Bursitis

Bursitis – Introduction

Bursitis is an inflammation of a bursa, which is a thin-walled, fluid-filled sac.
Bursae function as cushions to reduce friction and facilitate movement of tendons and muscles over bony prominences, or skin over bone.
Olecranon bursitis and prepatellar bursitis are the most common, usually due to chronic microtrauma from repetitive pressure or activity. ¹

Synonyms

Miner’s elbow, student’s elbow, draftsman’s elbow (olecranon bursitis)
Housemaid’s knee, carpet-layer’s knee, coal miner’s knee (prepatellar bursitis)
Weaver’s bottom (ischial gluteal bursitis)
Baker’s cyst (gastrocnemius-semimembranosus bursa)
Pump bumps (subcutaneous calcaneal bursitis)
Goosefoot bursitis (pes anserine bursitis)

ICD-10CM CODES
M75.80	Other shoulder lesions, unspecified shoulder
M70.20	Olecranon bursitis, unspecified elbow
M70.60	Trochanteric bursitis, unspecified hip
M70.70	Other bursitis of hip, unspecified hip
M76.899	Other specified enthesopathies of unspecified lower limb, excluding foot
M70.40	Prepatellar bursitis, unspecified knee
M71.20	Synovial cyst of popliteal space [Baker], unspecified knee
M77.50	Other enthesopathy of unspecified foot

Physical Findings & Clinical Presentation

•Local swelling, tenderness, erythema, warmth over the site of bursa are common with prepatellar and olecranon bursitis. Trochanteric bursitis presents most commonly as lateral hip pain without erythema or warmth.
•Subacromial bursitis may present with chronic shoulder pain, worse with overhead and repetitive activities, without weakness or stiffness. ²
•Range of motion (ROM) may be markedly limited in septic arthritis, whereas ROM is relatively preserved in nonseptic bursitis. ¹
•Subacromial/subdeltoid bursitis and trochanteric bursitis may also be found in polymyalgia rheumatica (PMR), and thus can present with symptoms of PMR.

Etiology – What causes Bursitis?

•Acute traumatic
•Chronic microtrauma from repetitive activity or pressure
•Infection (septic bursitis)—spread from contiguous skin or soft tissue infection ( Staphylococcus aureus causative in >80%) ³
•Crystal diseases (e.g., gout, pseudogout)
•Systemic inflammatory arthritis, particularly rheumatoid arthritis
•Bleeding (from diathesis, anticoagulation, or trauma)

Differential Diagnosis

•Acute monoarthritis caused by septic arthritis or crystal arthritis (gout, pseudogout)
•Tendinitis, tenosynovitis
•Cellulitis

Workup – How is this condition diagnosed?

Bursal fluid aspiration: Send for Gram stain, culture and sensitivity, cell count and differential, and crystal analysis ³
Blood testing: Send for blood cell count with differential and C-reactive protein and erythrocyte sedimentation rate testing, blood glucose level ¹

Imaging Studies

•Plain radiography can rule out foreign body penetration and other bone or joint problems
•MRI to define soft tissue involvement
•Musculoskeletal ultrasound to visualize superficial and deep bursae ⁴ ; assess inflammatory activity with Doppler and directly guide aspiration/injection

How is Bursitis treated?

Nonpharmacologic Therapy

•Avoid direct pressure or repetitive irritation
•Joint protection (e.g., kneeling pads, compression wraps)
•Rest, ice, elevation for acute phase
•Physical therapy
•Activity modification

Acute General Treatment

•Septic:
- 1.Appropriate antibiotic coverage and drainage. If methicillin-susceptible Staphylococcus aureus (MSSA), use nafcillin or oxacillin 2 g IV q4h or dicloxacillin 500 mg PO qid. If methicillin-resistant Staphylococcus aureus (MRSA), use vancomycin 15 to 20 mg/kg IV q8 to 12h or linezolid 600 mg PO bid
- 2.Serial aspirations of purulent fluid or surgical drainage may be indicated
•Nonseptic:
- 1.Aspiration of bursal fluid or blood from acute trauma
- 2.Trochanteric bursitis may respond well to physical therapy modalities, stretching, and corticosteroid injection
- 3.Traumatic bursitis may respond well to aspiration and corticosteroid injection
- 4.Inflammatory arthritis such as gout or rheumatoid arthritis (RA): Treat underlying condition with specific therapies and with systemic antiinflammatory medications for active disease; can consider intrabursal injection of steroids

Chronic Treatment

•Aspiration and drainage of fluid can provide symptomatic improvement if large fluid collection, followed by compression dressing to prevent fluid reaccumulation
•Steroid injection into nonseptic bursa if inflammatory, recurrent, or persistently symptomatic (40 mg triamcinolone mixed with 1 to 3 ml lidocaine, depending on size of bursa)
•Oral NSAIDs, over-the-counter analgesics
•Patients in whom conservative therapy fails to resolve symptoms of chronic inflammatory may be considered for surgical bursectomy. ¹ Arthroscopic bursectomy for olecranon and trochanteric bursitis may have some advantages over open surgical bursectomy.

Disposition

Conservative nonsurgical treatment is effective in most cases. Surgical drainage may be indicated for loculated bursitis or if septic. Recurrent bursitis affecting function may require open or arthroscopic bursectomy. ⁵

Referral

Orthopedic consultation may be needed as part of treatment of septic bursitis, or for persistent or recurrent bursitis that interferes with daily function.

Pearls & Considerations

Bursae in patients with RA are not usually the sole site of active flare.
Therefore, in patients with RA, acute bursitis should be considered septic bursitis until proven otherwise.

Comments

•Scapulothoracic bursitis is underrecognized and undertreated. It results from friction between superomedial angle of scapula and adjacent second and third ribs. Crepitus, snapping, and tenderness are suggestive findings; it can also cause chest wall pain. ⁶
•Do not incise and drain sterile bursae because chronic draining sinus tract may develop and risk iatrogenic septic bursitis.
•In bursitis caused by infectious or systemic inflammatory disorders, the leukocytosis in bursal fluid may be substantially less intense than the elevations in the joint fluid.
•Investigate crystal-induced bursitis for underlying metabolic or hematologic diseases (hemochromatosis, hyperparathyroidism [calcium pyrophosphate deposition disease]), and for hyperuricemia (gout).

Summary

• Bursitis is the condition that occurs when a bursa becomes inflamed.

• A bursa is a sac with a potential space that makes it easier for one tissue to glide over another. They are often located near, and sometimes communicate with, joints.

• There are approximately 160 bursae in the body, but only a few of them become clinically affected.

• Most bursae differentiate during development, but new ones may form in response to irritation, inflammation, or trauma.

References

1.Khodaee M.: Common superficial bursitis . Am Fam Physician 2017; 95 (4): pp. 224-231.

2.Boneti C., et al.: Scapulothoracic bursitis as a significant cause of breast and chest wall pain: underrecognized and undertreated . Ann Surg Oncol 2010; 217 (Suppl 3): pp. 321-324. Epub Sep 19, 2010 .

3.Khodaee M.: Common superficial bursitis . Am Fam Physician 2017; 95 (4): pp. 224-231.

4.Lormeau C., et al.: Management of septic bursitis . Joint Bone Spine 2019; 86 (5): pp. 583-588.

5.Baumbach S.F., et al.: Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm . Arch Orthop Trauma Surg 2014; 134 (3): pp. 359-370.

6.Consigliere P., et al.: Subacromial impingement syndrome: management challenges . Orthop Res Rev 2018; 10: pp. 83-91.