Bursitis

Aka: Bursitis

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II. Definitions

  1. Bursa
    1. Fluid-filled sac between adjacent musculoskeletal structures (e.g. tendon over bone, skin over bone) to reduce friction
    2. Bursa sacs are lined with synovial cells that secrete fluid in response to injury or inflammation
  2. Bursitis
    1. Inflammation or injury involving bursa

III. Causes: Bursitis

  1. Hemorrhage into bursa
    1. Direct Trauma
    2. Spontaneous with Coagulopathy
  2. Microtrauma
    1. Chronic, repetitive overuse (e.g. Olecranon Bursitis, Prepatellar Bursitis, calcaneal Bursitis)
  3. Inflammatory Bursitis
    1. Gouty Arthritis (esp. Olecranon Bursitis, Prepatellar Bursitis)
    2. Uncommon to rare causes include Pseudogout, Rheumatoid Arthritis
  4. Septic Bursitis
    1. Staphylococcus aureus accounts for >85% of cases, esp. Olecranon Bursitis, Prepatellar Bursitis
    2. Associated with focal erythema, warmth and tenderness

IV. Differential Diagnosis

  1. Joint effusion including Septic Arthritis
    1. Joint range of motion is maintained in Bursitis, but is reduced with joint effusion
  2. Cellulitis
  3. Fracture
  4. Tendinopathy

V. Imaging

  1. XRay Indications
    1. Trauma with suspected underlying Fracture
    2. Underlying deformity suspected (e.g. Haglund Deformity in calcaneal Bursitis)
  2. Ultrasound Indications
    1. Defines bursa when exam is difficult (e.g. overlying Cellulitis)
    2. Negative color doppler is associated with a low likelihood of inflammatory Bursitis and Septic Bursitis

VI. Labs

  1. Consider inflammatory markers (CBC, CRP, ESR)
  2. Bursa Aspiration
    1. See Septic Bursitis
    2. Indicated in suspected Septic Bursitis (and may consider in inflammatory Bursitis)
    3. Z-Track needle insertion to reduce risk of fistula
    4. Obtain cell count with differential, Gram Stain, culture, Glucose, crystal analysis
      1. Leukocyte count >10,000 with >50% Neutrophils (PMNs) is consistent with Septic Bursitis

VII. Management

  1. Exclude Septic Bursitis and inflammatory Bursitis
  2. Avoid further Trauma to the region (e.g. kneeling, resting elbows against table)
  3. Conservative management
    1. RICE-M
    2. Padding (to prevent recurrent Trauma, such as knee pads)
    3. Compression wraps
    4. NSAIDs
  4. Other measures
    1. Avoid intrabursal Corticosteroid Injection (poor evidence for benefit and associated risks)
    2. Aspiration may be considered in cases of large acute Traumatic bursal effusions
      1. However, fluid typically reaccumulates and risk of fistula formation
  5. Refractory, recurrent or persistent Bursitis that interferes with function
    1. Endoscopic bursectomy

VIII. References

  1. Raukar and Pensa (2022) EM:Rap 22(9): 10-1
  2. Khodaee (2017) Am Fam Physician 95(4): 224-31 [PubMed]

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