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Bursitis Workup

  • Author: Kristine M Lohr, MD, MS; Chief Editor: Harris Gellman, MD  more...
 
Updated: Oct 13, 2015
 

Blood Studies

Routine laboratory blood work is generally not helpful in the diagnosis of noninfectious bursitis. In cases of septic bursitis, however, the leukocyte count and erythrocyte sedimentation rate (ESR) may be mildly to moderately elevated. Blood cultures may be drawn if infection of deep bursae is a concern. ESR, antinuclear antibody (ANA), rheumatoid factor (RF), and anti–citric citrullinated peptide (anti-CCP) tests should all be ordered in cases where autoimmune disease is suspected because these inflammatory disorders can trigger bursitis.

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Joint Aspiration and Fluid Analysis

Aspiration and analysis of bursal fluid should be done to rule out infectious or rheumatic causes; they may also be therapeutic. Bursal fluid should be drawn for monosodium urate crystal determination, cell count with differential, Gram stain, and culture. Physicians should be more inclined to perform bursal fluid aspiration in the most frequently infected bursae—namely, the olecranon (see the image below), prepatellar, and infrapatellar bursae.

Olecranon bursitis: aspiration of hemorrhagic effu Olecranon bursitis: aspiration of hemorrhagic effusion. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Nonseptic bursitis has cell counts lower than 2000/µL, with a predominance of mononuclear cells. Septic bursitis may have cell counts exceeding 70,000/µL, with a predominance of polymorphonuclear leukocytes (PMNs). The WBC count in septic bursitis is typically lower than that in septic arthritis. A WBC count of 5000-20,000/µL or higher may be considered indicative of infection.

Gram stain and culture are performed to identify any pathogens. The accuracy of Gram staining varies considerably, with sensitivities between 15% and 100%. Therefore, fluid that has a high WBC count but is negative on Gram staining is still considered suspicious for infection.

Elevated protein level and reduced glucose level are associated with infection but are not sufficiently sensitive or specific to be used in isolation. Bursal fluid culture is the conclusive test for diagnosis. Culture in liquid medium has been shown to be superior to culture on solid medium. With chronic or recurrent bursitis, samples should be sent for acid-fast staining and cultured on special media for mycobacteria, Brucella, and algae.

Fluid should also be examined for crystals. Monosodium urate crystals are seen in gout; calcium pyrophosphate crystals are seen in pseudogout; cholesterol crystals are seen in rheumatoid chylous bursitis and in a variety of chronic effusions.

Arthrocentesis should be performed if joint involvement is suspected.

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Plain Radiography, Bone Scanning, MRI, and CT

Plain radiography usually is not helpful in the diagnosis of bursitis but may be useful for identifying osteophytes or other underlying bony pathology (eg, fractures or dislocations) that may be triggering the bursal inflammation. They may also show joint effusions. In chronic bursitis, the bursal walls or nearby tendons may be calcified and radiopaque.

Bone scanning is not a sensitive test for bursitis, but it may be done in cases in which the diagnosis is unclear to rule out other causes of pain.

Because of the characteristic clinical presentation of bursitis, magnetic resonance imaging (MRI) and computed tomography (CT) are usually unnecessary. MRI can be useful for delineating the anatomy of the entire joint (including adjacent soft tissues) and depicting bursal or prebursal fluid and associated abscesses[23] ; if needed, it is a very sensitive test for identification of bursitis. MRI is also helpful in ruling out suspected solid tumors and defining pathology for possible surgical excision.

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Ultrasonography

Ultrasonography is useful for further imaging of the bursa when the diagnosis is uncertain. For diagnostic aspiration or treatment injections, ultrasonography may be performed to elucidate the structures and to guide procedures. The accuracy of ultrasound-guided injections has increased; however, studies of the efficacy of ultrasound-guided versus blinded injections provide controversial results.[24] In addition, ultrasound studies distinguish solid from cystic masses and are helpful in detecting Baker cysts (popliteal bursitis) when there are extensive joint deformities.[11, 25] Baker cysts are often discovered incidentally when lower-extremity Doppler studies are done to rule out deep vein thrombosis.

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Contributor Information and Disclosures
Author

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Interim Chief, Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Coauthor(s)

Janet Kay Talbot-Stern, MD, FACEM, FCEM Emergency Medicine VMO, Ryde and Bankstown Hospitals, Australia Locum Consultant, St Thomas Hospital, UK

Disclosure: Nothing to disclose.

Alita Gonsalves, MD Physiatrist, Private Practice, Vero Orthopaedics and Neurology; Former Staff Physician, Department of Physical Medicine and Rehabilitation, New York Presbyterian Hospital

Alita Gonsalves, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Leon Root, MD Professor of Clinical Surgery, Department of Orthopedics, Weill Medical College of Cornell University; Founder and Director, Pediatric Outreach Program; Emeritus Chief of Osteogenesis Imperfecta Clinic, Attending Orthopedic Surgeon, Medical Director of Rehabilitation, Emeritus Chief of Pediatric Orthopedics, The Hospital for Special Surgery

Leon Root, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, New York Academy of Medicine, American Academy of Cerebral Palsy and Developmental Medicine, Pediatric Orthopaedic Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Ian D Dickey, MD, FRCSC Adjunct Professor, Department of Chemical and Biological Engineering, University of Maine; Consulting Staff, Adult Reconstruction, Orthopedic Oncology, Department of Orthopedics, Eastern Maine Medical Center

Ian D Dickey, MD, FRCSC is a member of the following medical societies: American Academy of Orthopaedic Surgeons, British Columbia Medical Association, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Stryker Orthopaedics Consulting fee Consulting; Cadence Honoraria Speaking and teaching

Gino A Farina, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Olecranon bursitis, shown here with elbow flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis: aspiration of hemorrhagic effusion. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Location of anserine (pes anserinus) bursa on medial knee. MCL=medial collateral ligament.
Acute infectious bursitis upon presentation to emergency department. Image courtesy of Christopher Kabrhel, MD.
Infectious bursitis. Image courtesy of Christopher Kabrhel, MD.
Shoulder anatomy muscle, anterior view.
 
 
 
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