Bursitis

Basic Patient education

What is bursitis? — Bursitis is a condition that can cause pain or swelling next to a joint. Most of the time, bursitis happens around the shoulder, elbow, hip, or knee. It can also happen around other joints in the body.

A “bursa” is a small fluid-filled sac that sits near a bone. It cushions and protects nearby tissues when they rub on or slide over bones. These sacs, called “bursae,” are found in many places throughout the body. Bursitis happens when a bursa gets irritated and swollen. This can happen when a person:

Moves a joint over and over again in the same way, over a short period of time

Sits on a hard surface or stays in a position that presses on the bursa for a long time

Has certain kinds of arthritis, such as gout or rheumatoid arthritis, that can affect their joints and bursae

Gets hurt near a bursa

Has an infection that spreads to a bursa

What are the symptoms of bursitis? — Symptoms of bursitis can include:

Pain or tenderness

Swelling

Trouble moving the joint

A bursa can get infected if a person gets a cut on the skin nearby. An infected bursa can cause a fever and the area around the bursa to be:

Red

Swollen

Warm

Painful

If you have any of the symptoms of an infected bursa, let your doctor or nurse know as soon as possible.

Is there a test for bursitis? — Yes. Your doctor or nurse will ask about your symptoms and do an exam.

If you have symptoms of an infected bursa, your doctor might use a needle to remove some fluid from the bursa. Then he or she can do lab tests on the fluid to find out what is causing the bursitis, and if you need antibiotics. He or she might also order imaging tests, such as an MRI scan or ultrasound. Imaging tests can create pictures of the inside of the body.

What can I do to treat my bursitis? 

— To treat your bursitis, you can:

Rest, cushion, and protect the area – Try not to irritate the area that hurts. For example, people with very painful shoulder bursitis might need to avoid lifting or carrying heavy things for a while. They might also need to wear an arm sling. People with bursitis behind the heel might need to use a thick heel pad. This can raise the heel so that it does not rub against the back of the shoe.

Avoid positions that put pressure on the area – For example, people with bursitis in the front of the knee should avoid kneeling.

Put ice on the area to reduce pain – Use a frozen bag of peas or a cold gel pack a few times a day for 20 minutes each time.

Put heat on the area to reduce pain and stiffness – Do not use heat for more than 20 minutes at a time. Also, do not use anything too hot that could burn your skin.

What other treatments might I have? — Your doctor or nurse might use other treatments, depending on your symptoms and where your bursitis is. Treatments can include:

Pain-relieving medicines called “nonsteroidal antiinflammatory drugs” or “NSAIDs” – NSAIDs include ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand name: Aleve). These medicines can reduce pain and prevent the bursae from getting swollen and painful.

Steroid injections – Steroid medicines help reduce inflammation. These medicines are different from the steroids athletes use to build muscle. Doctors can inject steroids into the area of the bursitis to help reduce symptoms.

Exercises and stretches – Your doctor or nurse might recommend that you work with a physical therapist. A physical therapist can teach you stretches and exercises to help reduce your symptoms.

Surgery – A doctor can do surgery if other treatments do not work and you have had symptoms for a long time.

People with an infected bursa might also have treatment that includes:

Antibiotics

Having the fluid in the bursa drained – A doctor can drain the fluid using a needle and syringe, or by doing surgery.

Can bursitis be prevented? — Yes. To help reduce the chance that you get bursitis, you can:

Use cushions or pads to avoid putting too much pressure on joints – For example, people who garden can kneel on a kneeling pad. People who sit for a long time can sit on a cushioned chair.

Take breaks, if you are using a certain joint too much

Stop an activity or change the way you are doing it, if you feel pain

Exercise

Lose weight, if you are overweight

Use good posture

BURSITIS OVERVIEW — Advanced Patient Education 

— Bursitis is an inflammation or irritation of the bursae (plural of “bursa”). The bursae are fluid-filled sacs in the joints that decrease friction and provide a cushion between bones, muscles, and skin.

Bursitis can be acute (often as a result of an injury or infection) or chronic (for example, following a long period of repetitive use or motion). It can affect almost any joint in the body, although some are more commonly affected than others.

BURSITIS CAUSES 

— Causes of bursitis include:

Injury, such as from a fall or hit

Prolonged pressure, which can result from kneeling, sitting, or leaning on a particular joint for a long period

Strain or overuse from repeating the same motion many times

Joint stress from an abnormal gait; for example, walking unevenly because one leg is shorter than the other

Gout or other crystal diseases

Certain types of arthritis, like rheumatoid arthritis or psoriatic arthritis

Infection resulting from bacteria entering the body through a cut or scrape in the skin

BURSITIS SYMPTOMS 

— Common symptoms of bursitis include pain and swelling in the affected joint. Visible swelling is more common in bursae that are closer to the surface of the skin (such as those around the elbows, kneecaps, and heels), and less common in deeper areas (such as the shoulders, hips, and inner knees).

In acute bursitis, there is often pain directly over the affected bursa; active motion (when the patient moves or bends the joint) also causes pain. People with chronic bursitis are more likely to have swelling, often with minimal pain. They may have limited range of motion due to avoiding moving the joint and surrounding muscles. Bursitis caused by an infection is called “septic bursitis.” Symptoms may include pain, swelling, warmth, and redness around the affected joint. Fever may also be present. This is a potentially serious condition, since infection can spread to nearby joints or the blood. Specific symptoms vary depending on the area that is affected. (See ‘Types of bursitis’ below.)

BURSITIS DIAGNOSIS 

— Diagnosing bursitis involves a physical examination, a review of your symptoms, and sometimes tests.

If infection or crystal disease (for example, gout) is suspected, your doctor may use a syringe and needle to remove a sample of fluid from the affected bursa. This is called “aspiration.” The fluid can then be examined under a microscope for crystals, bacteria, and white blood cells. Imaging (such as radiograph, MRI, or ultrasound) is not usually needed to diagnose bursitis. However, it can help in some situations, such as when other problems (for example, a tear in the cartilage or ligament) need to be ruled out quickly. It can also be useful if your doctor needs to remove fluid from a bursa near other areas that could be injured, such as nerves or blood vessels. Imaging can allow the doctor to see where the needle is going.

TYPES OF BURSITIS 

— Bursitis can affect many different areas of the body. The exact symptoms and preferred treatments depend on the location as well as the cause.

Shoulder (subacromial bursitis) — Shoulder bursitis causes pain in the shoulder and outside of the upper arm (figure 1). Pain is often present at rest but increases with movement of the arm, especially with lifting the arms above the head; it also often interrupts sleep. It can be difficult to differentiate shoulder bursitis from other issues such as a rotator cuff tear or tendinitis.

Upper back (scapulothoracic bursitis) — Upper back bursitis affects the space between the scapula (shoulder blade) and ribs, and can cause pain or a popping sensation. Reaching the arms overhead or doing pushups can make pain worse.

Elbow (olecranon bursitis) — Elbow bursitis usually causes a visible swelling at the tip of the elbow, like a golf ball. It can result from injury, infection, crystals (gout), or rheumatoid arthritis. It usually causes pain when the elbow is flexed, but not extended. The elbow often extends fully without discomfort.

Pelvis (ischial bursitis) — Pelvic bursitis has also been referred to as “weaver’s bottom” or “tailor’s bottom,” since it is often caused by prolonged sitting on hard surfaces. It causes pain in the lower buttocks that is aggravated by sitting (figure 2); pain may disappear when the person stands.

Hip

Greater trochanteric pain syndrome (formerly called trochanteric bursitis) — The greater trochanteric bursa is located in the upper outer part of the femur (thigh bone) (figure 2). Bursitis in this area is usually associated with inflammation of nearby tendons and can cause pain while lying or sleeping on the affected side of the body. People with greater trochanteric pain syndrome also tend to have pain when extending the leg to walk, but not while standing still. Symptoms can be aggravated by an abnormal gait, due to uneven stress on the hips. There are many contributing factors, including chronic back pain, contralateral knee pain (knee pain on the opposite side of the body from the bursitis), different leg lengths, and being overweight.

Iliopsoas bursitis — The iliopsoas bursa is deep in the front of the hip. This type of bursitis causes pain in the groin area, particularly when the hip is flexed against resistance. It can result from arthritis in the area, overuse (for example, excessive running), or injury. Because symptoms are similar to those of other hip problems (for example, problems with the bone or cartilage), imaging tests are often required to confirm the diagnosis. Infection in the psoas muscle (psoas abscess) can have similar symptoms. (The psoas muscle runs from the spine to the femur, and is used to flex the hip.)

Knee

Prepatellar and infrapatellar bursitis — The prepatellar bursa is located at the front of the knee, on top of the patella (kneecap) (figure 3); the infrapatellar bursa is below this. Bursitis in these areas can result from recurrent injury to the knee, and is often seen in people who frequently kneel (prepatellar bursitis has been referred to as “housemaid’s knee” or “nun’s knee”). It can also happen as a result of infection, gout, or rheumatoid arthritis. Swelling occurs within the bursa, not in the knee joint itself. People with prepatellar and infrapatellar bursitis usually feel more comfortable lying down with the knee extended, while people with swelling within the true knee joint tend to feel better lying down with the knee bent.

MCL bursitis — The medial collateral ligament (MCL) is located on the inner side of the knee, and connects the femur (thigh bone) to the tibia (shin bone) (figure 4). Bursitis in this area can cause pain and tenderness, but doesn’t usually involve swelling. It must be differentiated from an injury or tear to the MCL or meniscus (the cartilage in the knee).

Pes anserinus pain syndrome — The anserine bursa is located about two inches below the top of the tibia (shin bone), on the inner side of the knee. Pes anserinus pain syndrome (formerly referred to as anserine bursitis) causes pain on the inner side of the knee, which tends to come on abruptly, often during the night. It is common in people with arthritis of the knee; it can also result from an uneven gait (for example, walking with a limp or while favoring one leg over time), or from flat feet.

Heel (retrocalcaneal bursitis) — The retrocalcaneal bursa is between the heel bone and the Achilles tendon, which connects the heel to the calf muscle. It normally serves as a cushion to absorb impact when walking. Retrocalcaneal bursitis can cause pain and swelling in the area. It can be easily confused with tendinitis (inflammation of the Achilles tendon).

BURSITIS TREATMENT 

— Bursitis treatment focuses on relieving inflammation and pain, treating infection (if present), and preventing complications and future recurrence.

Medication — In most cases, nonsteroidal antiinflammatory drugs (NSAIDs) can help relieve pain and inflammation. NSAIDs include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve); other NSAIDs, as well as higher doses, are also available by prescription. (See “Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)”.)

A glucocorticoid (steroid) injection can also help with inflammation. This is more often used when the affected area is deep under the skin (see ‘Shoulder (subacromial bursitis)’ above and ‘Greater trochanteric pain syndrome (formerly called trochanteric bursitis)’ above and ‘MCL bursitis’ above and ‘Pes anserinus pain syndrome’ above). It is not usually helpful for more superficial types of bursitis, for example, in the olecranon bursa of the elbow, prepatellar bursa of the knee, or retrocalcaneal bursa of the heel. Septic bursitis requires drainage of the infected fluid and antibiotics to treat the underlying infection. (See ‘Treating infection’ below.)

Protecting the joints — It is important to protect the affected joints in order to help the bursae to heal, and to prevent the bursitis from getting worse or recurring. Examples of joint protection include:

Avoiding or modifying activities that cause pain

The use of pads or cushions for people who have to kneel or sit frequently

Modifying footwear to reduce pressure on the back of the heel (eg, cutting a “V”-shaped groove into the back of a shoe; using a pad inside the shoe to lift the heel)

Custom-fitted devices worn over the elbows to protect them and prevent fluid from building up again

Other measures 

— Ice can help relieve pain, particularly for bursitis affecting superficial areas like the elbow, kneecap, and heel. Heat (eg, a heating pad) may be more effective for deeper forms of bursitis, such as the hip, shoulder, or inner knee.

In many cases, physical therapy can help treat symptoms of bursitis and prevent future recurrence. The optimal exercises depend on the type and severity of bursitis, but may involve stretching, strengthening, or working to improve (and maintain) range of motion. Rarely, surgery is required to remove all or part of the affected bursa.

Treating infection — Septic bursitis is treated with antibiotics. The choice of which antibiotic to use, and for how long, is based on the type and severity of infection. For mild cases, a few weeks of oral antibiotics may be enough; for more severe infection, intravenous (IV) antibiotics (given in the hospital) may be required.

It is also often necessary to drain infected fluid using a needle. This is done in a doctor’s office, usually several times, until the infection has resolved.

WHERE TO GET MORE INFORMATION 

— Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

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