bursitis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The term “bursitis” refers to inflammation or irritation of a bursa. Bursae (the pleural of bursa) are small sacs located between moving structures such as bones, muscles, skin and tendons. The bursa acts as a cushion to allow smooth gliding between these structures.

Since both tendons and bursae are located near joints, inflammation in these soft tissues will often be perceived by patients as joint pain and mistaken for arthritis. Symptoms of bursitis and tendonitis are similar: pain and stiffness aggravated by movement. Pain may be prominent at night or after use. Almost any tendon or bursa in the body can be affected, but those located around a joint are affected most often. Tendonitis and bursitis are usually temporary conditions, but may become recurrent or chronic problems. Unlike arthritis, they do not cause deformity, but can cause significant pain and restrain motion.

The most common cause of tendonitis and bursitis is injury or overuse during work or play. Occasionally an infection within the bursa or tendon sheath will be responsible for the inflammation. Certain antibiotics, such as the quinolones (ciprofloxacin, others) may produce tendonitis. Tendonitis or bursitis may be associated with diseases such as rheumatoid arthritis, gout, psoriatic arthritis, thyroid disease and diabetes.

• Tendonitis and bursitis are common musculoskeletal problems in both the young and old populations.
• Overuse and sports injuries are common in physically active populations.
• These diseases often result in loss of work and income.

Diagnosis of tendonitis and bursitis requires a careful medical history and physical examination. X-rays may be helpful to exclude bony abnormalities or arthritis. Tendons and bursae are generally not visible on x-rays. MRI and ultrasound may be useful in the detection of bursitis and tendonitis. Aspiration of a swollen bursa may be performed to exclude infection or gout. Blood tests may be ordered to confirm underlying conditions but are generally not necessary to diagnose tendonitis or bursitis.

Treatment of these two conditions is based on the underlying cause. In overuse or injury, reduction or avoidance of a particular activity is useful. The use of modalities, especially ice, may help to reduce inflammation and pain. An adequate warm-up before and correct posture during exercise is useful.

The first steps of bursitis treatment are to keep pressure off of the affected area, and try to limit your activity of that joint. Some individuals benefit from placing an elastic bandage (Ace wrap) or immobilizing brace around the joint until the inflammation subsides. Movement an pressure of the inflamed area will only cause exacerbation and prolongation on symptoms.

The ice will help to control the inflammation and decrease swelling. By minimizing inflammation and swelling, the bursa can return to its usual state and perform its usual function.

The use of braces or splints for the affected area are helpful to decrease the stress on the area and support good alignment while symptoms are acute especially in the hand and wrist area. Orthotics and the temporary use of a cane can help unload the lower extremity to decrease pain and inflammation. Sometimes anti-inflammatory medications are needed to reduce inflammation and pain. Corticosteroid injections into the affected area are frequently helpful if symptoms persist.

Once the acute attack of tendonitis or bursitis subsides, preventing recurrences is crucial to avoid becoming a chronic problem. Education in joint protection and positioning to reduce repetitive activities is necessary. Appropriate splints or pads to protect susceptible areas can help to prevent recurrences. You may have learned to compensate for your symptoms so make sure you address adjacent structures in your treatment. Stretching and strengthening are very helpful to address any muscle imbalances to prevent a reoccurrence of symptoms. Occupational and physical therapists can help teach you what to do to meet your specific needs. Proper posture and body mechanics during activities is also a big component of treatment. You need to make sure you have ergonomically correct workstations and proper alignment when using exercise equipment or during the specific activities that aggravate your symptoms. Proper conditioning of involved muscles is another component of treatment.

Nonsteroidal anti-inflammatory medications (NSAIDs) include a long list of possibilities such as Ibuprofen, Motrin, Naprosyn, Relafen, Lodine, Daypro, Mobic, Celebrex, and many others. Bursitis treatment can be improved by these medications that will decrease pain and swelling. Be sure to talk to your doctor before starting these medications.

If the symptoms of bursitis are persistent, an injection of cortisone may be considered. Cortisone is a powerful anti-inflammatory medication, but instead of being given by mouth, it is injected directly to the site of inflammation. This can be extremely helpful for situations that are not improved with rest.

Proper strengthening technique can help you avoid bursitis by using your muscles in a safe, more efficient manner. For example, patients with shoulder bursitis can learn ways to move the shoulder that will not cause inflammation. Do not begin exercises until the inflammation of bursitis has resolved!

Alternate repetitive tasks with breaks to relieve pressure. Don't perform one activity continuously for hours at a time.

If your work involves an activity such as prolonged kneeling, use protective cushions. These can be purchased at hardware stores--ask for roofers pads.

The steps listed above are usually adequate bursitis treatment, and most patients have resolution of their symptoms. Learning to avoid activities that may cause a bursitis flare-up can also be important. If these steps are not sufficient, drainage of the bursa or surgical excision may also be considered. Usually, there are only necessary if the aforementioned treatments have failed.

As explained earlier, some cases of bursitis have a bacterial infection of the fluid in the swollen bursa. If this is the case, then the bursa will have to be drained, and you will need antibiotic treatment. It is important that you see your doctor if you think you may have infected bursitis.

Bursitis due to underlying conditions such as arthritis and gout are more difficult to treat and recur more frequently. The best management in these situations is to do your best to avoid flare-ups of gouty attacks or arthritic episodes, and to avoid activities which you have learned cause bursitis.

FLASH

A truly effective treatment for bursitis seems to be available in the form of percutaneous needle tenotomy with autologous tissue grafting. This is a minimally invasive procedure using a small needle with ultrasound guidance. Blood is drawn from a patient and spun in a special centrifuge in order to harvest the platelet rich plasma component. Platelets are cells that contain multiple growth and healing factors. The patient then has the skin over the inflamed bursa anesthetized with local lidocaine. A small needle is introduced into the bursa and multiple tiny holes are made. The platelet rich plasma is then injected. Healing takes place.