Bursitis is an inflammation a small fluid-filled sac called bursa that lubricates to reduce friction between a bone and muscle, skin or tendon. The most common places bursitis occurs is the olecranon and prepatellar bursae, but can also occur at the superficial infrapatellar and subcutaneous calcaneal bursea (Khodee, 2017). There various type of bursitis all of which depend on the affected bursa location. The commonly affected areas of the condition include the elbow, shoulder, hip, knees, and calf. The primary cause of this condition is sports injuries and repetitive movements although other factors such as bad posture, some types of arthritis, diabetes and certain medications effects may also cause bursitis (Sayegh & Strauch, 2014).
The exact prevalence and incidence of bursitis are not known. However, according to the report given by national health interview survey on disability, the incidence of bursitis is approximated to be 560 cases per every 100,000 admissions (Rhyou et al., 2016). The prevalence rate is estimated to be 32 cases in every 1000 people (Rhyou et al., 2016). Bursitis is a very common condition that even affects healthy individuals. It can occur at any age and affects both genders although the attack rate depends on the type of bursitis. For example, the incidence of trochanteric bursitis is higher in middle-aged groups as compared to elderly adults while prepatellar and septic bursitis commonly affects males than females.
On the pathophysiology of the condition, bursa inflammation causes the multiplication of synovial cells thereby increasing the formation of collagen and fluid production (Bonilla-Yoon et al,2014). As a result, high protein fluid entry is allowed by a more permeable capillary membrane causing the bursa to become filled with fluid often rich in fibrin. The fluid may become hemorrhagic. In septic arthritis, trauma causes bacteria inoculation into the bursa thereby triggering the inflammatory process (Bonilla-Yoon et al., 2014). The phases of bursitis are categorized into three which include acute, recurrent, and chronic. During acute bursitis phase, local inflammation occurs causing the thickening of synovial fluid that results in painful movement. In chronic bursitis phase, there is continual pain that causes weakening of overlying tendons and ligaments leading to ultimate rupture of the tendons (Bonilla-Yoon et al., 2014). In most cases, bursitis and tendinitis occur together due to the adverse effects of chronic bursitis on overlying structures.
- Acute bursitis is most often caused by trauma to the bursa. This is most often due to a trauma that causes bleeding into the area (Khodee, 2017).
- Chronic microtrauma is the most common cause of bursitis and is due to repetitive friction of tissue and bony prominences (Khode, 2017). These repetitive motions can include leaning on elbows, kneeling, crawling, or improperly fitted footwear or heels. It is also possible to have septic bursitis which usually starts as a cellulitis around the olecranon and prepatellar bursae (Khodee, 2017).
On physical assessment and examination, a patient presents tenderness at the inflamed bursa site. In a case of the superficial bursa, physical examination findings include localized tenderness, edema, warmth, and skin erythema. Also, during physical assessment, an active range of motion that is reduced with a preserved passive range of motion suggests the presence of bursitis (Rhyou et al., 2016). However, the differential diagnosis may include tendinitis and muscle injury that may have a similar clinical presentation. Patients with chronic bursitis may show disuse atrophy and weakness on the affected limb and weakened and tender tendons. Patients with septic bursitis during the physical examination may show signs and symptoms of fever, bursa warmth, and severe tenderness (Rhyou et al., 2016). Joint motion is preserved in bursitis that is septic, whereas the other bursitis types are related to a limited range of motion.
Differential diagnosis for bursitis include monoarthritis, tendinitis, gout, infection, joint effusions, or Morel-Lavallee lesions (Ferri, 2018). Diagnosis usually starts with a complete work. Patients will often times have a history of trauma to the area and have symptoms of pain, tenderness and a decreased range of motion to the area (Khodee, 2017). Fever may or may not be present. Diagnosis starts with fluid aspiration of the bursa fluid. Gram stains, culture and sensitivity, or crystal analysis maybe done on the fluid (Ferri, 2017). A plain radiography can be done to rule out foreign body or other bone or joint issues (Ferri, 2017). An ultrasound or MRI maybe performed to visualize the bursa when there is significant swelling to the area (Khodee, 2017).
The treatment of bursitis aims to conservatively reduce inflammation. Conservative treatment involves cold and heat treatments, elevation, rest, bursal aspiration, nonsteroidal anti-inflammatory drugs and intrabursal steroid injections (Sayegh & Strauch, 2014). In cases of septic bursitis treatment should include the use of antibiotics while awaiting culture results. On the other hand, oral outpatient therapy should be used to treat superficial septic bursitis (Rhyou et al., 2016). Those with systemic symptoms may require intravenous (IV) antibiotic therapy admission (Sayegh & Strauch, 2014). In cases of chronic or frequently recurrent bursitis surgical excision of bursae may be involved. This type of treatment is reserved for patients who experience failure of conservative treatment (Sayegh & Strauch, 2014). The operation varies depending on the infection site. Patient education could be another way of addressing the condition. Educating the patients on good posture, repetitive movement, and cushioning joints would help reduce bursitis cases (Rhyou et al., 2016). In most cases, patients respond to conservative management. Patients who do not respond well to nonoperative treatment may require further evaluation. Consultation with a general or orthopedic surgeon may be helpful (Rhyou et al., 2016).
Bonilla-Yoon, I., Masih, S., Patel, D. B., White, E. A., Levine, B. D., Chow, K., … & Matcuk, G. R. (2014). The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emergency Radiology, 21(1), 35-43.
Ferri, F. (2018). Ferri’s clinical advisor 2018. Elsevier: Philadelphia, PA.
Khodaee, M. (2017). Common superficial bursitis. American Family Physician,95(4), 224-231.
Rhyou, I. H., Park, K. J., Kim, K. C., Lee, J. H., & Kim, S. Y. (2016). Endoscopic Olecranon Bursal Resection of Olecranon Bursitis: A Comparative Study for Septic and Aseptic Olecranon Bursitis. The Journal of Hand Surgery (Asian-Pacific Volume), 21(02), 167-172.
Sayegh, E. T., & Strauch, R. J. (2014). Treatment of olecranon bursitis: A systematic review. Archives of Orthopaedic and Trauma Surgery, 134(11), 1517-1536.