eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Bursitis: Treatment & Medication

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

Treatment

Emergency Department Care

• Aseptic bursitis
  • Most patients with bursitis are treated conservatively to reduce inflammation. Conservative treatment includes rest, cold and heat treatments, elevation, nonsteroidal anti-inflammatory drugs (NSAIDs), bursal aspiration, and intrabursal steroid injections (with or without local anesthetic agents).
  • The affected area should be placed at rest. Shoulders should not be immobilized for more than a few days because of the risk of adhesive capsulitis. After immobilization, the patient should begin graduated range of motion exercises. Educate patients who have bursitis secondary to overuse about the importance of regular periods of rest and possible alternative activities to avoid recurrence. Applying cold treatments for 20 minutes every several hours may be of value in the first 24-48 hours. This may be followed with 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 are used as anti-inflammatory agents and for pain relief. One multicenter, double-blind, parallel study involved 372 patients with acute (ie, within 72 h) traumatic bursitis and/or tendonitis of the shoulder. Of those patients treated with 50 mg diclofenac bid/tid, 90% improved over 14 days, with 40-50% demonstrating at least moderate improvement.
  • Intrabursal steroid injections (with or without local anesthetics) should not be used if infection is suspected. In overuse injuries, injections should not replace cessation or modification of the offending activity. A wide range of steroids (eg, hydrocortisone, prednisolone, methylprednisolone, triamcinolone, betamethasone, dexamethasone) has been used. No single agent is demonstrably superior. Steroids can be mixed in the same syringe with lidocaine or bupivacaine. This therapy often is reserved for those patients in whom an adequate response has not been achieved by other measures after 7-14 days.
    • One study compared the short- and long-term effectiveness of betamethasone injections (6, 12, or 24 mg with 4 mL 1% lidocaine) for trochanteric bursitis.¹ Improvement in pain at 1, 6, and 26 weeks in 77, 69, and 61% of patients, respectively, was reported. Higher doses of steroids were significantly more effective (P <0.01).¹
    • In a second randomized study, 42 patients with olecranon bursitis were divided after bursal aspiration into 4 treatment groups.² The groups received intrabursal methylprednisolone (20 mg) plus naproxen (1 g/d for 10 d); intrabursal methylprednisolone without naproxen; naproxen; or placebo. The steroid injection was more successful in decreasing edema and preventing recurrence than naproxen or placebo.²
    • One small sample sized study has shown that injection under ultrasonographic guidance may be more efficacious than blind injection based on anatomy.
    • The potential complications of intrabursal injections include the following: infection, bleeding, allergy to injected agents, local subcutaneous atrophy, postinjection flare/pain, and tendon rupture. Postinjection pain may last several hours. Postinjection flares usually start within hours and may last up to 72 hours. Major tendons should not be injected.
  • 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.
• Septic bursitis
  • 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 antibiotics.
  • S aureus is the most common pathogen, 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 more rare and tend to occur in unusual clinical settings (especially in those who are predisposed to infection).
  • 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 Staphylococcus aureus (MRSA), vancomycin is an appropriate alternative treatment.
  • Duration of antibiotic treatment varies with the patient and clinical situation. Uncomplicated septic bursitis presenting within 7 days of infection should be treated with a minimum 10-day course. 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 of at least 15 days. Deep bursae infections have higher associations with bacteremia and require more aggressive and prolonged antibiotic therapy. Surgical drainage and/or debridement often are required.
  • Treatment for 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 tetracycline with or without rifampin.
  • Surgical intervention, such as incision and drainage with or without packing/wick placement is reserved for the following cases: 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; and recurrent or refractory disease after conservative treatment.

Consultations

• General/orthopedic surgery
• Rheumatology

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Nonsteroidal anti-inflammatory agents

Most commonly used for relief of mild to moderately severe pain. Although pain-relieving effects tend to be patient specific, ibuprofen is usually used for initial therapy.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Diclofenac (Voltaren)

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of prostaglandin precursors.

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderately severe pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Oxacillin (Bactocill, Prostaphlin)

Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Dicloxacillin (Dycill, Dynapen)

Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected.
Resistance to this drug results from alterations in penicillin-binding proteins.

Cephalexin (Keflex, Biocef)

First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens similar.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococci. Indicated for patients who cannot receive or have not responded to penicillins and cephalosporins or who have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures.
May need to adjust dose in renal impairment.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.

Betamethasone (Diprolene, Betatrex)

For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Hydrocortisone (Solu-Cortef, Westcort)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Methylprednisolone (AK-Pred, Delta-Cortef, Articulose-50, Econopred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Triamcinolone (Aristocort)

For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Dexamethasone (Decadron, Dexasone)

For various inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

• Search for CME/CE on This Topic »

• Pes Anserinus Bursitis (Physical Medicine and Rehabilitation)
• Bursitis (Orthopedic Surgery)
• Olecranon Bursitis (Physical Medicine and Rehabilitation)
• Olecranon Bursitis (Sports Medicine)

• Bursitis Overview
• Bursitis Causes
• Bursitis Treatment
• Arthritis Center
• Bursitis Symptoms

• Therapy Insight: The Changing Spectrum of Rheumatic Disease in HIV Infection
• Infectious Complications of Biological Therapy
• Polymyalgia Rheumatica Can Be Distinguished From Late Onset Rheumatoid Arthritis at Baseline: Results of a 5-yr Prospective Study