What is Bursitis?
Bursitis is a condition where a bursa in the body becomes swollen or inflamed. A bursa is a small, sac-like structure that’s found near the joints and between the bones, muscles, tendons, and ligaments. It has a synovium-lining and works to help movement in the body by providing a cushion between tissues that rub against each other. There are over 150 known bursa in the human body.
When bursitis happens, the bursa fills up with fluid and becomes larger. This causes pain whenever there is movement or direct pressure on the bursa. Bursitis can be caused by several things, including an injury from using a joint too much, an infectious disease, trauma, and inflammatory disorders.
It’s important to note that not all types of bursitis are due to inflammation. Some are caused by a swelling of the bursa due to something harmful, even though ‘bursitis’ is commonly used to refer to all such conditions.
What Causes Bursitis?
Bursitis has many different causes that the doctor needs to familiarize with. The most frequent cause is prolonged pressure when a bag of fluid, called bursa, is squeezed between a hard surface and bone prominence. Examples of this include students frequently resting their elbows on their desks or people working on their knees without enough padding. Repetitive motions can also lead to irritation of the bursa and result in bursitis.
The second most common cause of bursitis is injury from direct pressure on the bursa. Often, the patient may not remember the incident causing it because it might not have seemed serious at the time. This kind of bursitis can lead to septic bursitis, which is typically caused by direct penetration of the bursa through the skin.
Septic bursitis can also occur through infection spreading through the bloodstream. However, this is rare as the bursa doesn’t have a significant blood supply. The bacteria Staphylococcus aureus is most often the source of septic bursitis. Bursitis can also be caused by autoimmune and systemic inflammatory conditions, including rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, scleroderma, spondyloarthropathy, and gout. At times, bursitis can occur without a clear cause, and invasive procedures can cause septic bursitis.
Risk Factors and Frequency for Bursitis
Bursitis is a condition that affects both men and women fairly evenly. However, certain types of bursitis are more common in women, especially pes anserine and trochanteric bursitis, which also tend to affect overweight individuals more frequently. Men, specifically those who do manual labor jobs like gardening, plumbing, and construction, are more prone to olecranon bursitis.
- Some forms of bursitis have unique names that reflect common risk factors. For instance, prepatellar bursitis is also called “housemaid’s knee,” and olecranon bursitis may be called “student’s elbow.”
- Infrapatellar bursitis is often referred to as “clergyman’s knee,” while ischial bursitis is known as “weaver’s bottom.”
- Bursitis in the subcutaneous calcaneal bursa is often seen in dancers and figure skaters, and can be triggered by wearing shoes that are too tight or ill-fitting.
In most cases, applying prolonged pressure on the affected area causes bursitis. While anybody can get bursitis, elderly people or those suffering from chronic conditions like osteoarthritis are more at risk. People with weakened immune systems, including those with diabetes, rheumatologic disorders, those with alcohol addiction, and individuals with HIV, are specifically more prone to septic bursitis.
Signs and Symptoms of Bursitis
Bursitis is a condition that can either be chronic or acute, with both types presenting differently. A thorough medical history and understanding of the patient’s daily activities can assist a healthcare professional in distinguishing between these two types. The acute version generally results from an injury, infection, or a certain type of joint disease, while the chronic version is usually the outcome of conditions like inflammatory joint diseases or repetitive pressure or overuse causing minor injuries.
Acute bursitis is often detected when a patient feels pain while a healthcare professional is examining the affected area. Sometimes, the patient’s ability to move the affected joint is decreased due to the pain. However, this largely depends on the bursa’s location and the mechanism of how the bones, muscles, and tissues around the bursa move. Often patients experience pain when they move, but not when the joint is being moved by someone else (passive motion).
Contrary to acute bursitis, chronic bursitis is usually painless. Over time, the bursa expands to accommodate the increased fluid, causing significant swelling and thickening of the bursa. Skin examination is vital in diagnosing either acute or chronic bursitis. Changes such as injuries to the skin, redness, or warmth, can be indicative of this condition. A study found that an increase of 2.2 °C in temperature between the skin over the affected bursa, as compared to the opposite unaffected bursa, reliably suggests the presence of septic bursitis. However, deep bursitis, although acute, may not present any noticeable changes in skin or tenderness.
Lastly, certain musculoskeletal imbalances or specific anatomical variations can sometimes contribute to the development of bursitis. Conditions such as decreased core strength, chronic back pain, or specific tendon problems can increase the risk for a type of bursitis known as trochanteric bursitis. Moreover, mechanical factors such as flat feet (pes planus) and knocked knees (genu valgum) are risk factors for the development of pes anserine bursitis.
Testing for Bursitis
When it comes to diagnosing certain types of bursitis, which is inflammation of the small fluid-filled sacs called bursae, doctors often don’t need any additional tests. However, if the diagnosis is unclear, imaging might be needed. Imaging can help doctors eliminate other possible conditions or confirm the diagnosis in uncertain cases. For example, if there’s a history of injury or if a foreign object or fracture could be causing the symptoms, doctors might order an X-ray of the affected joint or bursa.
Magnetic Resonance Imaging (MRI) and ultrasound may also be used. These techniques can be useful for examining the deeper bursa. Ultrasound is particularly good for real-time imaging and observing changes associated with movement. It can clearly show irregularities like ‘cobblestoning’ (a pattern that looks like cobblestones) in the fat over a bursa, which can help doctors distinguish between bacterial skin infection (cellulitis) and infectious bursitis. Ultrasound can also use Color Doppler to signal infection through an increase in blood flow (hyperemia) in the bursa and surrounding tissues.
If doctors suspect septic bursitis (an infection in the bursa) or bursitis caused by a crystal-related disease, they might draw some fluid from the inflamed bursa for testing. This fluid can be tested for cell count, bacteria, glucose levels, and for the presence of crystals. A result of less than 500 white blood cells/mm3 from the fluid suggests the bursitis is not infectious and not caused by a crystal-related disease.
Treatment Options for Bursitis
Most cases of bursitis, which is inflammation of the small, fluid-filled pads called bursae that cushion the bones, tendons, and muscles near your joints, will get better on their own. There are several ways to relieve pain and help the affected area return to normal. The initial treatment typically involves rest, ice, compression, and elevation to relieve symptoms.
Patients should be advised about the right way to move to avoid making the condition worse. If their job involves prolonged pressure on the knees or elbows, padding can protect the superficial bursa, which are the ones close to the skin. A foam donut cushion can help those with bursitis in the buttock region. Stretching and strengthening the core muscles can also improve symptoms.
In the case of bursitis near the Achilles tendon, it’s recommended that patients wear shoes that fit properly and don’t put pressure on the affected area. For pain relief, initial treatments often include non-prescription anti-inflammatory drugs and/or paracetamol. For the deeper bursa, injecting a corticosteroid drug, sometimes with a local anesthetic, can provide relief.
However, these injections aren’t recommended for the superficial bursa, as they carry risks such as causing infection, local tendon injury, skin thinning, or leaks from the bursa. There’s also a risk that the injections might relieve the pain and delay diagnosis of another condition, like a rotator cuff tear, which might need to be treated surgically within a certain timeframe. Furthermore, the long-term benefits of corticosteroid injections for chronic bursitis aren’t well-established. Physical therapy and exercises to improve the range of motion can help strengthen the muscles around the bursa, which is especially beneficial for bursitis in the shoulder.
If bursitis is caused by systemic inflammatory conditions, it’s crucial to treat the underlying condition. For infected bursitis, the first-line treatment is antibiotics that can combat gram-positive bacteria. Most patients with infected bursitis can be treated with oral antibiotics at home, and hospitalization is necessary only if the infection has spread widely or the patient’s overall condition is unstable. In stubborn cases, the bursa can be removed surgically using minimally invasive techniques.
What else can Bursitis be?
There are many other health conditions that can be mistaken for bursitis, or might even happen at the same time in the same area. The reasons for joint pain are vast, made up of many different disorders. Certain types of bursitis can mimic conditions like osteoarthritis, rheumatoid arthritis, or other inflammatory problems. Also, what doctors consider as possible conditions can be heavily influenced by where the suspected bursitis is located. For example, if a patient has shoulder pain, the doctor might also consider things like torn rotator cuffs, tears in the labrum of the shoulder, or shoulder impingement.
In many cases, these health conditions happen together, and one might actually have caused the bursitis. Gout, a type of arthritis, can also be mistaken for bursitis, especially around the elbow, in front of the knee, and below the kneecap because these are common areas for gout crystals to form or for pseudogout pain. Ischial bursitis, which is inflammation in the part of the pelvis where you sit, might be mixed up with sciatica, a nerve pain condition, because the bursa is close to the sciatic nerve. However, the pain for ischial bursitis becomes sharper when sitting, which helps doctors figure out the difference between the two.
Ischial bursitis can also be confused with ankylosing spondylitis, an inflammatory condition that mostly affects the spine, or other conditions causing inflammation in the sacroiliac joints in the lower back. Trochanteric bursitis, inflammation near the hip, must be differentiated from iliotibial band syndrome; however, tenderness in IT band syndrome will be more towards the knee compared to the more towards the hip location of the trochanteric bursa. Iliopsoas bursitis, a condition wherein inflammation is present in the hip joint and the thigh, may seem similar to arthritis, too much running, synovitis (inflammation of the joint lining), labral tears, or avascular necrosis of the femoral head (death of bone tissue due to lack of blood supply). Medial collateral ligament bursitis and pes anserine bursitis may look like MCL strains or tears, meniscal injuries, or even fractures of the tibial plateau.
Knee bursitis doesn’t usually cause fluid accumulation in the joint, so this can help the doctor tell knee bursitis apart from the above pathologies. Retrocalcaneal bursitis, an inflammation of the bursa located between the calcaneus and the Achilles tendon, might be mistaken for Achilles tendonitis (an injury of the Achilles tendon), enthesopathy (a disorder involving the attachment of a tendon or ligament to a bone), pain from bone spurs, or even plantar fasciitis (inflammation of a thick band of tissue that connects the heel bone to the toes). A septic bursa, which is an infection of a bursa, can be mistaken with a septic joint or even simple cellulitis (a common and potentially serious bacterial skin infection) of the skin over the bursa. It’s important that doctors tell these infectious processes apart, as how they’re treated may be very different, and not realizing a joint is infected may lead to serious health issues for the patient.
What to expect with Bursitis
Bursitis, an inflammation of the cushioning pads in your joints, is typically not a life-threatening condition. Most patients experience positive recovery outcomes and are treated as outpatients, meaning they visit the hospital for treatment but don’t need to stay overnight. However, it’s important to note that those who don’t avoid the activities that triggered the inflammation, or who continue with the same activities, often have recurring cases of the condition.
