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Emergency and Acute Medicine – Bursitis
Overview And Definitions
Bursae are synovial fluid–filled sacs, approximately 150 in number, located between bones, tendons, ligaments, muscles, and skin, where they function to reduce friction during movement. Bursitis refers to inflammation of a bursa and may result from acute trauma, repetitive overuse, infection, crystal deposition, or systemic inflammatory disease. Chronic inflammation can lead to proliferative thickening of the bursal wall. Frequently involved locations include the subacromial bursa of the shoulder, the olecranon bursa of the elbow, trochanteric and iliopsoas bursae of the hip, prepatellar and pes anserine bursae of the knee, and the calcaneal bursa of the foot, often related to footwear.
Etiology And Pathophysiology
Trauma and repetitive microtrauma are the most common causes, either from a single injury or chronic pressure and overuse. Infectious bursitis usually results from direct inoculation through skin disruption, sometimes microscopic, and is more common in patients with diabetes, chronic alcohol use, uremia, gout, or immunosuppression. Staphylococcus species account for the majority of septic cases. Crystal-induced inflammation may occur from calcium phosphate or monosodium urate deposition. Systemic inflammatory disorders such as rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis, lupus, and rheumatic fever may also precipitate bursitis.
Clinical Features
Patients may present with acute or chronic symptoms. Pain is typically localized and worsened by joint movement or direct pressure. Functional complaints such as limping or activity limitation are common. Localized swelling is often evident, especially in superficial bursae. In aseptic bursitis, tenderness is usually mild, with reduced active range of motion but preserved passive motion. Septic bursitis is suggested by warmth, erythema, swelling, marked tenderness, and sometimes fever. A history of gout, pseudogout, rheumatologic disease, recent procedures, injections, or aspirations involving the bursa should be elicited.
Evaluation And Diagnostic Approach
A careful examination of adjacent joints, tendons, and soft tissues is essential. Any suspicion of infection warrants diagnostic aspiration, particularly for olecranon and prepatellar bursae, using a lateral approach to avoid needle tract complications. Deep bursae such as the hip may require ultrasound guidance or specialist involvement.
Laboratory evaluation may include CBC with differential when infection is suspected and targeted tests for systemic disease such as uric acid, ESR, or CRP. Aspirated bursal fluid should be analyzed for cell count with differential, glucose, protein, crystals, Gram stain, and culture, with cultures sent in all cases. Imaging with plain radiographs may show soft tissue swelling, calcifications, or underlying arthropathy, particularly after trauma. Ultrasound, MRI, or CT may assist in evaluating deep or septic bursitis.
Differential Diagnosis
Conditions that may mimic bursitis include septic or inflammatory arthritis, osteoarthritis, gout and pseudogout, tendonitis, fasciitis, epicondylitis, fractures, ligament or tendon injury, contusion, osteomyelitis, and nerve entrapment. Hip pain may also arise from lumbar spine disease, sacroiliitis, or neuritis.
Management Principles
Initial care includes joint immobilization when pain is significant, with caution to avoid prolonged shoulder immobilization due to the risk of adhesive capsulitis.
Nonseptic bursitis is treated with rest, avoidance of aggravating activities, protective padding, ice therapy, and NSAIDs continued for several days beyond symptom resolution to reduce recurrence. Fluctuant bursae may be aspirated and compressed. If symptoms persist after infection is excluded, intrabursal corticosteroid injection combined with local anesthetic may be considered using strict sterile technique, with limits on frequency of injections.
Septic bursitis requires aspiration and appropriate antimicrobial therapy. Superficial infections may be managed with aspiration and oral antibiotics if close follow-up is ensured, while deeper or more severe infections may require drainage and IV antibiotics. Therapy should be guided by Gram stain results and local resistance patterns, with continued treatment beyond clinical resolution. Underlying conditions such as gout should be addressed concurrently.
Disposition And Follow-Up
Most patients can be managed as outpatients and improve within several days. Septic bursitis requires close follow-up and may necessitate repeated aspirations until cultures are sterile. Admission is indicated for systemic illness, extensive cellulitis, immunosuppression, inability to tolerate oral therapy, or failure of outpatient management. Referral to rheumatology or orthopedics is recommended for recurrent, refractory, or surgically managed cases.
Key Clinical Insights And Common Errors
Clinical examination alone may not reliably distinguish septic from nonseptic bursitis, making aspiration and fluid analysis critical. NSAID-related gastrointestinal bleeding and renal toxicity should be considered, particularly with ketorolac use. Although erythema, warmth, swelling, and pain strongly suggest infection, aspiration and culture remain essential. Care must be taken during aspiration to avoid introducing infection into adjacent joints.
Overview And Definitions
Bursae are synovial fluid–filled sacs, approximately 150 in number, located between bones, tendons, ligaments, muscles, and skin, where they function to reduce friction during movement. Bursitis refers to inflammation of a bursa and may result from acute trauma, repetitive overuse, infection, crystal deposition, or systemic inflammatory disease. Chronic inflammation can lead to proliferative thickening of the bursal wall. Frequently involved locations include the subacromial bursa of the shoulder, the olecranon bursa of the elbow, trochanteric and iliopsoas bursae of the hip, prepatellar and pes anserine bursae of the knee, and the calcaneal bursa of the foot, often related to footwear.
Etiology And Pathophysiology
Trauma and repetitive microtrauma are the most common causes, either from a single injury or chronic pressure and overuse. Infectious bursitis usually results from direct inoculation through skin disruption, sometimes microscopic, and is more common in patients with diabetes, chronic alcohol use, uremia, gout, or immunosuppression. Staphylococcus species account for the majority of septic cases. Crystal-induced inflammation may occur from calcium phosphate or monosodium urate deposition. Systemic inflammatory disorders such as rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis, lupus, and rheumatic fever may also precipitate bursitis.
Clinical Features
Patients may present with acute or chronic symptoms. Pain is typically localized and worsened by joint movement or direct pressure. Functional complaints such as limping or activity limitation are common. Localized swelling is often evident, especially in superficial bursae. In aseptic bursitis, tenderness is usually mild, with reduced active range of motion but preserved passive motion. Septic bursitis is suggested by warmth, erythema, swelling, marked tenderness, and sometimes fever. A history of gout, pseudogout, rheumatologic disease, recent procedures, injections, or aspirations involving the bursa should be elicited.
Evaluation And Diagnostic Approach
A careful examination of adjacent joints, tendons, and soft tissues is essential. Any suspicion of infection warrants diagnostic aspiration, particularly for olecranon and prepatellar bursae, using a lateral approach to avoid needle tract complications. Deep bursae such as the hip may require ultrasound guidance or specialist involvement.
Laboratory evaluation may include CBC with differential when infection is suspected and targeted tests for systemic disease such as uric acid, ESR, or CRP. Aspirated bursal fluid should be analyzed for cell count with differential, glucose, protein, crystals, Gram stain, and culture, with cultures sent in all cases. Imaging with plain radiographs may show soft tissue swelling, calcifications, or underlying arthropathy, particularly after trauma. Ultrasound, MRI, or CT may assist in evaluating deep or septic bursitis.
Differential Diagnosis
Conditions that may mimic bursitis include septic or inflammatory arthritis, osteoarthritis, gout and pseudogout, tendonitis, fasciitis, epicondylitis, fractures, ligament or tendon injury, contusion, osteomyelitis, and nerve entrapment. Hip pain may also arise from lumbar spine disease, sacroiliitis, or neuritis.
Management Principles
Initial care includes joint immobilization when pain is significant, with caution to avoid prolonged shoulder immobilization due to the risk of adhesive capsulitis.
Nonseptic bursitis is treated with rest, avoidance of aggravating activities, protective padding, ice therapy, and NSAIDs continued for several days beyond symptom resolution to reduce recurrence. Fluctuant bursae may be aspirated and compressed. If symptoms persist after infection is excluded, intrabursal corticosteroid injection combined with local anesthetic may be considered using strict sterile technique, with limits on frequency of injections.
Septic bursitis requires aspiration and appropriate antimicrobial therapy. Superficial infections may be managed with aspiration and oral antibiotics if close follow-up is ensured, while deeper or more severe infections may require drainage and IV antibiotics. Therapy should be guided by Gram stain results and local resistance patterns, with continued treatment beyond clinical resolution. Underlying conditions such as gout should be addressed concurrently.
Disposition And Follow-Up
Most patients can be managed as outpatients and improve within several days. Septic bursitis requires close follow-up and may necessitate repeated aspirations until cultures are sterile. Admission is indicated for systemic illness, extensive cellulitis, immunosuppression, inability to tolerate oral therapy, or failure of outpatient management. Referral to rheumatology or orthopedics is recommended for recurrent, refractory, or surgically managed cases.
Key Clinical Insights And Common Errors
Clinical examination alone may not reliably distinguish septic from nonseptic bursitis, making aspiration and fluid analysis critical. NSAID-related gastrointestinal bleeding and renal toxicity should be considered, particularly with ketorolac use. Although erythema, warmth, swelling, and pain strongly suggest infection, aspiration and culture remain essential. Care must be taken during aspiration to avoid introducing infection into adjacent joints.
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