Bursitis in Emergency Medicine Treatment & Management

  • Author: Eileen Chang, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jan 13, 2010
 

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).[3]
    • 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.[4] Of those patients treated with 50 mg diclofenac bid/tid, 90% improved over 14 days, with 40-50% demonstrating at least moderate improvement.
    • The musculoskeletal injection for bursitis can be performed in the emergency department or the outpatient setting.[5] 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. The procedural method of injection of bursae has been detailed in recent literature.[6, 5]
      • 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.[7] 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).[7]
      • In a second randomized study, 42 patients with olecranon bursitis were divided after bursal aspiration into 4 treatment groups.[8] 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.[8]
      • One small sample-sized study has shown that injection under ultrasonographic guidance may be more efficacious than blind injection based on anatomy.[9]
      • 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.[10] 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 of 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.[11]
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Consultations

  • General/orthopedic surgery
  • Rheumatology
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Contributor Information and Disclosures
Author

Eileen Chang, MD  Attending, Department of Emergency Medicine, North Shore Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Janet Kay Talbot-Stern, MD, FACEM, FCEM  Emergency Medicine VMO, Ryde and Bankstown Hospitals, Australia

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

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 

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