Bursitus:
A bursa is a sac-like structure that protects soft tissues from injuries that
could be caused by pressure from nearby bones. Each bursa produces a
lubricating fluid that fills the sac and decreases friction between bones,
tendons, and ligaments.
Bursae are located throughout the body. However, certain joints are more
subject to increased pressure and repetitive use and are more likely to
develop bursitis, in which a bursa becomes inflamed and irritated. These
joints include the shoulders, elbows, knees, and feet. Bursa near the hip
joint, particularly those on the outer side of the hip and those in the lower
buttocks (which are subjected to pressure from sitting), are also prone to
bursitis.
BURSITIS CAUSES
Bursitis can develop with the following conditions:
Prolonged pressure on a bursa
Arthritis of a nearby joint
Repetitive movements that cause irritation
Physical conditions that increase stress on the joints, such as having
legs of unequal length
Injury, such as that resulting from a fall, or the wearing of ill-fitting shoes
Medical conditions such as gout, rheumatoid arthritis, or pseudogout
Infection of a bursa (referred to as septic bursitis), which may occur
following trauma to the nearby skin or, less often, by spreading
through the blood from distant sites
If a bursa becomes septic (infected), the skin in the area around the bursa
usually becomes red, warm, and swollen. Excess fluid may also
accumulate within an infected bursa. The elbow and the knee are the most
common sites of an infected bursa, often as a result of injury to the
overlying skin. When redness and swelling are present, urgent medical
attention is necessary to determine if an infection is present.
An infected (septic) bursa is treated with antibiotics and with needle
drainage of the bursa fluid. Occasionally, if needle drainage is not possible
or is not effective, surgical drainage or removal of the bursa may be
necessary.
Surgery may also be recommended in some people with uninfected
bursitis, including those who have not responded to conservative treatment
and those who have had bothersome symptoms of bursitis for more than a
year.
BURSITIS SYMPTOMS
Bursitis can cause pain and tenderness, both with motion and at rest. It
may be difficult to move the joint due to the pain, and the area may be
swollen if the bursa is close to the skin surface.
BURSITIS TESTS
Bursitis can usually be diagnosed based upon your symptoms and upon
an examination by a clinician. If you have signs of an infected bursa
(swelling, redness, pain), a clinician may use a syringe and needle to
remove a sample of fluid from the bursa; the fluid is later examined with a
microscope for bacteria and white blood cells.
Imaging tests, such as ultrasound or magnetic resonance imaging (MRI),
may be used if your diagnosis is not clear based upon your medical history
and physical examination.
Bursitis may be the first sign of gout, pseudogout, or rheumatoid arthritis. If
you have bursitis that recurs or that does not respond to treatment, further
testing may be recommended to determine if there is an underlying cause.
BURSITIS TREATMENT
Bursitis treatment focuses on relieving inflammation and pain, on treating
infection (if needed), and on reducing factors that led to the bursitis.
General measures — During the recovery process, it is important to
protect the bursa from further injury, to rest the joint, and to apply ice.
Nonsteroidal antiinflammatory drugs (NSAIDs), heat, and steroid injections
may also be recommended.
• Protecting the bursa helps to decrease pressure within the bursa sac.
Cushioning the affected area, avoiding positions that place pressure
on it, and resting the joint help to minimize pressure and to relieve
pain.
• You can apply ice in the form of a frozen gel pack or a frozen bag of
peas. You can apply ice for 20 minutes several times per day, as
needed to reduce pain.
• Nonsteroidal antiinflammatory drugs (NSAIDs), like ibuprofen,
indomethacin, or naproxen, may relieve pain and swelling.
Prescription strength tablets can make it more convenient to take the
relatively high doses of NSAIDs that are needed to control the
attack.
• In some cases, heat treatments may be recommended to relieve pain
and stiffness. Heat can be applied to the joints with a hot pack, a hot
water bottle, or a heating pad. However, it is important to avoid
burning the skin. Hot water bottles should be filled with warm, not
boiling, water, and heating pads should be set on a timer and should
be used for no more than 20 minutes at a time.
• An injection of a steroid (glucocorticoid) and local anesthetic mixture may
be considered in some situations, such as if the pain is persistent or
is severe at night or if the area is visibly swollen.
Specific types of bursitis — The features and treatments for specific
types of bursitis are discussed in the following sections.
Knee bursitis — There are two major bursae of the knee.
• Prepatellar bursitis — The prepatellar bursa is located in front of the
knee cap (patella) Prepatellar bursitis is a common condition that is
related to repetitive pressure on the knee cap, seen in people who
kneel frequently. Prepatellar bursitis may also be due to infection or
gout.
•
• Swelling over the patella (knee cap) is usually visible. The inflammation
usually resolves with rest.
• Anserine bursitis — The anserine bursa is over the lower leg bone on the
inner aspect of the knee, near a site at which several tendons attach
to the bone Anserine bursitis causes pain over the tibia, located just
below and to the inside of the knee joint. Anserine bursitis is
commonly caused by an abnormal gait (eg, limping) and is common
in people with arthritis of the knee. It is also common in women who
have a large fat pad over the anserine bursa. Repetitive knee
bending such as stair climbing can aggravate anserine bursitis.
•
• Treatment includes eliminating squatting and avoiding repetitive knee
bending, crossing of your legs, and other activities that increase
pressure on the bursa. Putting a pillow between the knees may
reduce pain at night. You can apply ice for 15 minutes every four to
six hours to relieve pain. An NSAID may help to reduce pain and
swelling. If you continue to have pain after six to eight weeks, you
may benefit from a steroid and local anesthetic injection into the
bursa.
Retrocalcaneal (heel) bursitis — Bursae may form at the surface of or
beneath the Achilles tendon, which connects the muscles in the calf to the
heel bone. Pain from retrocalcaneal bursitis can be chronic and severe.
Use of NSAIDs may be recommended to reduce inflammation. To reduce
pain, you can cut a “V”-shaped groove into the back of an old shoe, or you
can wear shoes without a back. Alternately, you can insert a thick heel pad
in the shoe to raise the heel slightly above the back of a shoe.
Glucocorticoid injections are not recommended for heel bursitis because
the Achilles tendon may rupture. Surgery is sometimes necessary for
permanent relief.
Intermetatarsal (foot) bursitis — With aging, the arches in the feet
flatten, and the long bones of the feet (called the metatarsals) can press on
the bursae that separate these bones from one another. Tight and narrow
shoes contribute to these events. Intermetatarsal bursitis may cause pain
in the foot, or pain may travel to the toes. Visible swelling is rare.
Treatment includes use of wider shoes, a rocker bar (a device added to the
soles of the shoes to decrease pressure on the metatarsals) and injection
of the area with a steroid and local anesthetic combination.
BURSITIS PREVENTION
Many routine activities, such as kneeling, carrying heavy objects, or
wearing tight-fitting shoes place stress and pressure on joints and irritate
bursal sacs. Small modifications can help to protect the joints and to
reduce the risk of bursitis. These include:
• Use cushions and pads to reduce pressure — Some positions, such as
kneeling and sitting, significantly increase joint pressure. Avoid
staying in one position for too long, and use pads to cushion the
joints. For example, a kneeling pad can be used to decrease
pressure on the knee, particularly during activities such as
gardening; cushioned knee protectors can be worn for other
activities on hard surfaces, such as laying carpet. Padded seat
cushions help to protect the bony prominences affected by sitting.
• Balance work and rest — Take periodic short breaks from tasks and
activities that increase joint pressure or that require repetitive
movements. If possible, alternate tasks with activities that use
different joints and muscle groups.
• Respect pain — Pain is often a sign that too much stress is being placed
on a joint and that an activity should be moderated or avoided.
When you notice pain or discomfort, take a break, change the way
you perform the activity, or move on to another activity.
• Maintain good posture — Avoid slouching forward when sitting, walking,
and standing.
• Maintain strength and range of motion — An exercise program can help
to maintain flexibility and strength. If you play sports, perform
conditioning exercises year-round to strengthen and maintain the
muscles that surround the joints most commonly used in the activity.
• Maintain normal weight — Excess body weight increases the pressure
placed on many joints. If you experience recurrent bursitis and are
overweight, you should consider a weight loss program. (See
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions
and concerns related to your medical problem.