Bursitis
Definition
Bursitis is a painful inflammation of a bursa, a fluid-filled sac located near a joint.
Description
There are approximately 150 bursae (plural of bursa) throughout the body. Bursae act like air-filled bubble wrap that cushions the movement of a joint.
Located near the tendons of joints, bursae reduce friction between the bones and tendons, making joints flexible and easier to move. Bursae are not filled with air, but are filled with a clear, lubricating liquid called synovial fluid.
Bursitis occurs when the bursae become inflamed. Sometimes this inflammation causes the bursae to produce more fluid and to swell. Since bursae are located near every joint in the body, bursitis can potentially appear anywhere. The most common sites for bursitis are the shoulder, hip, elbow, knee, ankle, buttocks, and sometimes the thumb or toes. These specific areas of the body produce different types of bursitis with different symptoms and sometimes different methods of treatment and therapy.
Shoulder bursitis
Bursitis in the shoulder is called subdeltoid bursitis or subacromial bursitis and may be more complex that just having inflamed bursae. Shoulder impingement can occur at the same time. This condition happens when the rotator cuff (shoulder muscles and tendons) becomes inflamed and begins to swell between the shoulder bones. This can lead to inflamed bursae and, therefore, to shoulder bursitis.
Hip bursitis
There are two different types of hip bursitis. Trochanteric bursitis occurs on the side of the hip and thigh. Ischial bursitis (called ischiogluteal bursitis) affects the base of the hips and buttocks.
Knee bursitis
Knee bursitis can be found in two regions of the knee. Prepatellar bursitis is located in front of the kneecap. Pes anserine bursitis occurs on the inner side of the knee below the knee joint. The muscles here allow the knee to bend and facilitate crossing the legs.
Elbow bursitis
Called olecranon bursitis, this condition is found in the elbow.
Ankle bursitis
Ankle bursitis can take many forms. One of the most common presentations is called Achilles tendon bursitis. The inflammation occurs in the bursae along the Achilles tendon that runs along the back of the heel and ankle.
Demographics
Bursitis is a common condition that can affect people of any age. It is most often seen among people engaged in sports, especially runners, and people who work or take part in hobbies that require repetitive movement. Direct trauma to a joint or infection can produce bursitis at any age.
Bursitis is most frequently found in people who are middle aged or older and in people who are overweight or diabetic. Trochanteric bursitis is often seen in people over forty years old. About 85% of bursitis caused by infection occurs among men.
Causes and symptoms
Causes
The most frequent cause of bursitis is repeated movement of a joint. Trauma such as having a fall or sports injury can irritate the bursae. Rheumatoid arthritis, scoliosis, and scleroderma, can cause bursitis because of bony growth around the joints that can irritate the bursae. Gout can be a factor due to the formation of crystal deposits. In gout, the body is not able to break down uric acid, causing it to crystallize and be deposited in the joints where the bursae can become inflamed. In addition, Staphylococcus aureus or Staphylococcus epidermis bacteria can cause septic bursitis.
Keeping a joint locked in one position can cause inflammation when the joint is then exercised. For example, a person can have hip bursitis from running or marathon walking as well as from sitting at a desk without getting up and moving.
Shoulder bursitis can be caused by an injury to the shoulder from a fall or accident. It can also be caused by overuse in sports or work, such as swimming, pitching a baseball, painting a wall, or hanging wallpaper. Infection or rheumatoid arthritis can cause shoulder bursitis. Arthritis can produce bony growths on the bones of the shoulder that can rub against the tendons and the bursae, thereby inflaming them.
Trochanteric (hip) bursitis is most often caused by overuse of the joint, such as in running, climbing stairs, hiking, or bicycling. It can also be caused by sitting at a desk for extended periods without getting up and moving around. Having one leg shorter than the other can cause hip bursitis. Weak muscles around the hip and thigh can cause the bursae to become inflamed because they are overused to cushion the joint.
Ischial (hip) bursitis can be caused by standing or sitting on hard surfaces for long periods. It was commonly found among weavers who sat on a hard surface for extended periods weaving; thereby garnering the name weaver's bottom.
Prepatellar (knee) bursitis is most often caused by putting continued pressure on the front of the knee. It has often been called clergyman's knee or housemaid's knee; two occupations that were reported to require spending extended periods of time on the knees. Prepatellar bursitis is common in wrestlers from continued contact with the mat and in volleyball players who dive on their knees for the ball. Among older adults, it is most often found in gardeners who spend long hours kneeling in their gardens.
Pes anserine (knee) bursitis is found among swimmers who do the breaststroke or among soccer kickers, which is why it has been called breastroker's knee or soccer knee. It can be found among older adults who lift heavy loads from a squat position, runners, or those participating in sports that require jumping, pivoting, and squatting.
Elbow bursitis is caused by overusing the elbow. Roofers, painters, and carpenters often have elbow bursitis. Thus, it has been called carpenter's elbow and even miner's elbow because miners used to swing heavy hammers in their work. It can be caused by playing tennis or even by vacuuming.
Achilles tendon bursitis is caused by pressure on the ankle and heel. It can be caused by running on uneven paths in parks or by wearing poorly fitting shoes that rub against the heel. Ankle bursitis is also caused by overusing the ankles by running and jumping or even walking. Sometimes, it is seen in women who either are starting to wear high heels or who have worn them many years.
Symptoms
The most common symptom of bursitis is pain. If the joint is moved or pressure is applied to the surrounding area, pain is present. The affected joint may feel warm or appear red or swollen. In rare cases, infection is present and fever accompanies the pain. Besides pain, a person with bursitis may not have full range of motion in a joint.
Shoulder bursitis can be felt in the shoulder whenever it is moved, especially when reaching over the head. Pain is felt when resting the shoulder and can even wake someone from sleep. Weakness and limited range of motion may be present.
Pain in hip bursitis is usually felt on the outside of the hip and thigh (trochanteric bursitis) or in the buttocks and down the back of the thigh (ischial). Often there is stiffness and a constant ache. Some people report hearing or feeling a “pop” or “snap” when the hip is moved before the pain is felt. Erroneously, some people assume that they have thrown their hip out.
Knee bursitis causes pain and stiffness when walking, kneeling, or climbing stairs. The top or the inside of the knee may swell.
Most often people with elbow bursitis feel pain when they bend the affected arm. The entire elbow appears red and can swell to the size of a goose egg.
Symptoms of Achilles tendon bursitis are pronounced. Often, there is limping, pain in the heel, or stiffness in the ankle. Wearing shoes may become painful. The back of the heel may swell and appear red and warm.
If fever and flu-like symptoms are present, the patient should seek medical help immediately. If the bursitis has continued without relief from home care for more than a week, a medical professional should be consulted for additional treatment options.
Diagnosis
Bursitis is diagnosed by a doctor by first taking a careful history of the patient, especially what the patient was doing before pain appeared. Temperature and blood pressure are taken. The doctor examines the affected area, looking for swelling and redness. Often pressure is placed on the affected area to see if the pain is intensified when pressed. The doctor may also put the patient through a series of range of motion activities to evaluate any limited movement.
X rays are only considered if the patient has a history of disorders that produce uric crystals. If septic bursitis is suspected, the doctor may insert a needle into the affected bursae to draw a sample of synovial fluid to test for bacteria. Blood tests may be ordered to determine any underlying conditions such as diabetes, which can affect the treatment plan.
Treatment
Treatment for any form of bursitis is basically the same. The patient is asked to rest and elevate the affected area, if possible. Ice is applied for 20 minutes three or four times a day for the first day or two, then heat is applied at the same frequencies. Moist heat is most often preferred. The patient may take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, or aspirin. Splinting or wrapping affected joints may help rest the joints. If bursitis is particularly severe or recurs often, the doctor may inject a corticosteroid drug into the bursa.
If the patient has septic bursitis, antibiotics are prescribed and the bursa may be surgically drained. This may require hospitalization. Surgery to remove a bursa is rare; however, surgery may be used to remove calcium deposits.
Patients are told not to sleep on their affected side. Using a pillow between the knees when sleeping can help both knee and hip bursitis. Patients with shoulder bursitis may be asked to sleep on their backs.
ALTERNATIVE TREATMENT Some patients find additional relief through alternative therapies. Acupuncture has been effective in pain relief. Chiropractic, magnetic field therapy, body work, and applied kinesiology may also be helpful.
Nutrition/Dietetic concerns
Calcium malabsorption, magnesium deficiency, and food allergies may contribute to bursitis. Dietary changes, vitamin supplements, and herbal treatments may be beneficial for some patients.
Therapy
When pain is under control, the doctor may recommend physical therapy to stretch the joints and strengthen surrounding muscles. Yoga is often suggested for patients with hip and shoulder bursitis because yoga postures can help stretch muscles in those areas. Yoga postures that facilitate balance help to strengthen the muscles in affected areas.
Massage or ultrasound may be recommended to increase blood flow to the affected area.
Prognosis
The length of time in recovery depends on the type of bursitis present and the patient's age and general health. For example, many people take about six weeks for recovery from hip bursitis. Some patients with hip or other types of bursitis may have continued difficulty for months or years. In some cases, patients have repeated episodes of bursitis, especially if proper exercises are not continued or patients do not modify their activities.
Prevention
To prevent recurrence of bursitis, the patient should avoid repetitive activities that aggravate the bursae. If the patient does decide to participate in such activities, then the patient should take frequent breaks and be sure to warm up before using the affected joints. The patient should gradually build up strength and endurance in activities, starting with limited repetitions, time, and distance.
Stretching exercises should be continued daily and especially before any activity that uses the affected joints. The patient should take frequent breaks to move around when sitting for long periods or sit with feet elevated if standing for too long.
Proper joint positioning during activity is important to prevent bursitis. Having ergonomically correct work stations that put the body in proper alignment while working or using padding for knees or elbows can help prevent recurrence.
Patients with ankle bursitis may be asked to buy properly fitting shoes and to avoid high heels. Heel pads may be added to shoes to cushion the heel.
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KEY TERMS Diabetes —A metabolic disease caused by the body's inability to make or use insulin to process carbohydrates in the body. Gout —A metabolic disease causing inflammation of the joints, uric deposits in and around the joints, and excessive uric acid in the blood. Inflammation —The body's response to cellular injury. Kinesiology —The study of the movement of the body. Orthotics —Inserts put into shoes to support or correct muscles, joints, or skeletal parts. Rotator cuff —The shoulder muscles and tendons. Synovial fluid —A clear, lubricating liquid found in bursae.
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Good shoes may help patients with hip bursitis. For those with one leg shorter than the other, wearing a shoe lift can bring both hips to an even height. Orthotics (shoe inserts) can align not only the feet but the spine, hips, and knees. This can help prevent bursitis.
In addition, patients who are overweight may find that losing weight eases the stress on bursae in the hips, knees, and ankles.
Caregiver concerns
Use of NSAIDs for extended periods of time should be carefully monitored by the physician since these medications can cause ulcers and other gastro-intestinal-problems.
Response to corticosteriod injections is very individual. Statistically, only about one-third of patients respond immediately from one injection. Some patients get worse, while others may require several injections. Corticosteriod injections should only be given every three months. Caution should be taken with diabetic patients because corticosteriods can elevate blood sugar. Corticosteriods are also contraindicated for septic bursitis.
It is important for the doctor to identify the underlying cause of recurrent bursitis. Undiagnosed medical problems such as diabetes, arthritis, or an autoimmune disorder may contribute to bursitis or complicate its treatment.
Resources
PERIODICALS
“Bursitis (Adult Health Advisor 2007).” Clinical Reference Systems May 31, 2007.
Rouzier, Pierre. “Pes Anserine (Knee) Bursitis.” Clinical Reference Systems—Sports Medical Advisor 2007. May 31, 2007.
Sanchez-Yamamoto, Deanna and Thomas M. Bush. “Corticosteroids Often Relieve Symptoms When Other Treatments Do Not—Injection Therapy for Bursitis and Tendonitis: Mastering the Basics.” The Journal of Musculoskeletal Medicine October 1, 2006: 720.
OTHER
“Ankle bursitis.” drugs.com. March 6, 2008 [cited April 5, 2008]. CareNotes.http://www.drugs.com/cg/ankle-bursitis.html.
Mayo Clinic Staff. “Bursitis.” MayoClinic.com. September 27, 2007 [cited April 5, 2008]. Mayo Foundation for Medical Education and Research.http://www.mayoclinic.com/health/bursitis/DS00032.
Shiel, William C. Jr. “Bursitis.” MedicineNet August 27, 2007 [cited April 5, 2008]. http://www.medicinenet.com/script/main/art.asp?articlekey=11615&pf=3&page=1.
Shiel, William C. Jr. “Cortisone Injection (Corticosteroid Injection) of Soft Tissue & Joints.”MedicineNet. April 11, 2007 [cited April 5, 2008]. http://www.medicinenet.com/script/main/art.asp?articlekey=11574&pf=3&page=1.
Steinfeldt, Jennifer L., et al. “Bursitis.
” eMedicineHealth. October 25, 2005 [April 5, 2008]. WebMD.http://www.emedicinehealth.com/bursitis/article_em.htm.
ORGANIZATIONS
American Academy of Orthopaedic Surgeons, 6300 North River Rd., Rosemont, IL, 60018-4262, (847) 823-7186, (800) 346-2267, (847) 823-8125, http://www.aaos.org.
Arthritis Foundation, P.O. Box 7669, Atlanta, GA, 30357-0669, (404) 872-7100, (800) 283-7800,http://www.arthritis.org.
Janie F. Franz
