What Is Bursitis?

Overview

Bursitis is an acute or chronic inflammatory condition characterised by joint pain and swelling in the bursa (a fluid-filled sac that cushions the joints). The primary purpose of the bursae is to reduce friction between the moving parts of the joint whilst facilitating movement.  Bursitis predominantly affects young children and adults, causing issues with knee, hip, elbow, feet or shoulder joints. 

Causes of bursitis

Bursitis can be caused by  trauma, joint overuse, inflammatory disorders, or infectious diseases.¹

• Repetitive microtrauma - overhead activities or blunt traumas such as falls can lead to subacromial bursitis (a bursain the shoulder).This condition occurs most frequently in patients with rotator cuff tendinitis
• Autoimmune diseases e.g. rheumatoid arthritis (RA) - Hip joint pain  is a common finding in RA patients. In particular lateral hip pain which is caused by trochanteric bursitis may occur from excessive exercise such as cycling or running, or sometimes without any identifiable cause. Inactive persons are also susceptible to trochanteric bursitis, as the continuous pressure over the greater trochanter bursa can trigger an inflammatory response²
• Soft tissue stress - Adventitious bursitis is a common cause of forefoot pain, more specifically, in the plantar fat pad. The plantar fat pad is a specialised soft tissue structure providing the cushioning effect for the heel l of the foot, helping to absorb forces as our feet take on heavy loads each day. Adventitious bursitis in adults happens due to repetitive high friction and pressure. Adventitious bursitis is more likely to happen in people who are exposed to chronic  forefoot overload because of their job or because they wear high-heeled shoes³
• Metabolic conditions - Lower extremity complications are common among people with diabetes, resulting from complex interactions between diabetic vasculopathy, neuropathy, and diminished immunity response. Prepatellar bursitis is a very common condition affecting the kneecap in immunocompromised diabetic patients. These patients are also predisposed to septic bursitis, often with preceding repetitive trauma.⁴ Other conditions that cause immunosuppression and increase the risk of bursitis are  hemodialysis and chronic steroid use

Signs and symptoms of bursitis

• Joint pain and inability to move the joint through its full range of motion which can be acute or chronic
• Tenderness or warmth that does not usually include the surrounding skin
• Swelling of the affected joint¹

Management and treatment for bursitis

The vast majority of bursitis cases heal on their own. Nevertheless, there are numerous treatment options for pain management. These include;

Conservative treatment

• Rest, ice application to the affected area, compression, and elevation.

Also, patient education is crucial to avoid any exacerbating movements. Superficial bursae can be protected with padding/cushioning where prolonged pressure on the elbows or knees in  some occupations can be effectively prevented.  

Pharmaceutical

• Antibiotics (for septic bursitis)
• Oral non-steroidal anti-inflammatories (NSAIDs) and acetaminophen are first-line therapies for analgesia, symptomatic pain relief and bursitis treatment

*It is always important to consult your GP before starting any medication as some medcations can have some serious side effects.

Corticosteroid Injections

• A localised injection of cortisone, combined with local anaesthetic lidocaine or marcaine, offer symptomatic relief and directly targets the inflammatory process in bursitis. However, corticosteroid injections are not indicated for superficial bursitis. Because it increases the risk of iatrogenic (acquired) septic bursitis, local tendon injury, or skin atrophy. Additionally, a study conducted in 2018 demonstrated that the long-term benefits of receiving corticosteroid injections were similar to those who underwent physical therapy^1,5

Physical therapy

• Physical therapy plays an important role in increasing muscle strength in the area around the bursa. In the case of subacromial bursitis of the shoulder physical therapy is crucial as sustained immobilisation may result in muscle atrophy, retraction, and frozen shoulder. Additionally, hip trochanteric bursitis is managed by strengthening the quadriceps muscle (the front thigh muscle)and stretching the iliotibial band. In addition to treatment, teaching young athletes proper running techniques is vital in maintaining hip mobility and flexibility.¹

Surgical management

• Initial management for bursitis is always non-operative, and surgery is very rarely employed. The surgery is usually endoscopic or arthroscopic, though often reserved for those not responding to conservative treatment or any of the management strategies mentioned above. 

FAQs

How is bursitis diagnosed?

The diagnosis of bursitis is done by reviewing the patient's symptoms, medical history, and  physical examination. Other pathologic processes and conditions may be confused for bursitis, especially if occurring simultaneously in the same location. Therefore your clinician will distinguish between these processes, as their management may drastically differ.

How can I prevent bursitis?

Prevention strategies to lower the risk of bursitis recurrence include;

• Taking frequent breaks from repetitive movements that may irritate the bursa
• Maintaining a healthy weight and exercising regularly to strengthen the muscles around joints
• Clean any open cuts on elbows and knees to reduce the risk of infection
• Wearing cushioned knee or elbow pads (for example, when kneeling is advised)
• Wearing comfortable shoes or orthotics
• Treating underlying conditions that increase the risk of bursitis, such as rheumatoid arthritis

Who is at risk of bursitis?

Anyone can develop bursitis. However, there are some factors that can increase risk;

• Age
• Occupation / sport activities that require repetitive motion or put pressure on particular bursae
• Certain systemic diseases and conditions — such as RA, gout, and diabetes
• Being overweight or obese increases the risk of hip and knee bursitis

When should I see a doctor?

It is best to seek medical advice when;

• Symptoms have not improved or are progressively getting worse after self-treatment for 1 to 2 weeks
• Inability to move the affected joint
• Feeling hot and shivering due to a high body temperature
• Experiencing very severe, sharp or shooting pains in the joint

Summary

• Bursitis is a mild condition , most patients are managed as outpatients
• It is best managed by an interprofessional team including; nurses, a sports physician, primary care provider, a rheumatologist, and an orthopaedic surgeon
• Most cases of non-infectious bursitis resolve on their own within a few weeks and many benefit from physical therapy to restore functionality
• Surgery is considered as a last resort, recommended only for cases that fail conservative treatment