- Author: Kristine M Lohr, MD, MS; Chief Editor: Harris Gellman, MD more...
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.
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.
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.
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 ; 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.
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. 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.
Crenshaw AH, Canale ST. Nontraumatic disorders. Canale ST, ed. Campbell’s Operative Orthopaedics. 9th ed. St Louis: Mosby; 1998. 776-85.
DeLee JC, Drez D. Imaging effusions, cysts, and ganglia. DeLee JC, Drez D, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine: Principles and Practice. Philadelphia: WB Saunders; 2003. 1646-8.
Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention. 3rd ed. Baltimore: Williams and Wilkins; 1996.
Salzman KL, Lillegard WA, Butcher JD. Upper extremity bursitis. Am Fam Physician. 1997 Nov 1. 56(7):1797-806, 1811-2. [Medline].
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996 May 15. 53(7):2317-24. [Medline].
Keplinger FS, Gupta N. :. Knee bursitis. Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. 340-4. Philadelphia: Hanley & Belfus; 2002.
Reilly JP, Nicholas JA. The chronically inflamed bursa. Clin Sports Med. 1987 Apr. 6(2):345-70. [Medline].
Chen MJ, Lew HL, Hsu TC, Tsai WC, Lin WC, Tang SF, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil. 2006 Jan. 85(1):31-5. [Medline].
Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006 Dec. 27(6):568-71. [Medline].
Turan H, Serefhanoglu K, Karadeli E, Timurkaynak F, Arslan H. A case of brucellosis with abscess of the iliacus muscle, olecranon bursitis, and sacroiliitis. Int J Infect Dis. 2009 Nov. 13(6):e485-7. [Medline].
Malkin J, Shrimpton A, Wiselka M, Barer MR, Duddridge M, Perera N. Olecranon bursitis secondary to Mycobacterium kansasii infection in a patient receiving infliximab for Behcet's disease. J Med Microbiol. 2009 Mar. 58:371-3. [Medline].
Brinks A, van Rijn RM, Bohnen AM, Slee GL, Verhaar JA, Koes BW, et al. Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice. BMC Musculoskelet Disord. 2007 Sep 19. 8:95. [Medline]. [Full Text].
Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: trochanteric bursitis. J Clin Rheumatol. 2004 Jun. 10(3):123-4. [Medline].
Rowand M, Chambliss ML, Mackler L. Clinical inquiries. How should you treat trochanteric bursitis?. J Fam Pract. 2009 Sep. 58(9):494-500. [Medline].
Viradia NK, Berger AA, Dahners LE. Relationship between width of greater trochanters and width of iliac wings in tronchanteric bursitis. Am J Orthop (Belle Mead NJ). 2011 Sep. 40(9):E159-62. [Medline].
Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007 Apr. 13(2):63-5. [Medline].
Alvarez-Nemegyei J, Canoso JJ. Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis. J Clin Rheumatol. 2004 Aug. 10(4):205-6. [Medline].
Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012 Feb. 28(2):283-93. [Medline].
Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009 Feb. 35(1):45-62. [Medline].
Le Manac'h AP, Ha C, Descatha A, Imbernon E, Roquelaure Y. Prevalence of knee bursitis in the workforce. Occup Med (Lond). 2012 Jul 9. [Medline].
Guanche CA. Clinical update: MR imaging of the hip. Sports Med Arthrosc. 2009 Mar. 17(1):49-55. [Medline].
D'Agostino MA, Schmidt WA. Ultrasound-guided injections in rheumatology: actual knowledge on efficacy and procedures. Best Pract Res Clin Rheumatol. 2013 Apr. 27(2):283-94. [Medline].
Tsai YH, Huang TJ, Hsu WH, Huang KC, Li YY, Peng KT, et al. Detection of subacromial bursa thickening by sonography in shoulder impingement syndrome. Chang Gung Med J. 2007 Mar-Apr. 30(2):135-41. [Medline].
Zuinen C. Diclofenac/misoprostol vs diclofenac/placebo in treating acute episodes of tendinitis/bursitis of the shoulder. Drugs. 1993. 45 Suppl 1:17-23. [Medline].
Jacobs JW. How to perform local soft-tissue glucocorticoid injections. Best Pract Res Clin Rheumatol. 2009 Apr. 23(2):193-219. [Medline].
Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006 Oct 18. CD006189. [Medline].
Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med. 1989 Nov. 149(11):2527-30. [Medline].
Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg. 2014 Nov. 134 (11):1517-36. [Medline].
Shbeeb MI, O'Duffy JD, Michet CJ Jr, O'Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol. 1996 Dec. 23(12):2104-6. [Medline].
Costantino TG, Roemer B, Leber EH. Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis. J Emerg Med. 2007 Apr. 32(3):295-7. [Medline].
Farmer KW, Jones LC, Brownson KE, Khanuja HS, Hungerford MW. Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment. J Arthroplasty. 2010 Feb. 25(2):208-12. [Medline].
Hong JY, Yoon SH, Moon do J, Kwack KS, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial. Arch Phys Med Rehabil. 2011 Dec. 92(12):1951-60. [Medline].
Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2013 Dec 23. 12:CD010071. [Medline].
Martinez-Taboada VM, Cabeza R, Cacho PM, Blanco R, Rodriguez-Valverde V. Cloxacillin-based therapy in severe septic bursitis: retrospective study of 82 cases. Joint Bone Spine. 2009 Dec. 76(6):665-9. [Medline].
Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. 1995 Jun. 24(6):391-410. [Medline].
Slawski DP, Howard RF. Surgical management of refractory trochanteric bursitis. Am J Sports Med. 1997 Jan-Feb. 25(1):86-9. [Medline].
Baker CL Jr, Massie RV, Hurt WG, Savory CG. Arthroscopic bursectomy for recalcitrant trochanteric bursitis. Arthroscopy. 2007 Aug. 23(8):827-32. [Medline].
Baums MH, Spahn G, Nozaki M, Steckel H, Schultz W, Klinger HM. Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis. Knee Surg Sports Traumatol Arthrosc. 2007 May. 15(5):638-44. [Medline].
Le Lievre HM, Murrell GA. Long-term outcomes after arthroscopic capsular release for idiopathic adhesive capsulitis. J Bone Joint Surg Am. 2012 Jul 3. 94(13):1208-16. [Medline].
Pretell J, Ortega J, García-Rayo R, Resines C. Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis. Int Orthop. 2009 Oct. 33(5):1223-7. [Medline]. [Full Text].
Dillon JP, Freedman I, Tan JS, Mitchell D, English S. Endoscopic bursectomy for the treatment of septic pre-patellar bursitis: a case series. Arch Orthop Trauma Surg. 2012 Jul. 132(7):921-5. [Medline].
Lohrer H, Nauck T. Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes. Arch Orthop Trauma Surg. 2014 Aug. 134 (8):1073-81. [Medline].
Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD007400. [Medline].