Acute or chronic inflammation of
Bursae are saclike cavities or potential
cavities that contain synovial fluid located at tissue
sites where friction occurs (eg, where tendons or
muscles pass over bony prominences). Bursae facilitate
normal movement, minimize friction between moving parts,
and may communicate with joints.
Bursitis usually occurs in the shoulder
(subacromial or subdeltoid bursitis). Other sites
include the olecranon (miners' elbow), prepatellar
(housemaid's knee) or suprapatellar, retrocalcaneal
(Achilles), iliopectineal (iliopsoas), ischial (tailor's
or weaver's bottom), greater trochanteric, and first
metatarsal head (bunion). Bursitis may be caused by
trauma, chronic overuse, inflammatory arthritis (eg,
gout, RA), or acute or chronic infection (eg, pyogenic
organisms, particularly Staphylococcus aureus;
tuberculous organisms, which now rarely cause bursitis).
Symptoms and Signs
Acute bursitis causes
pain, localized tenderness, and limited motion. Swelling
and redness are frequent if the bursa is superficial (eg,
prepatellar, olecranon) because the bursal wall secretes
a serous effusion when inflamed. Chemical (eg,
crystal-induced) or especially bacterial inflammation is
particularly painful, red, and warm.
Chronic bursitis may
follow previous attacks of bursitis or repeated trauma.
Attacks may last a few days to several weeks, with
multiple recurrences. Acute symptoms may follow unusual
exercise or strain. The bursal wall is thickened, with
proliferation of the synovial lining. The bursa may
eventually develop adhesions, villus formation, tags,
and calcareous deposits. Pain, swelling, and tenderness
may lead to muscle atrophy and limited range of motion.
X-rays may demonstrate subdeltoid calcific deposits,
particularly in the supraspinatus tendon of the rotator
cuff. In gout, crystals may be isolated in the olecranon
and prepatellar bursae during acute inflammation.
Subacromial bursitis (subdeltoid
bursitis) presents with localized pain and tenderness of
the shoulder, particularly when abducted in an arc from
50 to 130°. Subacromial bursitis and calcific
supraspinatus tendinitis may be indistinguishable
clinically and on x-ray. The latter may result from
partial or complete tears or from calcium apatite
Localized tenderness over the particular
bursa should be elicited, or swelling or synovial fluid
from superficial bursae (eg, olecranon, prepatellar)
should be demonstrated. Infection should be excluded in
cases of particularly painful, red, and warm swellings.
Periarticular tendon or muscle tears, pyogenic bursitis,
bleeding into the bursa, synovitis, osteomyelitis, and
cellulitis must be ruled out. Pathologic processes may
simultaneously involve a communicating bursa and joint.
For noninfected acute bursitis,
temporary rest or immobilization and high-dose NSAIDs,
sometimes with narcotic analgesics, may be helpful.
Voluntary movement should be increased as pain subsides.
Pendulum exercises are particularly helpful for the
shoulder joint. Aspiration and intrabursal injection of
depot corticosteroids 0.5 to 1 mL (triamcinolone
diacetate 25 or 40 mg/mL) mixed with at least 3 to 5 mL
of local anesthetic after infiltration with 1% local
anesthetic (eg, lidocaine) is the treatment of choice
when rest alone is inadequate. The depot corticosteroid
dose and volume of mixture are gauged to the size of the
bursa. Reaspiration and injection may be required with
resistant inflammation. Systemic corticosteroids
(prednisone 15 to 30 mg/day or equivalent for 3 days)
are occasionally indicated in resistant acute cases
after infection and gout have been excluded.
Chronic bursitis is
treated as acute bursitis, except that splinting and
rest are less likely to be helpful. Rarely, surgical
removal or large-needle aspiration of radiologically
demonstrated calcification in chronic calcific
supraspinatus tendinitis may be necessary if
corticosteroid injections are not helpful. Disabling
adhesive capsulitis of the shoulder may require repeated
corticosteroid injections in multiple intra- and
extra-articular areas and intensive physical therapy.
Manipulation under anesthesia does not improve long-term
results unless measures to correct adhesive capsulitis
are followed. Muscle atrophy should be corrected with
exercise to reestablish range of motion and strength.
Infection requires antibiotics and drainage or excision
therapy. Bursitis may recur if the underlying cause (eg,
RA, gout, chronic occupational strain) is not corrected.