eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Bursitis: Differential Diagnoses & Workup

Author: Eileen Chang, MD, Resident, Department of Emergency Medicine, Brigham and Women's Hospital, Massachusetts General Hospital
Coauthor(s): Janet Talbot-Stern, MD, Director, Clinical Senior Lecturer, Departments of Emergency Medicine and Surgery, University of Sydney, Royal Prince Alfred Hospital
Contributor Information and Disclosures

Updated: Jul 9, 2008

Differential Diagnoses

Arthritis, Rheumatoid
Cellulitis
Gout and Pseudogout
Knee Injury, Soft Tissue
Osgood-Schlatter Disease
Tendonitis

Other Problems to Be Considered

Septic arthritis
Ligamentous injury
Fracture
Osteoarthritis

Workup

Laboratory Studies

  • Routine laboratory blood work is generally not helpful in the diagnosis of noninfectious bursitis. In cases of septic bursitis, however, leukocyte count and erythrocyte sedimentation rate may be mildly to moderately elevated. Blood cultures may be drawn if infection of deep bursae is a concern.

Imaging Studies

  • Plain film radiography is usually not helpful in the diagnosis of bursitis but may be helpful to exclude other suspected pathologies (eg, fractures, dislocations). Of note, the bursal walls or nearby tendons may be calcified and radiopaque in chronic bursitis. For diagnostic aspiration or treatment injections, ultrasonography may be used to elucidate the structures and to guide procedures. If needed, MRI helps depict bursal/prebursal fluid, associated abscesses, and adjacent soft tissue structures.

Procedures

  • Aspiration and analysis of bursal fluid distinguishes septic bursitis from aseptic bursitis and may also be therapeutic.
    • Physicians should be more inclined to perform bursal fluid aspiration in the most frequently infected bursae, which are the olecranon, prepatellar, and infrapatellar bursae.
    • The septic bursitis white blood cell count (WBC) is lower than that of septic arthritis. A WBC count from 5,000/mm3 to 20,000/mm3 or higher may be considered indicative of infection. Gram stain accuracy varies considerably, with sensitivities between 15% and 100%. Therefore, fluid with a high WBC count but negative for Gram stain is still considered suspicious for infection. Elevated protein level and reduced glucose level are associated with infection but are not a sufficiently sensitive or specific finding 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. Chronic or recurrent bursitis 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.
    • Arthrocentesis should be performed if joint involvement is suspected.

More on Bursitis

Overview: Bursitis
Differential Diagnoses & Workup: Bursitis
Treatment & Medication: Bursitis
Follow-up: Bursitis
Multimedia: Bursitis
References
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References

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Further Reading

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Keywords

bursal synovitis, inflammation of a bursa, deep bursae, superficial bursae, subacromial bursitis, subdeltoid bursitis, polymyalgia rheumatica, olecranon bursitis, lunger elbow, iliopsoas bursitis, trochanteric bursitis, rheumatoid arthritis, osteoarthritis,Patrick-Faberetest, ischial bursitis, weaver bottom, prepatellarbursitis, housemaid knee, carpet-layer knee, beat knee, infrapatellar bursitis, clergyman knee, anserine bursitis, calcaneal bursitis, overuse injuries, gout, pseudogout, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic osteoarthropathy, idiopathic hypereosinophilic syndrome, infective bursitis, septic bursitis

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Contributor Information and Disclosures

Author

Eileen Chang, MD, Resident, Department of Emergency Medicine, Brigham and Women's Hospital, Massachusetts General Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Janet Talbot-Stern, MD, Director, Clinical Senior Lecturer, Departments of Emergency Medicine and Surgery, University of Sydney, Royal Prince Alfred Hospital
Disclosure: Nothing to disclose.

Medical Editor

Mark Louden, MD, FACEP, Assistant Medical Director, Emergency Department, Duke Raleigh Hospital
Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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