Bursitis Treatment & Management

Most patients with bursitis are treated conservatively to reduce inflammation. Conservative treatment includes the following ^[15] :

• Rest
• Cold and heat treatments
• Elevation
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Bursal aspiration
• Intrabursal steroid injections (with or without local anesthetic agents)

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 (IV) antibiotic therapy.

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.

Most patients respond well to conservative management. Patients who do not respond to nonoperative treatment or who have signs of tendinous or ligamentous injury require further evaluation. Consultation with a general or orthopedic surgeon or a rheumatologist may be helpful.

With regard to resumption of activities, patients should let pain be their guide.

Conservative treatment involves control of pain and inflammation, which may be guided by the PRICEMM acronym, as follows:

• Protect - Use padding, braces, or changes in technique
• Rest - Avoid activities that exacerbate pain
• Ice - Cryotherapy can relieve pain and decrease inflammation
• Compression - Elastic dressings can ease pain, as in olecranon bursitis
• Elevation - Raise the affected limb above the level of the heart
• Modalities - Employ electrical stimulation, ultrasonography, or phonophoresis
• Medications - Administer nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or corticosteroid injections

Physical measures

The affected area should be placed at rest. Because of the risk of adhesive capsulitis, shoulders should not be immobilized for more than a few days. After immobilization, patients should begin graduated range-of-motion exercises. Patients who have bursitis secondary to overuse should be educated about the importance of regular periods of rest and possible alternative activities to prevent recurrence.

Applying cold treatments for 20 minutes every several hours may be of value in the first 24-48 hours. Such treatments may be followed by heat treatments. Elevation is useful, particularly in lower-limb bursitis. Consider site-specific therapy (eg, cushions for ischial bursitis; well-fitted, padded shoes for calcaneal bursitis).

A randomized comparative clinical trial by Homayouni et al in 56 patients with pes anserinus tendino-bursitis concluded that kinesiotaping of the tender area is more effective than 10 days of naproxen (250 mg three times daily) plus daily physical therapy for reducing pain and swelling. Kinesiotaping, using a space-correction (lifting) technique, was repeated three times in 1 week. ^[35]

NSAIDs

NSAIDs are used to reduce inflammation and relieve pain. In a multicenter, double-blind, parallel study involving 372 patients with acute (≤72 hours) traumatic bursitis or tendinitis of the shoulder, 90% of patients treated with diclofenac 50 mg two or three times daily improved over 14 days, with 40-50% demonstrating at least moderate improvement. ^[36]

A randomized trial by Kim et al in 133 patients with olecranon bursitis treated with compression bandaging and NSAIDs, aspiration, or aspiration with steroid injections found no differences in the proportion of patients whose bursitis resolved by week 4. Although treatment with steroid injection after aspiration was associated with the earliest resolution, the authors acknowledge the risk of complications with that method, along with the possibility of recurrence; thus, they suggest that “compression bandaging and a short course of NSAIDs may offer the most appropriate balance of safety and efficacy”. ^[37]

Topical NSAIDs have been used for reducing pain due to chronic musculoskeletal conditions; this may be complicated by mild skin reactions or other local adverse effects, but it reduces the risk of gastrointestinal adverse effects. ^[38] Some NSAIDs are commercially available in topical form, and any NSAID can be prepared for topical administration by a compounding pharmacy.

Intrabursal corticosteroid injections

Corticosteroid injections can be helpful if the patient does not respond to other treatment within 7-14 days. Various steroids (eg, hydrocortisone, prednisolone, methylprednisolone, triamcinolone, betamethasone, and dexamethasone) have been used in this setting, but no single agent has been found to be demonstrably superior. Steroids can be mixed in the same syringe with lidocaine or bupivacaine.

Corticosteroid injections can be performed either in the emergency department (ED) or in an outpatient setting. ^{[39, 40]} A 1.5-4 inch, 20-gauge spinal needle may be used as a probe to determine the points of maximal tenderness in the affected bursa. Typically, a mix of corticosteroid and local anesthetic is injected into each tender site. The corticosteroid dose should be 20 mg or less per lesion, and no more than a total of 40 mg of corticosteroid should be used. ^{[11, 13, 41]}

The potential complications of intrabursal injections include the following:

• Infection
• Bleeding
• Allergy to injected agents
• Local subcutaneous atrophy (Methylprednisolone is associated with the lowest incidence)
• Postinjection flare/pain (usually starts within hours and may last up to 72 hours)
• Tendon rupture (major tendons should not be injected)

Intrabursal steroid injections (with or without local anesthetics) should not be performed if infection is suspected. In overuse injuries, injections should not replace cessation or modification of the offending activity.

In a randomized study of 42 patients with olecranon bursitis who were assigned after bursal aspiration to 1 of 4 treatment groups (intrabursal methylprednisolone 20 mg plus naproxen 1 g/day for 10 days, intrabursal methylprednisolone without naproxen, naproxen only, or placebo), steroid injection was more successful in decreasing edema and preventing recurrence than naproxen or placebo was. ^[42]

In a systematic review of 29 studies involving a total of 1278 patients with olecranon bursitis, Sayegh and Strauch found that treatment of aseptic bursitis with corticosteroids was associated with significantly increased rates of overall complications and skin atrophy. Patients with aseptic bursitis had a significantly higher overall complication rate than those with septic bursitis. Compared with nonsurgical management, surgical management was significantly less likely to result in clinical resolution of septic or aseptic bursitis, and it was associated with significantly higher rates of overall complications, persistent drainage, and bursal infection. ^[43]

A study comparing the short- and long-term effectiveness of betamethasone injections (6, 12, or 24 mg with 4 mL of 1% lidocaine) for trochanteric bursitis reported that improvement of pain was achieved at 1, 6, and 26 weeks in 77%, 69%, and 61% of patients, respectively. ^[44] Higher doses of steroids were significantly more effective.

Ultrasound (US) can be used to guide aspiration and injection. ^[45] However, Mitchell et al reported that US-guided injection of the trochanteric bursa provides 2-week and 6-month outcomes similar to those of injection guided by anatomic landmarks, but is considerably more expensive. These authors advise that anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle (at least 2 in [50.8 mm]), with US guidance reserved for cases of extreme obesity or injection failure. ^[33]

In a study of 25 cases of postarthroplasty trochanteric bursitis requiring corticosteroid injection, Farmer et al found that corticosteroid injections were effective therapy and that nonoperative management may be more likely to fail in young patients and patients with leg-length discrepancies. ^[46] Of the 25 hips, 11 required multiple corticosteroid injections, and symptoms resolved in 20 cases.

An 8-week placebo-controlled study of acromial injections demonstrated that steroids brought about a decrease in pain and an improvement in function as compared with placebo. ^[47] Furthermore, the study showed no significant differences between higher (40 mg) and lower (20 mg) doses of triamcinolone acetonide. Therefore, in general, lower doses of steroids should be used initially.

Other injected agents

Experiences with platelet-rich therapy (PRT) injections of soft-tissue injuries (ligament, muscle, and tendon tears or tendinopathies) are increasingly being published. ^[48] A Cochrane review cited insufficient evidence to support the use PRT and a need for standardization of platelet-rich plasma preparations. ^[49]

Isolated case reports describe management of recurrent non-septic bursitis.with aspiration followed by injection of a sclerosing agent (eg, polidocanol). ^[50]

In cases in which septic bursitis is suspected, the bursa should be aspirated. The skin over the bursa is sterilized, and the area is anesthetized with lidocaine via a 27-gauge needle. A sterile 20- or 22-gauge needle is then introduced into the bursa. Fluid is aspirated and sent for analysis to identify any infectious organisms or crystals.

Staphylococcus aureus is the most common pathogen in septic bursitis, 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 rarer and tend to occur in unusual clinical settings (especially in patients who are predisposed to infection).

After aspiration and fluid analysis, antibiotic therapy is driven by the severity of the bursitis, the patient's clinical status (eg, toxic, febrile), underlying prostheses, history of methicillin-resistant S aureus (MRSA) or MRSA colonization, allergies, and ability to tolerate oral antibiotics. Based on these factors, there are various options, which include but are not limited to oxacillin (or a penicillinase-resistant penicillin), cefazolin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, ciprofloxacin, and rifampin. In severe cases or immunocompromised patients, admission for parenteral vancomycin therapy may be the appropriate treatment.

In a study involving 82 patients with severe septic bursitis, Martinez-Taboada et al concluded that in patients with severe septic bursitis but without extensive cellulitis, aspiration plus IV cloxacillin may be sufficient treatment, whereas in patients with more severe cases of septic bursitis, aspiration along with cloxacillin plus gentamicin may be appropriate in the majority. ^[51]

The duration of antibiotic treatment varies with the patient and the clinical situation. Patients with uncomplicated septic bursitis who present within 7 days of infection should be treated with a minimum 10-day course. ^[52] Outpatient treatment is effective in 40-50% of patients with mild to moderate infections. A 4-week course is advisable, using high doses of sensitivity-directed antibiotics. 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 at least 15 days of treatment. Deep bursae infections have higher associations with bacteremia and call for more aggressive and prolonged antibiotic therapy. In particularly severe cases, hospitalization is required, with 1 week of parenteral antibiotics followed by 30 days of oral antibiotics. Surgical drainage or debridement is often necessary.

Treatment of tuberculous bursitis involves full excision of the bursa and surrounding tissue with concomitant antituberculous therapy for 6-12 months. Infection with atypical mycobacteria may be successfully treated with conservative drainage and appropriate antibiotics. Brucella bursitis is treated with excision of bursae and administration of tetracycline with or without rifampin.

In general, bursitis is not treated surgically. However, there are some cases in which surgical interventions such as the following are appropriate:

• Incision and drainage
• Excision of chronically inflamed bursae
• Removal of underlying bony prominences

As a rule, surgical intervention is reserved for the following situations ^[53] :

• 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
• Recurrent or refractory disease after conservative treatment

Surgical release may be indicated when adhesive bursitis develops that severely limits joint motion. During surgery, the adhered bursa is removed, and the contiguous tissues are released. ^{[54, 55, 19, 56]}

In the upper extremity, subscapular bursitis can be caused by bony exostoses, and surgery may be needed to reduce these structures. In addition, the association of subacromial bursitis with rotator cuff impingement and tears is high, and surgical repair of the tear may be indicated. Singh and Bain describe a technique for treatment of olecranon spurs in which the spur is dissected out and excised in its entirety under endoscopic vision; this technique results in less morbidity compared with open excision and avoids an incision in the sensitive skin over the olecranon. ^[57]

In the lower extremity, Baker cysts (popliteal bursitis) are often removed surgically. Before open excision, arthroscopy should be performed to evaluate for intra-articular conditions. Most cysts are approached posteromedially through a hockey-stick incision.

For treatment of recalcitrant trochanteric bursitis, Pretell et al described distal “Z” lengthening of the fascia lata in 13 hips and found that 12 of the 13 patients reported good results. ^[58] According to the authors, this technique is less aggressive, can be performed with local anesthesia, and is associated with little morbidity and disability. The mean operating time for the procedure was 15 minutes, and one seroma was reported as a complication.

Lohrer and Nauck, in a prospective study of 89 athletes who underwent surgery for recalcitrant retrocalcaneal bursitis or recalcitrant midportion Achilles tendinopathy, found that clinical severity scores improved significantly at 6 and 12 months following surgery, and that improvements were similar among patients who did or did not undergo tendon repair. ^[59]

Endscopic procedures

A small case series from Australia found endoscopic bursectomy to be safe and effective as therapy for infectious prepatellar bursitis and suggested that it reduced the duration of hospitalization and hastened return to work as compared with conventional open surgical treatment. ^[60]

A systematic review from The Netherlands found that for surgical treatment of chronic retrocalcaneal bursitis, endoscopic approaches appear to yield better results than open approaches; however, more evidence is needed to establish the optimal surgical approach. ^[19]

A Korean review of endoscopic resection in 30 patients with olecranon bursitis (15 of them septic) reported excellent outcomes without recurrence or joint motion limitation in both septic and aseptic cases. Average follow-up was 21.1 months. ^[61]

A series of 27 endoscopic bursectomies for recalcitrant septic bursitis (14 cases of olecranon bursitis and 13 cases of prepatellar bursitis) reported good results, with no wound healing complications and only 1 minor recurrence. ^[62]