BURSITIS

 A Comprehensive Overview with Treatment Options

INTRODUCTION

            Over the past two to three decades, advances in medical research, in addition to ever-increasing social pressures, have placed a profound importance upon maintaining a healthy lifestyle.  Consequently, there has been an increasing prevalence of participation in recreational sports amongst individuals of all age groups.  There is of course, an inherent danger of sustaining injury that coincides with the numerous health benefits derived from physical activity of any sort.  The diagnosis of bursitis is one such condition that has become increasingly prevalent, exhibiting a strong relationship to recreational and occupational activities that require prolonged, repetitive use of a specific area of the body.

NORMAL FUNCTION AND PROGRESSION TO DISEASE

            The human body contains more than one hundred fifty bursae.²  The actual structure of a bursa is that of a thin-walled, fluid-filled sac.¹  Bursae are associated collectively with muscles, tendons, and bones, and are situated in close proximity to the multitude of joints located throughout the body.²  Muscles normally give way to rigid tendons, which in turn make their way across joints, and attach to bony prominences in proximity to these joints.⁵  Contraction of a muscle, or groups of muscles, requires energy.⁵  This energy is transmitted from the involved muscles, through their respective tendons, and consequently across joints, resulting in movement of the joint.⁵  The specific function of the numerous bursae is to lubricate and cushion muscles and tendons, in order to allow smooth, painless movement of joints.¹  As an individual ages, their tendons become increasingly less elastic and more rigid.³  Bursae must therefore work much harder, and subsequently may become unable to compensate for the high amount of rubbing and friction of tendons that comes with joint movement.³  As a result, the involved bursa becomes inflamed, manifested as pain and tenderness.²  Participation in physical activity that involves repetitive, frictional movement of isolated joints is the most important risk factor for developing bursitis.³  Examples include, but are not limited to running, tennis, golf, skiing, and throwing.³  Likewise, occupations involving similar repetitive motions, most commonly those involving some form of physical labor, increase an individual’s risk.³  Less common but important causes of bursitis include trauma, infection, and specific systemic diseases-rheumatoid arthritis, gouty arthritis, and psoriatic arthritis being most common.¹

SPECIFIC AREAS OF INJURY

·        Shoulder

Subacromial bursitis, or bursitis of the shoulder, is the most prevalent area of the body involved

in the development of bursitis.¹  The most common mechanism of injury is repetitive overhead

arm movements.¹  This condition is often associated with concomitant rotator cuff tendonitis.¹

·        Elbow

Olecranon bursitis, or bursitis of the elbow, results from activities involving repeated flexion and

extension of the elbow.²  Three conditions in particular often manifest with elbow bursitis:

1.      Tennis elbow, properly termed lateral epicondylitis, is characterized by the long-term degeneration of the tendon of the extensor carpi radialis brevis muscle, located on the lateral aspect of the elbow.⁶

2.      Golfer’s elbow, properly termed medial epicondylitis, is characterized by the long-term degeneration of the tendon of the flexor carpi radialis muscle, located on the medial aspect of the elbow.⁶

3.      Baseball pitchers are at increased risk for numerous musculoskeletal injuries to the elbow, any of which may occur in conjunction with bursitis of the elbow.⁶

·        Buttocks

Ischial bursitis, or bursitis of the buttocks, often develops due to periods of prolonged sitting and pivoting on the buttocks, such as with bicycling.²

·        Hip

Bursitis of the hip is most commonly associated with macro or microtrauma to the hip, arthritis of the hip, or occupations that involve standing for long periods of time.²   Tight muscles and tendons predispose a person to developing bursitis of the hip, as well as bursitis of other body parts.  Repetitive climbing of stairs may also result in bursitis of the hip.¹              

·        Knee

Bursitis of the knee is associated with numerous mechanisms of injury.  Often times, a prepatellar bursitis may occur over the front of the knee due to prolonged kneeling.¹  This condition is commonly termed Housemaid’s Knee.¹  Frequent running predisposes one to knee bursitis, as does chronic arthritis of the knee.¹

·        Ankle

Use of improper footwear is a leading cause of ankle bursitis.²

CLINICAL MANIFESTATIONS AND DIAGNOSIS

            While episodes of bursitis may occur at any age, adults over the age of forty have the highest risk of developing the condition.³  Physically active individuals, especially those who play sports requiring repetitive motions, also show an increased prevalence for bursitis.¹  While physically demanding labor involving repetitive movements also predisposes one for developing bursitis, any particular occupation involving repetitive movements may result in development of the condition.²

            Often times, the onset of bursitis is signaled by swelling, warmth, and redness over the involved area.²  A dull ache, tenderness, and local stiffness may be present as well.²  Commonly, associated pain worsens with movement or when pressure is applied to the area.²  Bursitis pain may exhibit a gradual onset and escalate over time, or may occur suddenly with severe pain.³  Because the diagnosis of bursitis cannot be confirmed with traditional medical imaging techniques such as x-ray, a thorough history and physical examination of the patient is imperative.  This will allow a connection to be traced between recent physical activity and the localized pain.²  Additional screening may be necessary to rule out other causes of joint pain and inflammation.²  More expensive imaging modalities such as MRI may be able to visualize bursitis, however this is rarely needed as the diagnosis is primarily a clinical one in uncomplicated cases.

TREATMENT AND PREVENTION

            The initial treatment for bursitis simply involves avoiding the implicated activity.³  Temporary immobilization and the application of ice to the affected area will reduce inflammation and swelling.²  Topical analgesics may be useful for this condition as the medication can be delivered superficially via a spray, cream, or lotion without the risks associated oral medications.

With persistent pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDS) may be useful.²  Although many NSAIDS may be acquired over the counter, it is always prudent to consult a physician before initiating treatment.  The most common side effect of NSAIDS is the development of peptic ulcers with resultant gastrointestinal bleeding.⁷  It is therefore important to take these medications with food.  Less commonly, NSAIDS may cause kidney damage.⁷  

Corticosteroid injections directly into the bursa may be employed by the treating physician.²  Corticosteroids are potent anti-inflammatory drugs and can be very effective for the treatment of bursitis.  Corticosteroid injections should only be performed by an experienced physician under sterile conditions as bleeding and infection are potential side effects.  Too many injections can lead to serious injury including tendon rupture. 

Finally, physical therapy and range of motion exercises should be part of any treatment approach.  This modality of treatment is effective in maintaining strength and function of the involved joint, and may even expedite an early return to previous activities.  With infective bursitis, the bursa may need to be surgically drained, with a regimen of antibiotics initiated.²  If bursitis is accompanied by fever, chills, night sweats, nausea, vomiting, and/or diarrhea, a physician should be consulted immediately.³

            Numerous, simple measures may be employed to prevent the onset of bursitis.  Proper stretching before any physical activity is extremely helpful.²  Maintaining strength and conditioning of the muscles surrounding the involved bursa will help to prevent further exacerbations.²  Good posture, maintaining proper mechanical movement of the joint, and cushioning or supporting the area is both preventative and palliative.²  This involves the use of proper footwear, braces, and wrapping the inflamed area as needed.  Finally, taking breaks from repetitive tasks, or changing routines, will often help prevent the onset of bursitis, as well as alleviate any ongoing pain.²

AUTHORS

Jason P. Welter, BS, New York College of Osteopathic Medicine, Old Westbury, NY.

Grant Cooper, MD, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell

REFERENCES

1. Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL.  Harrison’s Principles of Internal Medicine 16^th Edition 2005:  2064-2065

2. Bursitis.  www.mayoclinic.com/health/bursitis/DS00032/DSECTION=1 2005:  1-9

3. Smith MW.  Arthritis:  Bursitis.  www.webmd.com/content/article/78/95604.htm 2005

4. Schuenke M, Schulte E, Schumacher U, Ross LM, Lamperti ED.  Thieme Atlas of Anatomy 2006:  231-232

5. Kumar V, Abbas AK, Fausto N.  Robins and Cotran Pathologic Basis of Disease 7^th Edition 2005:  1273-1315

6. Brinker MR, Miller MD.  Fundamentals of Orthopedics 1999:  158

7. Katzung BG.  Basic and Clinical Pharmacology 9^th Edition 2004:  576-603, 641-660