Bursitis is defined as an inflammation of a bursa. In bursitis, the synovial lining becomes thickened and there is a production of excessive fluid resulting in swelling and pain.
Following are commonly affected bursae.
Upper limb
- Subacromial
- Subscapular
- Olecranon
Lower limb
Hip
- Ischiogluteal
- Iliopsoas
- Greater trochanter
Knee
- Medial collateral ligament
- Pes anserinus bursitis
- Prepatellar
Ankle
- Retrocalcaneal
Bursitis is found more in athletes, especially runners. Men are more affected by this condition.
[ Read More: Anatomy of Bursa ]
Pathophysiology of Bursitis
Repeated trauma or infection caused inflammation of the bursa which results in multiplication of synovial cells. This leads to increased formation of collagen and fluid. Capillary membrane becomes permeable and allows extravasation of high protein fluid. The bursa becomes filled with fibrin-rich fluid.
Recurrent acute episodes lead to chronic bursitis. This leads to continuous pain and weakening of overlying ligaments and tendons. Bursitis and tendinitis may occur together due to their proximity.
Infectious bursitis usually results from direct inoculation of microorganisms through traumatic injury or spread from cellulitis. Less commonly, it could be due to contiguous septic arthritis or bacteremia.
Staphylococcus aureus is involved in about 80% of cases. Other organisms are streptococci, mycobacteria, candida, and algae.
Patients with diabetes mellitus, steroid therapy, uremia, alcoholism, skin disease have a higher risk of getting an infection.
Cause of Bursitis
Bursitis has many causes, including
- Autoimmune disorders
- Crystal deposition (gout and pseudogout)
- Infection
- Overuse
- Trauma
- Hemorrhagic disorders -Hemophilia
Following Conditions have been associated with bursitis
- Rheumatoid arthritis
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- Scleroderma
- Systemic lupus erythematosus
- Pancreatitis
- Whipple disease
- Uremia
- Hypertrophic pulmonary osteoarthropathy
- Idiopathic hypereosinophilic syndrome
Presentation of Bursitis
Patient of bursitis presents with pain and swelling in the affected region. The movement of the nearby joint may be limited. On examination, the part may be red, warm to the touch and tender. There would be a history of repetitive trauma or inflammatory disease. An occupation involving frequent movement that leads to bursal irritation [i.e. kneeling in case of prepatellar bursa] may be present.
There is reduced the active range of motion with a preserved passive range of motion. In chronic bursitis, limb wasting and weakness may be present.
Fever, severe tenderness and excess warmth indicate infection.
Subacromial bursitis
Subacromial bursitis is inflammation of subacromial bursa and is frequently associated with supraspinatus. The frequent pitching of a baseball or lifting luggage overhead are examples of overuse. Rheumatoid arthritis, gout, or tuberculosis, may also lead to subacromial bursitis.
The patient presents with shoulder pain and tenderness over the greater tuberosity with the limitation of abduction movement of the shoulder.
Olecranon bursitis
Olecranon bursa is a superficial bursa and prone to inflammation.
It usually occurs due to repetitive forward-leaning positions with pressure on the elbows such as students or occupation like carpet laying. The term dialysis elbow or lunger elbow is also used when this occurs in dialysis patient or patient of chronic obstructive lung disease where elbow position makes them prone for this.
Gout, followed by pseudogout, rheumatoid arthritis, and uremia are nontraumatic causes.
It presents as painful fluctuant bulge posterior to the olecranon process with restriction of extreme flexion.
Iliopsoas bursitis
The patient presents with pain that radiates down the anteromedial side of the thigh to the knee and worsened by extension, adduction, and internal rotation of the hip.
At the middle of the inguinal ligament or lower and lateral to the femoral artery, tenderness may be present. Occasionally, swelling or a palpable mass or tenderness may be found lateral to the femoral vessels.
Trochanteric bursitis
This bursitis is more in females and found in runners, dancers, leg length inequalities, hip arthritis, and low back diseases.
There is chronic, intermittent, aching pain over the lateral hip which often radiates to the lateral aspect of the thigh. The pain is exacerbated on walking and lying on the affected side.
On examination, the pain can be reproduced by hip adduction. Abduction against resistance also leads to pain.
Hip movements are generally not affected.
Ischiogluteal bursitis
Trauma, prolonged sitting on a hard surface (weaver’s bottom), or prolonged sitting in the same position (spinal cord injury). Pain may radiate down the back of the thigh which can be reproduced by applying pressure over the ischial tuberosity.
Prepatellar bursitis
Prepatellar bursitis is usually seen in frequent kneelers and present fluctuant, well-circumscribed warm swelling over the lower pole of the patella. The knee joint itself is normal.
Infrapatellar bursitis or Clergyman’s knee
This bursa is located more distally than prepatellar bursitis and is also caused by frequent kneeling in an upright position. There is a pain with flexion and extension at the extremes of the range of motion. Edema is located on both sides of the patellar tendon and is associated with tenderness.
In anserine bursitis, the tenderness is present on the medial aspect of the knee 5 cm below the joint margin at the site of the tibial tubercle. Pain is exacerbated with stair climbing and extremes of flexion or extension. Anserine bursitis may occur bilaterally.
Calcaneal bursitis can lead to pain on the posterior aspect of heel at Achilles tendon insertion. Inflammation can occur secondarily from Achilles tendinitis.
The pain is worsened with dorsiflexion and often a bump is palpable at the posterior aspect of the eel.
Differential Diagnoses
- Cellulitis
- Gout and Pseudogout
- Rheumatoid Arthritis
- Soft Tissue Knee Injury
- Tendonitis
Lab Studies
Routine laboratory blood work is generally not required. CBC, ESR, CRP may be needed if an infection is suspected. Antinuclear antibody, rheumatoid factor, and anti – citric citrullinated peptide tests should be done in cases of autoimmune diseases.
Aspiration and analysis of bursal fluid should be done to rule out infectious or rheumatic causes. Fluid is tested for biochemical and cytological analysis. Gram stain and culture for infection can be done in cases of infection.
Imaging
Xrays are normal in most of the cases but are done to identify any underlying bony pathology. Tendon calcifications may be found in chronic bursitis..
MRI is generally not done in routine but is able to define the lesion better and even differentiate from abscess and tumors.
Ultrasonography may help in injection application or aspirations in deep bursae.
Treatment of Bursitis
Non-Infectious Bursitis
The treatment includes
- RICE therapy
- NSAIDs, oral steroids
- Bursal aspiration
- Intrabursal steroid injections
- Protection of the bursa by use of padding or braces
- Electrical stimulation, ultrasonography
Septic Bursitis
- Antibiotic broad spectrum initially to cover Staph aureus, then specific according to culture result
- Oral in most cases
- IV in immunocompromised or with systemic symptoms
Repeated aspiration of the infected bursa
Antibiotics are usually given for 10 days but longer duration is necessary in immunocompromised patients and severe cases.
Tuberculous bursitis is treated by full excision of the bursae and surrounding affected tissue with concomitant antituberculous therapy for 6-12 months.
Surgery for Bursitis
In general, bursitis is not treated surgically. Surgical procedures that can be done are
- Incision and drainage
- Excision of bursa
- Removal of underlying bony prominences
Surgery is indicated in
- Failure of needle aspiration
- Bursa not accessible to repeated needle aspirations due to location
- Abscess, necrosis, or sinus formation
- Recurrent or refractory disease after conservative treatment
- Exostoses removal
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