eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Bursitis

Author: Eileen Chang, MD, Attending, Department of Emergency Medicine, North Shore Medical Center
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: Jan 13, 2010

Introduction

Background

Bursitis is inflammation of a bursa caused by repetitive use, trauma, infection, or systemic inflammatory disease. Bursae are flattened sacs that serve as a protective buffer between bones and overlapping muscles (deep bursae) or between bones and tendons/skin (superficial bursae). These synovial-lined sacs are filled with minimal amounts of fluid to facilitate movement during muscle contraction. Deep bursae, such as the subacromial and iliopsoas bursae, are located in the fascia. Superficial bursae, such as the olecranon and prepatellar bursae, are located in the subcutaneous tissue. Humans have approximately 160 bursae. Bursitis most commonly affects the subacromial, olecranon, trochanteric, prepatellar, and infrapatellar bursae. Symptoms of bursitis may include localized tenderness, edema, erythema, and/or reduced movement.

Pathophysiology

Inflammation causes synovial cells to multiply and thereby increases collagen formation and fluid production. A more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. Hemorrhage may occur. One study suggests this process may be mediated by cytokines, metalloproteases, and cyclooxygenases. In septic arthritis, local trauma usually causes inoculation of bacteria into the bursa, which triggers the inflammatory process.

Clinical

History

• History of patients with bursitis may include the following:
  • Localized tenderness
  • Decreased range of motion or pain with movement
  • Erythema or edema (seen in superficial bursitis)
  • History of repetitive movement (eg, frequent kneeling leading to prepatellar or infrapatellar bursitis)
  • History of inflammatory disease (eg, rheumatoid arthritis, systemic lupus erythematosus)
  • History of trauma

Physical

There are specific bursae that are more likely to become inflamed.

• Subacromial (subdeltoid) bursitis
  • The subacromial bursa lies between the acromion and the rotator cuff. It cushions the coracoacromial ligament from the supraspinatus muscle. When the arm is resting at the side, the bursa protrudes laterally from beneath the acromion. When the arm is abducted, it rolls medially beneath the bone. Subacromial bursitis is frequently associated with supraspinatus tendonitis because inflammation extends from one structure to the next.
  • Repetitive activities with an elevated arm most frequently cause inflammation of the bursae. Examples of this include frequent pitching of a baseball or lifting luggage overhead.
  • Less commonly, a primary process, such as rheumatoid arthritis, gout, or tuberculosis, may lead to bursitis.
  • Patients often exhibit tenderness over the greater trochanter. Difficulty in abduction may occur, specifically from 70-100 degrees.
• Olecranon bursitis
  • The olecranon bursa lies posteriorly between the olecranon process and the overlying skin. Because of its superficial location, it is easily traumatized from acute blows or chronic stress.
  • Trauma of the skin and surrounding tissues makes the olecranon a frequent location for infectious bursitis. The risk of septic bursitis increases in those who have a history of chronic disease. Because of the higher likelihood of infection, some physicians encourage aspiration and analysis of the bursa even when tenderness and erythema are minimal.
  • Chronic stress from repetitive forward-leaning positions with pressure on the elbows is seen in patients on long-term hemodialysis (dialysis elbow), in patients with chronic obstructive lung disease, in students, and in those with the occupation of laying down carpet. Lunger elbow has been suggested as a term to describe this affliction.
  • Nontraumatic causes of olecranon bursitis most commonly include gout, followed by pseudogout, rheumatoid arthritis, and uremia.
  • When inflamed, the bursa is evident as fluctuant bulge posterior to the olecranon process. Pain and tenderness over the bursa may be increased in extreme flexion as tension increases. Infectious bursitis is shown in the images below.
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    Acute infectious bursitis upon presentation to an emergency department. Image courtesy of Christopher Kabrhel, MD.

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    Acute infectious bursitis upon presentation to an emergency department. Image courtesy of Christopher Kabrhel, MD.

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    Infectious bursitis. Image courtesy of Christopher Kabrhel, MD.

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    Infectious bursitis. Image courtesy of Christopher Kabrhel, MD.

• Iliopsoas bursitis
  • The iliopsoas bursa, the largest bursa in the body, lies between the iliopsoas tendon and the lesser trochanter, extending upward into the iliac fossa beneath the iliacus muscle. Ten percent of patients develop a defect in the anterior part of the hip joint capsule, allowing communication of the joint with the bursa.
  • Iliopsoas bursitis is often associated with hip pathology (eg, rheumatoid arthritis, osteoarthritis) or recreational injury (eg, running). Infection of this bursa is rare.
  • Pain from iliopsoas bursitis radiates down the anteromedial side of the thigh to the knee and is increased on extension, adduction, and internal rotation of the hip. Typically, pain worsens slowly over weeks or months, and pain may be the only symptom present. Tenderness may occur anteriorly below the middle of the inguinal ligament and lateral to the femoral artery. Occasionally, a palpable mass or visible edema may be found lateral to the femoral vessels. Pulsations from the femoral artery are sometimes transmitted through this mass.
  • Retroperitoneal extension can cause an abdominal or pelvic mass that causes compressive syndromes in the groin (eg, femoral vein compression, femoral neuropathy) or pelvis (eg, medial displacement of pelvic structures, superior displacement of abdominal structures). Early authors described the classic triad of a palpable mass, extrinsic pressure on adjacent structures, and radiographic changes of advanced arthritis. It is now known that this triad is not sensitive for early disease. Imaging (eg, bursography, CT scan, MRI) may assist with diagnosis.
• Trochanteric bursitis
  • The trochanteric bursa has superficial and deep components. The superficial bursa lies between the tensor fascia lata and the skin; the deep bursa is located between the greater trochanter and the tensor fascia lata.
  • Patients are predominately women (male-to-female ratio of 2-4:1) in their fourth to sixth decade of life. Runners and ballet dancers may develop deep trochanteric bursitis from overuse injury. The disease is also associated with rheumatoid arthritis of the hips, osteoarthritis of the hips, lumbosacral disease, and leg-length discrepancies.
  • Patients experience chronic, intermittent, aching pain over the lateral hip. In 40% of cases, this radiates down to the lateral thigh. Walking or lying on the affected side exacerbates the pain. In the seated position, local tenderness is present over the greater trochanter or more posteriorly for deep bursa. Pain can be reproduced by hip adduction (superficial bursitis) or resisted active abduction (deep bursitis). More than one half of patients have pain on Patrick-Fabere testing (sequential flexion, abduction, external rotation, extension of the hip with the contralateral knee flexed). Range of motion of the hip joint itself should not be affected.
• Ischial bursitis
  • The ischial bursa lies between the ischial tuberosity and the overlying gluteus muscle.
  • Inflammation commonly arises as a result of trauma, prolonged sitting on a hard surface (weaver bottom), or prolonged sitting in the same position (spinal cord injury).
  • Pain may radiate down the back of the thigh and mimic sciatic nerve inflammation. In ischial bursitis, however, pain can be reproduced by pressure over the ischial tuberosity.
• Prepatellar bursitis
  • The prepatellar bursa lies between the patella and the skin.
  • Inflammation arises secondary to trauma or constant friction between the skin and the patella, most commonly when frequent forward kneeling is performed. Previously referred to as housemaid knee, it now is seen regularly in many other occupations, including carpet laying (carpet-layer knee), coal mining (beat knee), roofing, gardening, and plumbing. Bursitis may also develop 7-10 days after a single blow, such as a fall. Rheumatoid arthritis and gout may also be the cause of bursitis. The superficial location of the prepatellar bursa allows for easy introduction of microorganisms and predisposes to septic arthritis. Therefore, aspiration of fluid to rule out infection is highly recommended if any clinical suspicion is present.
  • Prepatellar bursitis is often visualized as fluctuant, well-circumscribed warm edema over the lower pole of the patella. Knee flexion causes increased tension over the bursa and increased pain. The knee joint itself, however, is normal.
• Infrapatellar bursitis
  • The infrapatellar bursa can be divided into superficial and deep components. The superficial component lies between the patellar ligament and the skin, while the deep component lies between the patellar ligament and the proximal anterior tibia.
  • Superficial infrapatellar bursitis (clergyman knee) is located more distally than prepatellar bursitis and is often caused by frequent kneeling in an upright position. It can also be seen in gout or syphilis. The differential diagnosis includes Osgood-Schlatter disease. The deep infrapatellar bursa is less frequently inflamed.
  • Clinically, the patient exhibits pain with flexion and extension at the extremes of the range of motion. Edema is located on both sides of the patellar tendon and is tender.
• Pes anserine bursitis
  • The anserine bursa separates the insertions of the sartorius, gracilis, and semitendinosus tendons from the tibial plateau. The name anserine originated because the edematous bursa, restrained by the 3 tendons, gives the appearance of a goose's foot.
  • Abnormal pull of any of the 3 tendons or an abnormal gait predisposes to repetitive friction and to bursitis. Patients with anserine bursitis are commonly obese, older females with a history of osteoarthritis of the knees. Association has also been described between this bursitis and type 2 diabetes mellitus. Other risk factors include long distance running, valgus knee alignment, and excess external rotation of the lower leg. Unlike prepatellar bursitis, anserine bursitis is almost never septic. The differential diagnosis includes medial collateral ligament strain and osteoarthritis of the medial compartment of the knee. It is helpful to ensure the medial collateral ligament is intact by performing a valgus stress maneuver.
  • Tenderness is present on the medial aspect of the knee 5 cm below the joint margin at the site of the tibial tubercle. Neither swelling nor warmth is present. Pain radiates along the medial joint line to the inner thigh and calf. Pain is exacerbated with stair climbing and extremes of flexion or extension. Anserine bursitis may occur bilaterally.
• Calcaneal bursitis
  • Two bursae are found at the level of insertion of the Achilles tendon. The superficial one is located between the skin and the tendon, and the deep one is located between the calcaneus and the tendon. The calcaneal bursa can become inflamed in patients with heel spurs or in patients with poor-fitting shoes (eg, high heels). Inflammation can occur secondarily from Achilles tendonitis, especially in young athletes.
  • Patients have tenderness to palpation of the bursa anterior to the Achilles tendon on both the medial and lateral aspects. They have pain with movement, worsened with dorsiflexion.

Causes

• General bursitis: Bursal inflammation may occur from many causes, including the following: acute trauma, chronic friction (eg, overuse injuries), crystal deposition (eg, gout and pseudogout), infection, and systemic diseases (eg, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic pulmonary osteoarthropathy, idiopathic hypereosinophilic syndrome).
• Septic bursitis
  • Septic bursitis occurs from direct introduction of microorganisms through traumatic injury or through contiguous spread from cellulitis (50-70% of cases). Less commonly, infection of deep bursae is due to contiguous septic arthritis or bacteremia (10% of cases). The most common causative organism is Staphylococcus aureus (80% of cases) followed by streptococci. Other organisms include mycobacteria (both tuberculous and nontuberculous strains), fungi (Candida), and algae Prototheca wickerhamii.¹
  • Predisposing factors include diabetes, alcoholism, steroid therapy, uremia, trauma, and skin disease. A history of noninfectious inflammation of the bursa also increases the risk of septic bursitis.
  • Although septic bursitis is not diagnosed based on clinical signs alone, certain signs that favor the diagnosis of septic over sterile inflammatory bursitis include the following:
    • Bursal tenderness/erythema
    • Bursal warmth
    • Peribursal cellulitis
    • Fever

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