (osteoarthritis)
- Gout and pseudogout
- Tendonitis, fasciitis, epicondylitis
- Fracture, tendon/ligament tear, contusion, sprain
- Osteomyelitis
- Nerve entrapment
- Also in hips: Neuritis, lumbar spine disease, sacroiliitis
Treatment
Pre-Hospital
May be difficult to distinguish from fractures; suspicious joints should be immobilized, particularly in the setting of trauma.
Initial Stabilization/Therapy
- Immobilize joint if pain is severe.
- Shoulders should not be immobilized for >2-3 days because of the risk of adhesive capsulitis.
Ed Treatment/Procedures
- Nonseptic bursitis:
- Rest and removal of aggravating factors (e.g., avoid direct pressure and repetitive use; protective padding where necessary)
- Ice affected areas for 10 min, 4 times a day until improved; may alternate with heat.
- NSAIDs for at least 7 days; best if continued for 5 days after improvement to help prevent recurrence
- If fluctuant, then aspirate and place compression dressing
- If no improvement within 5-7 days and infection has been ruled out (by culture), injection of lidocaine and corticosteroids may be considered:
- Mix 2 mL of 2% lidocaine with appropriate depo-corticosteroid (see below) and inject 1-3 mL of this mixture into the bursa using sterile technique.
- Steroid injections should not be repeated until 4 wk have passed, and no >2 injections per bursa should be performed without consultation.
- Septic bursitis:
- Superficial bursae: Aspiration and antibiotics may be sufficient with close follow-up.
- Other major bursae: Antibiotics and drainage of bursae (leaving in perforated drainage catheter can reduce period of treatment and avoid eventual bursectomy)
- Febrile patients may need IV antibiotics.
- Base antibiotic choice on the Gram stain when available or empiric coverage based on local susceptibilities:
- Penicillinase-resistant penicillins may be used if Gram stain shows gram-positive cocci in chains but should be broadened for MRSA coverage if cocci in clusters are seen
- If gram-negative organisms are found, blood cultures should be done and another primary source for the infection should be sought.
- Antibiotics should be continued for 5-7 days beyond resolution of signs of infection (thus may require follow-up)
- Treat associated diseases as needed (e.g., gout).
Medication
- NSAIDs (many choices; a few are listed here):
- Naprosyn: 500 mg PO q12h
- Ibuprofen: 600 mg PO q6h (peds: 5-10 mg/kg PO q6h)
- Ketorolac: 30 mg IV/IM q6h or 10 mg PO q4h-q6h
- Meloxicam: 7.5 mg PO q12h or 15 mg PO daily
- Corticosteroids for intrabursal injection:
- Triamcinolone acetonide: 20-40 mg (1st choice)
- Methylprednisolone acetate: 20-40 mg
- Dexamethasone acetate/sodium: 8 mg
Follow-Up
Disposition
- Most patients may be treated as outpatients.
- Most patients respond to therapy in 3-4 days and may follow-up within 1 wk or PRN.
- Septic bursitis requires repeated bursal aspiration every 3-5 days until sterile.
Admission Criteria
- Patients with systemic inflammatory response syndrome (SIRS), large surrounding cellulitis, unable to take PO antibiotics, failed outpatient therapy, or immunosuppressed
- Unusual organisms, extrabursal primary site, or deep bursal involvement
Discharge Criteria
- Able to tolerate pain
- Septic bursitis are safe to discharge if appropriately treated and close follow-up is secure
Issues for Referral
Rheumatology or orthopedic referral is recommended for patients who do not respond to intrabursal steroids or recurrent bursitis or need operative management.
Follow-Up Recommendations
- Close follow-up for septic bursitis
- PRN to the emergency department for worsening symptoms but otherwise follow-up with primary care physician.
Pearls and Pitfalls
- Exam alone may be unreliable in distinguishing between traumatic and septic bursitis:
- Aspiration and fluid analysis may be the only method of distinguishing.
- Beware of risk for GI hemorrhage associated with PO NSAIDs and for nephrotoxicity with ketorolac
- If presents with the 4 signs of infection-humor, dolor, rubor, and calor-then it is likely septic but still needs an aspiration and culture
- Beware of the potential of seeding organisms to adjacent joints when aspirating septic bursae.
Additional Reading
- DeLee JC, Drez D, Miller MD, ed. DeLee & Drezs Orthopaedic Sports Medicine: Principles and Practice. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2010:889-891, 1209-1212, 1246-1249, 1455-1458, 2030-2041.
- Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: Role of CT in the emergency department. Radiographics. 2007;27(6):1723-1736.
- Larsson L, Baum J. The syndromes of bursitis. Bull Rheum Dis. 1986;36(1):1-8.
- Stephens MB, Beutler Al, O'Connor FG. Musculoskeletal injections: A review of the evidence. Am Fam Physician. 2008;78(8):971-976.
- Baumbach SF, Wyen H, Perez C, et al. Evaluation of current treatment regimens for prepatellar and olecranon bursitis in Switzerland. Europ J Trauma Emerg Surg. 2013;39(1):65-72.
Codes
ICD9
- 726.10 Disorders of bursae and tendons in shoulder region, unspecified
- 726.33 Olecranon bursitis
- 727.3 Other bursitis
- 726.5 Enthesopathy of hip region
- 726.65 Prepatellar bursitis
- 726.79 Other enthesopathy of ankle and tarsus
ICD10
- M70.20 Olecranon bursitis, unspecified elbow
- M71.9 Bursopathy, unspecified
- M75.50 Bursitis of unspecified shoulder
- M70.60 Trochanteric bursitis, unspecified hip
- M70.21 Olecranon bursitis, right elbow
- M70.22 Olecranon bursitis, left elbow
- M70.2 Olecranon bursitis
- M70.30 Other bursitis of elbow, unspecified elbow
- M70.31 Other bursitis of elbow, right elbow
- M70.32 Other bursitis of elbow, left elbow
- M70.3 Other bursitis of elbow
- M70.40 Prepatellar bursitis, unspecified knee
- M70.41 Prepatellar bursitis, right knee
- M70.42 Prepatellar bursitis, left knee
- M70.4 Prepatellar bursitis
- M70.50 Other bursitis of knee, unspecified knee
- M70.51 Other bursitis of knee, right knee
- M70.52 Other bursitis of knee, left knee
- M70.5 Other bursitis of knee
- M70.61 Trochanteric bursitis, right hip
- M70.62 Trochanteric bursitis, left hip
- M70.6 Trochanteric bursitis
- M70.70 Other bursitis of hip, unspecified hip
- M70.71 Other bursitis of hip, right hip
- M70.72 Other bursitis of hip, left hip
- M70.7 Other bursitis of hip
- M75.51 Bursitis of right shoulder
- M75.52 Bursitis of left shoulder
- M75.5 Bursitis of shoulder
- M77.50 Other enthesopathy of unspecified foot
- M77.51 Other enthesopathy of right foot
- M77.52 Other enthesopathy of left foot
- M77.5 Other enthesopathy of foot
SNOMED
- 84017003 Bursitis (disorder)
- 239961006 Bursitis of shoulder (disorder)
- 425940002 inflammation of bursa of olecranon (disorder)
- 81498004 bursitis of hip (disorder)
- 111243002 bursitis of knee (disorder)
- 287025008 Bursitis - ankle/foot (disorder)