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BURSITIS OVERVIEW — Bursitis is an inflammation or irritation of the bursae (plural of "bursa"). The bursae are fluid-filled sacs around joints and tendons, which decrease friction from movement and provide a cushion between bones, tendons, muscles, and skin.
Bursitis can be rapid in onset (acute) or build up slowly over time (chronic). Acute bursitis is often the result of an injury (bleeding), infection, or inflammatory condition. Chronic bursitis often follows a long period of repetitive use, motion, or compression. Bursitis can involve almost any joint in the body, although some areas are more commonly affected than others.
BURSITIS CAUSES — Causes of bursitis include:
●Injury, such as from a fall or hit; this usually causes bleeding into a bursa. People who take anticoagulant medications (blood thinners) to prevent or treat blood clots are at higher risk for this condition.
●Infection resulting from bacteria entering the body through a cut or scrape in the skin.
●Gout or other crystal diseases.
●Certain types of arthritis, like rheumatoid arthritis or psoriatic arthritis.
●Prolonged pressure, which can result from kneeling, sitting, or leaning on a particular joint for a long period.
●Strain or overuse from repeating the same motion many times
●Joint stress from an abnormal gait; for example, walking unevenly because one leg is shorter than the other
BURSITIS SYMPTOMS — Common symptoms of bursitis include pain and/or swelling at the affected site. Visible swelling is more common in superficial bursae that are closer to the surface of the skin, such as those around the elbows, kneecaps, and heels. Swelling is less commonly a feature of bursitis that affects deep structures, such as the bursae of the shoulders, hips, and inner knees.
In acute bursitis, there are often features of inflammation at the bursa. Pain is a common feature and typically localizes directly over the affected bursa. Active motion (when the person moves or bends the joint) also causes pain if the motion stretches the affected bursa. Acute bursitis of a superficial bursa is often accompanied by redness, warmth, and swelling.
People with chronic bursitis may have swelling, but usually only if a superficial bursa is affected. Pain is present with chronic bursitis of any location, but the intensity of pain can vary. These patients may also have limited range of motion because pain from the bursitis restricts motion of the nearby joint and surrounding muscles.
Bursitis caused by an infection is called "septic bursitis." Symptoms may include pain, swelling, warmth, and redness around the affected joint. Fever may also be present. This is a potentially serious condition since infection can spread to nearby joints, bone, or the bloodstream. Bursitis caused by gout is not infection-related but can mimic septic bursitis in the intensity of inflammation.
Specific symptoms of bursitis vary depending on the area that is affected. (See 'Types of bursitis' below.)
BURSITIS DIAGNOSIS — Diagnosing bursitis involves a physical examination, a review of your symptoms, and sometimes tests.
If your health care provider suspects infection or crystal disease (for example, gout), they may use a syringe and needle to remove a sample of fluid from the affected bursa. This is called an "aspiration." The fluid can then be examined under a microscope for crystals, bacteria, and white blood cells.
Imaging such as X-ray, magnetic resonance imaging (MRI), or ultrasound is not usually needed to diagnose bursitis. However, it can help in some situations, such as when other problems need to be ruled out (for example, a tear in the cartilage or ligament). It can also be useful for deeper forms of bursitis or if your doctor needs to remove fluid from a bursa near other areas that could be injured, such as nerves or blood vessels. Imaging can allow the doctor to visualize where the needle is going.
TYPES OF BURSITIS — Bursitis can affect many different areas of the body. The exact symptoms and preferred treatments depend on the location as well as the cause. The following examples cover the most common types of bursitis, but are not inclusive of all types.
Shoulder (subacromial bursitis) — Shoulder bursitis causes pain in the shoulder and often extends to the upper arm (figure 1). Pain is often present at rest but increases with movement of the arm, especially with lifting the arms above the head; it also often interrupts sleep. It can be difficult to differentiate shoulder bursitis from other issues such as a rotator cuff tendinitis, rotator cuff tear, shoulder arthritis, or labral tear.
Upper back (scapulothoracic bursitis) — Upper back bursitis affects the space between the scapula (shoulder blade) and ribs and can cause pain or a popping sensation. Reaching the arms overhead or doing pushups can make pain worse.
Elbow (olecranon bursitis) — Elbow bursitis usually causes a visible swelling at the tip of the elbow, like a golf ball. It can result from injury (bleeding into the bursa), infection, crystals (gout), or rheumatoid arthritis. It usually causes pain when the elbow is flexed, but not extended. The elbow often extends fully without discomfort.
Pelvis (ischial bursitis) — Pelvic bursitis has also been referred to as "weaver's bottom" or "tailor's bottom" since it is often caused by prolonged sitting on hard surfaces. It causes pain in the lower buttocks that is aggravated by sitting (figure 2); pain may disappear when the person stands.
Hip
Greater trochanteric pain syndrome (formerly called trochanteric bursitis) — The greater trochanteric bursa is located in the upper outer part of the femur (thigh bone) (figure 2). Bursitis in this area is usually associated with inflammation of nearby tendons and can cause pain while lying or sleeping on the affected side of the body. Because the primary problem may be more an irritation of the tendons in the area, the term "greater trochanteric pain syndrome" has replaced the former term of "trochanteric bursitis." People with greater trochanteric pain syndrome also tend to have pain when extending the leg to walk, but not while standing still. Symptoms can be aggravated by an abnormal gait, due to uneven stress on the hips. There are many contributing factors, including chronic back pain, deconditioning of the core muscles in the abdomen and back (eg, when the muscles become weak from lack of use), contralateral knee pain (knee pain on the opposite side of the body from the bursitis), different leg lengths, and being overweight.
Iliopsoas bursitis — The psoas muscle runs from the spine to the femur and is used to flex the hip. The iliopsoas bursa abuts the psoas muscle deep in the front of the hip. This type of bursitis causes pain in the groin area, particularly when the hip is flexed against resistance or when climbing stairs. It can result from arthritis in the area, overuse (for example, excessive running), or injury. Because symptoms are similar to those of other hip problems (for example, problems with the bone or cartilage), imaging tests are often required to confirm the diagnosis. Infection in the psoas muscle (psoas abscess) can have similar symptoms, although these are usually more severe.
Knee
Prepatellar and infrapatellar bursitis — The prepatellar bursa is located in front of the patella (kneecap) (figure 3); the infrapatellar bursa is below this. Bursitis in these areas can result from recurrent injury to the knee and is often seen in people who frequently kneel. Prepatellar bursitis has been referred to as "housemaid's knee" or "nun's knee." It can also happen as a result of infection, gout, or rheumatoid arthritis. Swelling occurs within the bursa, not in the knee joint itself. People with prepatellar and infrapatellar bursitis usually feel more comfortable lying down with the knee extended, while people with swelling within the true knee joint tend to feel better lying down with the knee partially bent.
MCL bursitis — The medial collateral ligament (MCL) is located on the inner side of the knee, and connects the femur (thigh bone) to the tibia (shin bone) (figure 4). Bursitis in this area can cause pain and tenderness, but doesn't usually involve swelling. It must be differentiated from an injury or tear to the MCL or meniscus (the cartilage in the knee).
Pes anserinus pain syndrome — The pes anserine bursa is located about two inches below the top of the tibia (shin bone), on the inner side of the knee. Because the primary problem may be more an irritation of the tendons in the area, the term "pes anserinus pain syndrome" has replaced the former term of "pes anserine bursitis." This syndrome causes pain on the inner side of the knee, which tends to come on abruptly, often during the night. It is more common in people with osteoarthritis of the knee, obesity, and/or genu valgum (a condition in which the knees point inward, also called knock-knee deformity).
Heel (retrocalcaneal bursitis) — The retrocalcaneal bursa is between the heel bone and the Achilles tendon, which connects the heel to the calf muscle. It normally serves as a cushion to absorb impact when walking. Retrocalcaneal bursitis can cause pain and swelling in the area. It can be easily confused with Achilles tendinitis (inflammation of the Achilles tendon).
BURSITIS TREATMENT — Bursitis treatment focuses on relieving inflammation and pain, treating infection (if present), maintaining range of motion, and preventing complications and future recurrence.
Pain-relief medication — In most cases, nonsteroidal antiinflammatory drugs (NSAIDs) can help relieve pain and inflammation. NSAIDs include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve); other NSAIDs, as well as higher doses, are also available by prescription. Topical NSAIDs (for example, diclofenac gel) may be an appropriate option for patients who cannot tolerate oral NSAIDs. However, topical NSAIDs are not likely to be helpful for deep forms of bursitis (eg, ischial bursitis or greater trochanteric pain syndrome).
NSAIDs are not appropriate for everyone. For example, people who take anticoagulants (blood thinners) or have a history of kidney disease, heart disease, high blood pressure, or bleeding stomach ulcers should talk with their health care provider about whether they can safely take NSAIDs. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Steroid injections — A glucocorticoid (steroid) injection, which may also include an anesthetic (pain reliever), can also help with pain and inflammation from bursitis. Steroid injection is indicated for some types of bursitis but not others. This is more often used when the affected area is deep under the skin (see 'Shoulder (subacromial bursitis)' above and 'Greater trochanteric pain syndrome (formerly called trochanteric bursitis)' above and 'MCL bursitis' above and 'Pes anserinus pain syndrome' above). It is not usually helpful (and can even be harmful) for more superficial types of bursitis, for example, in the olecranon bursa of the elbow, prepatellar bursa of the knee, or retrocalcaneal bursa of the heel. Steroid injections may only provide short-term pain relief, and the effects often start to wear off after several weeks.
Protecting the joints — It is important to protect the affected joints in order to rest the affected area and help the bursae to heal. Bursal protection can also prevent the bursitis from getting worse or recurring. Examples of joint protection include:
●Avoiding or modifying activities that cause pain
●The use of pads or cushions for people who have to kneel or sit frequently
●Modifying footwear to reduce pressure on the back of the heel (eg, cutting a "V"-shaped groove into the back of a shoe; using a pad inside the shoe to lift the heel)
●Custom-fitted devices worn over the elbows to protect them and prevent fluid from building up again
Other measures — Ice can help relieve pain, particularly for bursitis affecting superficial areas like the elbow, kneecap, and heel. Heat (eg, a heating pad) may be more effective for deeper forms of bursitis, such as the hip, shoulder, or inner knee.
In many cases, physical therapy can help treat symptoms of bursitis and prevent future recurrence. The optimal exercises depend on the type and severity of bursitis, but may involve stretching, strengthening, or working to improve (and maintain) range of motion.
Treating infection — Septic bursitis is a potentially very serious condition that needs to be addressed quickly. It is treated with antibiotics and (when possible) by draining any infected fluid from the bursa. The choice of which antibiotic to use, and for how long, is based on the type and severity of infection. For mild cases, a few weeks of oral antibiotics may be enough; for more severe infection, intravenous (IV) antibiotics (given in the hospital) may be required.
When it is possible to drain infected fluid, this is done using a needle and syringe. This happens in a doctor's office, until the infection has resolved, which can mean repeating the procedure several times over multiple days. Rarely, surgery is required to remove all or part of an infected bursa. This may be necessary in people with septic bursitis that does not improve with conventional treatments of antibiotics and needle drainage.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Bursitis (The Basics)
Patient education: Hip pain in older people (The Basics)
Patient education: Shoulder impingement (The Basics)
Patient education: Knee pain (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Gout (Beyond the Basics)
Patient education: Calcium pyrophosphate crystal deposition (CPPD) disease (Beyond the Basics)
Patient education: Arthritis (Beyond the Basics)
Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)
Patient education: Knee pain (Beyond the Basics)
Patient education: Losing weight (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Bursitis: An overview of clinical manifestations, diagnosis, and management
Evaluation of elbow pain in adults
Approach to the adult with unspecified knee pain
Approach to the adult with unspecified hip pain
Evaluation of the adult with shoulder complaints
Knee bursitis
Overview of running injuries of the lower extremity
Overview of soft tissue musculoskeletal disorders
Greater trochanteric pain syndrome (formerly trochanteric bursitis)
Septic bursitis
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/healthtopics.html)
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
(https://www.niams.nih.gov/health-topics/sports-injuries)
●The Arthritis Foundation
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Robert Sheon, MD, who contributed to an earlier version of this topic review.
