Bursitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Bursitis is characterized by the inflammation of a bursa and the buildup of the fluid in the bursal sac. A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving parts: muscles, tendons, or skin. Over 160 bursa are found throughout the body but relatively few of them can cause bursitis. Based on the nature of the inflammation, bursitis may be classified into 2 subtypes: septic and aseptic. The most common bursitis subtypes include subacromial, olecranon, trochanteric, prepatellar, and retrocalcaneal. Aseptic bursitis can be caused by overuse or repetitive injury to the joint, abnormal and bony structure, and/or crystal deposit in the bursa. Additionally, septic bursitis can be caused by bacterial infection of the bursa through a skin injury following repetitive trauma. Common causes of septic bursitis include Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus spp. Bursitis must be differentiated from tendonitis, cellulitis, osteoarthritis, ligamentous injuries, and septic arthritis. The symptoms of bursitis differ based on the location of the inflammation. Focal swelling, pain, and redness are symptoms common to all forms of bursitis. The diagnosis of bursitis is usually made clinically. There are no diagnostic lab findings associated with bursitis. However, patients with septic bursitis may have elevated ESR, CRP, and white blood cell count. Ultrasonography may be a useful tool for confirming the diagnosis of bursitis, while the aspiration of bursal fluids is usually reserved for the diagnosis of septic bursitis.^[1][2] Medical therapy for non-septic bursitis depends on the involved bursa and includes the RICE regimen (rest, ice, compression, elevation), NSAIDs, and/or corticosteroid injections. Restriction of activity is encouraged to prevent further injury and promote healing. Antimicrobials are the mainstay of therapy for septic bursitis. Surgical management is often reserved for non-responders.^[3][4][5]

Based on the nature of the inflammation, bursitis may classified into 2 subtypes: septic and aseptic. Common anatomic locations of bursitis include the shoulder, elbow, hip, knee, and ankle. The most common bursitis subtypes include:^[6][7][8][9]

• Subacromial bursitis
• Olecranon bursitis
• Trochanteric bursitis
• Prepatellar bursitis
• Retrocalcaneal bursitis

Bursitis is characterized by acute or chronic inflammation of a bursa and buildup of fluid in the bursa sac. A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving parts: muscles, tendons, or skin. Over 160 bursae are found throughout the body, though relatively few of them can cause bursitis. Aseptic bursitis can be caused by overuse and repetitive injuries to the joint, abnormal bony structure and crystal deposit in the bursa. It commonly affects the knee or elbow as a result of kneeling or leaning on the elbows longer than usual. Moreover, septic bursitis can be caused by bacterial infection of the bursa through the skin injury following repetitive trauma.^[7][10][11]

The following images depict different cases of bursitis:^[12]

• 
  Prepatellar bursitis – By Thomas Kees – Own work (Original text: eigenes Archiv (selbst photographiert)), CC BY-SA 3.0 de, https://commons.wikimedia.org/w/index.php?curid=25418133
• 
  Prepatellar bursitis – By Atropos235 – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=4079323
• 
  Olecranon bursitis – By en:User:NJC123 – en:Image:Bursitis_Elbow_WC.JPG, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2814450

Common causes of bursitis include:^{[1][8][13][14][15]}

Aseptic bursitis:

• Prolonged pressure, overuse, or strenuous activity
  • Elbows and knees are most commonly affected because they are rested upon more than many parts of the body with bursae and they also tend to endure the most repetitive use.
  • Shoulder bursitis is more commonly due to overuse of the shoulder joint and muscles.
• Other inflammatory conditions (e.g., rheumatoid arthritis and spondyloarthritis)
• Gout and pseudogout

Septic bursitis:

• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus spp

Bursitis symptoms and signs are relatively non-specific. Even after detailed history and physical examination, imaging studies are often necessary to rule out other musculoskeletal conditions. Bursitis must be differentiated from tendonitis, cellulitis, osteoarthritis, ligamentous injuries, and septic arthritis.^[7][8][9]

Bursitis accounts for 400 visits per 100,000 visits to primary care clinic. The exact prevalence and incidence of bursitis are unknown.^[15]

Common risk factors in the development of bursitis include:^[15]

• rheumatoid arthritis
• osteoarthritis
• gout or pseudogout
• cellulitis
• diabetes mellitus
• use of systemic glucocorticoids
• alcoholism
• malignancy
• leukopenia
• having a hobby or job that involves repetitive motions (e.g., bicycling, playing baseball, gardening, setting tiles)

Screening for bursitis is not recommended.^[16]

Bursitis is often caused by overuse and repetitive injuries to the joint. Symptoms of bursitis may develop rapidly within 2 to 3 days in an acute form. Patients with bursitis usually present with edema, erythema, and tenderness over the involved joint. In most cases, after an appropriate lifestyle adjustment, bursitis will gradually clear within a few days to weeks without any long-term consequences. If left untreated, acute bursitis may lead to chronic bursitis, which can result in cicatricial adhesions, reduced mobility, and progressive pain. With proper treatment and an activities adjustment, septic and aseptic bursitis are associated with an excellent prognosis.

Obtaining a complete history will be helpful in determining whether the bursitis is associated with any specific activities.^[7][8][9]

The diagnosis of bursitis is usually made clinically. There are no diagnostic lab findings associated with bursitis. However, patients with septic bursitis may have elevated ESR, CRP, and white blood cells.^[23][8][9]

X ray is rarely required in patients with bursitis. X ray may be used as a diagnostic measure to support a clinical diagnosis of bursitis. Joint x ray is generally reserved for patients with histories of significant trauma. A standard x ray may be helpful in diagnosing a fracture or dislocation.^[24][21][25]

CT scans are rarely required in patients with bursitis. CT scans are usually reserved for patients who do not respond to initial treatment. On a CT scan, superficial bursitis may be characterized by fluid density at the subcutaneous tissue.^[24][21]

MRI is rarely required in patients with bursitis. Due to the associated cost and time requirements, the utility of MRI is limited compere to ultrasound. MRI is often reserved for patients who are likely to have other medical conditions such as tumors, ligamentous injures, or tendon injuries. On MRI, bursitis is characterized by bursal fluid collection, subcutaneous edema, and joint effusion.^[24][21]

Ultrasonography may be helpful in confirming a diagnosis of bursitis. On an ultrasound, bursitis may be characterized by bursal wall distention with presence of local hypoechoic or anechoic intra-bursal material, synovial proliferation, calcifications, and rheumatoid nodules.^[26][27]

Other diagnostic studies for bursitis include aspiration of the bursal fluid. Aspiration of bursal fluids is not recommended for the diagnosis of all types of bursitis. It is usually reserved for confirming a diagnosis of septic bursitis.^[1][2]

Medical therapy for non-septic bursitis depends on the involved bursa and can include the RICE regimen (rest, ice, compression, elevation), NSAIDs, and/or corticosteroid injections. Restriction of activity is encouraged to prevent further injury and promote healing. Antimicrobials are the mainstay of therapy for septic bursitis. Surgical intervention is generally reserved for non-responders.^[3][4][5]

Surgical intervention is not recommended for the management of bursitis. However, surgical techniques including bursectomy or longitudinal band release are usually reserved for patients with chronic, recurrent, or septic bursitis.^[28][29]

Effective measures for the primary prevention of bursitis include maintaining a healthy weight, taking regular breaks from repetitive tasks, using foam for knee- and elbow-pads, and practicing good posture.^[30]

There are no established methods for secondary prevention of bursitis. However, a fast recovery may be facilitated by an adjustment in activities, the consistent use of foam for knee- or elbow-pads, and regular breaks during repetitive tasks.^[30]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Based on the nature of the inflammation, bursitis may classified into two subtypes: septic and aseptic. Common anatomic location include the shoulder, elbow, hip, knee, and ankle. The most common bursitis subtypes include subacromial, olecranon, trochanteric, prepatellar, and retrocalcaneal. Moreover, based on the location of the affected bursa in relation to the skin, bursitis may be further classified into two additional subtypes: superficial and deep. Superficial bursa are more prone to get infected with bacteria and develop septic bursitis. Common locations of septic bursitis include the knee (prepatellar bursitis) and elbow (olecranon bursitis).^[1][2][3][4]

Based on the nature of inflammation bursitis may classified as:^[1][2][3][4]

• Aseptic
• Septic

Common anatomic locations include:

• Elbow bursae
  • Olecranon bursa
• Shoulder bursae
  • Subacromial/subdeltoid bursa
  • Subscapularis recess
  • Subcoracoid bursa
  • Coracoclavicular bursa
  • Supra-acromial bursa
• Hip bursae
  • Trochanteric bursa
  • Iliopsoas bursa
  • Subgluteus medius bursa
  • Subgluteus minimus bursa
• Knee bursae
  • Prepatellar bursa
  • Infrapatellar bursa
  • Suprapatellar bursa
  • Medial collateral ligament bursa
  • Baker’s cyst
  • pes anserine bursa
• Ankle bursae
  • Retrocalcaneal bursa
  • Achilles bursea

Based on the location of the affected bursa in relation to the skin, bursitis may be further classified into two subtypes: superficial and deep.

• Common superficial forms of bursitis include:
  • Olecranon bursitis
  • Prepatellar bursitis
  • Infrapatellar bursitis
  • Retrocalcanea bursitis
• Common deep forms of bursitis include:
  • Trochanteric bursitis
  • Anserine bursitis
  • Subacromial bursitis

Additionally, based on duration of symptoms and presentation bursitis may classified as acute, subacute or chronic.

The following are images associated with different type of bursitis.^[1]

• 
  Subacromial-subdeltoid bursa – By Zameer Hirji – Zameer Hirji, Jaspal S Hunjun, Hema N Choudur (2011). “Imaging of the Bursae”. Journal of Clinical Imaging Science 1 (1): 22. DOI:10.4103/2156-7514.80374. ISSN 2156-7514.Figure 1, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=25309551

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Bursitis is characterized by acute or chronic inflammation of a bursa and buildup of fluid in the bursal sac. A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving parts: muscles, tendons, or skin. Over 160 bursae are found throughout the body, though relatively few of them can cause bursitis. Aseptic bursitis can be caused by overuse and repetitive injuries to the joint, abnormal bony structure, and crystal deposit in the bursa. It commonly affects the knee or the elbow as a result of kneeling or leaning on the elbows for a longer period of time than usual. Moreover, septic bursitis can be caused by bacterial infection of the bursa through skin injury following repetitive trauma.^[1][2][3]

Bursitis is characterized by acute or chronic inflammation of a bursa and buildup of fluid in the bursal sac. A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving parts: muscles, tendons, or skin. Over 160 bursae are found throughout the body, though relatively few of them can cause bursitis.

• Bursitis commonly affects a knee or elbow, from kneeling or leaning on the elbows longer than usual on a hard surface.
• Aseptic bursitis can be caused by the following factors:^[3]
  • Injuries, overuse, and repetitive stress to the joint
  • Abnormal bony structures or soft-tissue changes that affect the movement of the joint
  • Crystal deposit in the bursa in patients with gout and pseudogout

• Septic bursitis can be caused by bacterial infection of the bursa via the following routes:^[1][2][3]
  • Through a skin injury following repetitive trauma
  • Via fistula (vascular access) in chronic hemodialysis patients
• Bursa close to the surface of the skin are the most likely to become infected with bacteria. Common locations of septic bursitis include:
  • Olecranon bursitis (in carpenters, athletes, or hemodialysis patients)
  • Prepatellar or infrapatellar septic bursitis (in athletes and those whose occupations involve regular kneeling)
  • Ischiogluteal bursitis (in weavers and patients with spinal cord injuries)
  • A bursa on medial aspect of the first metatarsophalangeal joint (due to skin breakdown in patients with hallux valgus and inappropriate shoes)

On gross pathology, characteristic findings of bursitis include a thickened, erythematous, and shaggy bursal wall with fibrinous exudates.^[4]

On microscopic histopathological analysis, chronic inflammation and scarring are characteristic findings of bursitis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2] Luke Rusowicz-Orazem, B.S.

Aseptic bursitis is commonly caused by prolonged pressure, overuse, or strenuous activity. Elbows and knees are the most commonly affected because they are rested upon more than many other parts of the body with bursae and they also get the most repetitive use. Shoulder bursitis is more commonly due to overuse of the shoulder joint and muscles. Inflammation of bursae can also be caused by other inflammatory conditions such as rheumatoid arthritis and Spondyloarthritis. Gout and pseudogout can also be a cause of bursitis. Common causes of septic bursitis include Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus spp.^{[1][2][3][4][5]}

Common causes of aseptic bursitis include:^[1][2][3]

• Direct injury or trauma
  • Prolonged pressure (can occur after prolonged kneeling or leaning on an elbow)
  • Overuse or excessive strenuous activity
• Systemic inflammatory disease
  • rheumatoid arthritis (RA)
  • Spondyloarthritis
• A crystal-depositing condition
  • Gout
  • Pseudogout

Common causes of septic bursitis include:^[2][4][5]

• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus spp

Less commonly, septic bursitis is caused by:

• Mcobacteria
• Haemophilus influenzae
• Sporothrix schenckii

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Bursitis symptoms and signs are relatively non-specific. Even after collecting a detailed history and performing a physical examination, imaging studies are often necessary to rule out other musculoskeletal conditions. Bursitis must be differentiated from tendonitis, cellulitis, osteoarthritis, ligamentous injuries, and septic arthritis.^[1][2][3]

Bursitis must be differentiated from:^[1][2][3]

• Tendonitis
• Cellulitis
• Osteoarthritis
• Gout and Pseudogout
• Rheumatoid Arthritis (RA)
• Septic arthritis
• Ligamentous injury
• Fracture

Based on anatomic location, bursitis must be differentiated from:

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Bursitis accounts for 400 visits per 100,000 visits to primary care clinics. The exact prevalence and incidence of bursitis are unknown.^[1]

• The exact incidence and prevalence of bursitis are not known.
• The incidence of septic olecranon and prepatellar bursitis is estimated to be 10 to 100 cases per 100,000 hospital admissions.^[1]
• In sport medicine practice, the incidence of trochanteric bursitis was estimated to be 560 cases per 100,000 cases.^[2]

• Prepatellar bursitis can affect all age groups. However, the incidence of septic bursitis is higher in children, particularly immunocompromised patients.
• Olecranon bursitis affects middle-aged people (between the ages of 30 and 60 years).
• Trochanteric bursitis can affect all age groups, though the incidence of trochanteric bursitis may be higher in middle-aged to elderly adults.^[3]

• Males are more commonly affected by prepatellar bursitis and septic bursitis than women.
• Females are more commonly affected by trochanteric bursitis or greater trochanteric pain syndrome (GTPS) than male. The female to male ratio is approximately 4 to 1.^[3]

• There is no racial predilection to bursitis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Common risk factors in the development of bursitis include rheumatoid arthritis, osteoarthritis, gout, pseudogout, cellulitis, diabetes mellitus, use of systemic glucocorticoids, alcoholism, malignancy, and leukopenia. Additionally, having a hobby or job that involves repetitive motions such as bicycling, playing baseball, gardening, or setting tiles may lead to bursitis.^[1]

Common risk factors in the development of aseptic bursitis include:^[1]

• Middle age
• Diabetes
• Rheumatoid arthritis
• Osteoarthritis
• Gout
• Pseudogout
• Having a hobby or job that involves repetitive motions (e.g., bicycling, playing baseball, gardening, setting tiles)

Common risk factors in the development of septic bursitis include:^[1]

• Repetitive trauma
• Prior history of septic bursitis
• Cellulitis
• Diabetes mellitus
• Use of systemic glucocorticoids
• Alcoholism
• Malignancy
• Leukopenia
• Chronic renal failure
• Uremia

Based on anatomic location, common risk factors in the development of bursitis include:

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Screening for bursitis is not recommended.^[1]

Screening for bursitis is not recommended.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Bursitis is often caused by recurrent micro-trauma and overuse. Symptoms of bursitis may develop rapidly within 2 to 3 days in an acute form. Patients with bursitis usually present with edema, erythema, and tenderness over the involved joint. In most cases after adjustment of activities, bursitis will gradually clear within a few days to weeks without any long-term consequences. If left untreated, acute bursitis may lead to chronic bursitis, which can result in cicatricial adhesions, reduced mobility, and progressive pain. With treatment and an adjustment in activities, septic and aseptic bursitis are associated with excellent prognoses.^[1][2][3][4]

Aseptic bursitis is often caused by recurrent micro-trauma and overuse. Symptoms of bursitis may develop rapidly within 2 to 3 days in an acute form. It usually presents with edema, erythema, tenderness, and stiffness over the involved joint. In most cases, after an adjustment of activities, bursitis will gradually clear within a few days to weeks without any long-term consequences. If left untreated, acute bursitis may lead to chronic bursitis, which can result in cicatricial adhesions, reduced mobility, and progressive pain.^[5][6]

Septic bursitis often occurs in patients with underlying medical conditions such as diabetes, immunosuppression, and alcoholism. Symptoms of septic bursitis develop rapidly after bursal infection with a bacterial organism that has entered a patient’s system through a skin breakdown or cut. Patients may present with fever, warmth, erythema, edema, and pain over the joint. If left untreated, septic bursitis may lead to osteomyelitis or cutaneous fistula formation. Additionally, bursitis may lead to recurrent infection in immunocompromised patients.^[7]

Common complications of bursitis include:^[4][7]

• Cicatricial adhesions in the joint
• Reduced range of motion or mobility
• Progressive pain
• Limited activity level

• With treatment and an appropriate adjustment in activities, aseptic bursitis is associated with an excellent prognosis.
• With appropriate antibiotic treatment, septic bursitis is associated with a good prognosis. In rare cases, the infected bursa may have to be removed surgically if other treatments are ineffective.^[4]

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