Bursitis Treatment & Management
- Author: Kristine M Lohr, MD, MS; Chief Editor: Harris Gellman, MD more...
Most patients with bursitis are treated conservatively to reduce inflammation. Conservative treatment includes rest, cold and heat treatments, elevation, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), bursal aspiration, and intrabursal steroid injections (with or without local anesthetic agents).
Patients with suspected septic bursitis should be treated with antibiotics while awaiting culture results. Superficial septic bursitis can be treated with oral outpatient therapy. Those with systemic symptoms or who are immunocompromised may require admission for intravenous (IV) antibiotic therapy.
Surgical excision of bursae may be required for chronic or frequently recurrent bursitis. Surgery is reserved as a last resort for patients in whom conservative treatment fails. The operation varies according to site.
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. Consultation with a general or orthopedic surgeon or a rheumatologist may be helpful.
With regard to resumption of activities, patients should let pain be their guide.
Conservative treatment involves control of pain and inflammation, which may be guided by the PRICEMM acronym, as follows:
P rotect - Use padding, braces, or changes in technique
R est - Avoid activities that exacerbate pain
I ce - Cryotherapy can relieve pain and decrease inflammation
C ompression - Elastic dressings can ease pain, as in olecranon bursitis
E levation - Raise the affected limb above the level of the heart
M odalities – Employ electrical stimulation, ultrasonography, or phonophoresis
M edications – Administer nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or corticosteroid injections
The affected area should be placed at rest. Because of the risk of adhesive capsulitis, shoulders should not be immobilized for more than a few days. After immobilization, patients should begin graduated range-of-motion exercises. Patients who have bursitis secondary to overuse should be educated about the importance of regular periods of rest and possible alternative activities to prevent recurrence.
Applying cold treatments for 20 minutes every several hours may be of value in the first 24-48 hours. Such treatments may be followed by heat treatments. Elevation is useful, particularly in lower-limb bursitis. Consider site-specific therapy (eg, cushions for ischial bursitis, well-fitting padded shoes for calcaneal bursitis).
NSAIDs and corticosteroids
NSAIDs are used to reduce inflammation and relieve pain. In a multicenter, double-blind, parallel study involving 372 patients with acute (≤72 hours) traumatic bursitis or tendinitis of the shoulder, 90% of patients treated with diclofenac 50 mg two or three times daily improved over 14 days, with 40-50% demonstrating at least moderate improvement.
Corticosteroid injections can be helpful if the patient does not respond to other treatment within 7-14 days. Various steroids (eg, hydrocortisone, prednisolone, methylprednisolone, triamcinolone, betamethasone, and dexamethasone) have been used in this setting, but no single agent has been found to be demonstrably superior. Steroids can be mixed in the same syringe with lidocaine or bupivacaine.
Corticosteroid injections can be performed either in the emergency department (ED) or in an outpatient setting.[27, 28] 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. Typically, 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.[10, 14, 29]
The potential complications of intrabursal injections include the following:
Allergy to injected agents
Local subcutaneous atrophy (Methylprednisolone is associated with the least frequent development of local subcutaneous atrophy.)
Postinjection flare or pain – Postinjection flares usually start within hours and may last up to 72 hours; postinjection pain may last several hours
Tendon rupture – Major tendons should not be injected
Intrabursal steroid injections (with or without local anesthetics) should not be performed if infection is suspected. In overuse injuries, injections should not replace cessation or modification of the offending activity.
In a randomized study of 42 patients with olecranon bursitis who were assigned after bursal aspiration to 1 of 4 treatment groups (intrabursal methylprednisolone 20 mg plus naproxen 1 g/day for 10 days, intrabursal methylprednisolone without naproxen, naproxen only, or placebo), steroid injection was more successful in decreasing edema and preventing recurrence than naproxen or placebo was.
In a systematic review of 29 studies involving a total of 1278 patients with olecranon bursitis, Sayegh and Strauch found that treatment of aseptic bursitis with corticosteroids was associated with significantly increased rates of overall complications and skin atrophy. Compared with patients with septic bursitis, those with aseptic bursitis had a significantly higher overall complication rate. Compared with nonsurgical management, surgical management was significantly less likely to clinically resolve septic or aseptic bursitis, and it was associated with significantly higher rates of overall complications, persistent drainage, and bursal infection.
A study comparing the short- and long-term effectiveness of betamethasone injections (6, 12, or 24 mg with 4 mL of 1% lidocaine) for trochanteric bursitis reported that improvement of pain was achieved at 1, 6, and 26 weeks in 77%, 69%, and 61% of patients, respectively. Higher doses of steroids were significantly more effective.
A small-sample-size study found that injection under ultrasonographic guidance may be more efficacious than blind injection based on anatomy.
In a study of 25 cases of postarthroplasty trochanteric bursitis requiring corticosteroid injection, Farmer et al found that corticosteroid injections were effective therapy and that nonoperative management may be more likely to fail in young patients and patients with leg-length discrepancies. Of the 25 hips, 11 required multiple corticosteroid injections, and symptoms resolved in 20 cases.
An 8-week placebo-controlled study demonstrated that steroids brought about a decrease in pain and an improvement in function as compared with placebo. Furthermore, the study showed no significant differences between higher (40 mg) and lower (20 mg) doses of triamcinolone acetonide. Therefore, in general, lower doses of steroids should be used initially.
Experiences with platelet-rich therapy (PRT) injections of soft tissue injuries (ligament, muscle, and tendon tears; tendinopathies) are increasingly being published. A recent Cochran review cited insufficient evidence to support the use PRT and a need for standardization of platelet-rich plasma preparation.
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 via 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 identify any infectious organisms or crystals present.
Staphylococcus aureus is the most common pathogen in septic bursitis, accounting for more than 80% of cases. Streptococcal species (mostly group A hemolytic streptococci) account for 5-20% of cases. Other gram-positive, gram-negative, and anaerobic infections are rare. Mycobacterial, fungal, algal, and spirochetal infections are even rarer and tend to occur in unusual clinical settings (especially in those who are predisposed to infection).
If bursitis is found to be secondary to infection after aspiration and fluid analysis, treatment should be initiated with antibiotics. An appropriate antistaphylococcal antibiotic should be started empirically. This should be a penicillinase-resistant penicillin, such as oxacillin, or a first-generation cephalosporin, such as cefazolin. In penicillin-allergic patients or in carriers of methicillin-resistant S aureus (MRSA), vancomycin is an appropriate alternative treatment.
In a study involving 82 patients with severe septic bursitis, Martinez-Taboada et al concluded that in patients with severe septic bursitis but without extensive cellulitis, aspiration plus IV cloxacillin may be sufficient treatment, whereas in patients with more severe cases of septic bursitis, aspiration along with cloxacillin plus gentamicin may be appropriate in the majority.
The duration of antibiotic treatment varies with the patient and the clinical situation. Uncomplicated septic bursitis presenting within 7 days of infection should be treated with a minimum 10-day course. 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.
Aspiration should be repeated every 1-3 days while antibiotics are being administered. Antibiotics should be continued for 5 days past sterilization of bursal fluid as seen by aspiration. Aspiration also helps to decrease the bacterial load and to promote comfort.
Immunocompromised patients require a longer course of treatment, at least 15 days. Deep bursae infections have higher associations with bacteremia and call for more aggressive and prolonged antibiotic therapy. In particularly severe cases, hospitalization is required, with 1 week of parenteral antibiotics followed by 30 days of oral antibiotics. Surgical drainage or debridement is often necessary.
Treatment of tuberculous bursitis involves full excision of the bursae and surrounding affected tissue with concomitant antituberculous therapy for 6-12 months. Atypical mycobacteria occasionally may be successfully treated with conservative drainage and appropriate antibiotics. Brucella bursitis is treated with excision of bursae and administration of tetracycline with or without rifampin.
Surgical Drainage and Excision
In general, bursitis is not treated surgically. However, there are some cases in which surgical interventions such as the following are appropriate:
Incision and drainage
Excision of chronically inflamed bursae
Removal of underlying bony prominences
As a rule, surgical intervention is reserved for the following situations :
Failure of needle aspiration to drain the bursa adequately
Bursa site inaccessible to repeated needle aspirations
Abscess, necrosis, or sinus formation
Need for exploration to assess the extent of infection of adjacent structures
Recurrent or refractory disease after conservative treatment
Surgical release may be indicated when adhesive bursitis develops that severely limits joint motion. During surgery, the adhered bursa is removed, and the contiguous tissues are released.[40, 41, 20, 42]
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 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.
Pretell et al described distal “Z” lengthening of the fascia lata in 13 hips and reported that 12 of the 13 patients reported good results. According to the authors, this technique is less aggressive, can be performed with local anesthesia, and is associated with little morbidity and disability. The mean operating time for the procedure was 15 minutes, and one seroma was reported as a complication.
A small case series from Australia found endoscopic bursectomy to be safe and effective as therapy for infectious prepatellar bursitis and suggested that it reduced the duration of hospitalization and hastened return to work as compared with conventional open surgical treatment.
A systematic review from The Netherlands found that for surgical treatment of chronic retrocalcaneal bursitis, endoscopic approaches appear to yield better results than open approaches; however, more evidence is needed to establish the optimal surgical approach.
Lohrer and Nauck, in a prospective study of 89 athletes who underwent surgery for recalcitrant retrocalcaneal bursitis or recalcitrant midportion Achilles tendinopathy, found that clinical severity scores improved significantly at 6 and 12 months following surgery, and that improvements were similar among patients who did or did not undergo tendon repair.
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