There are more than 150 bursae in the body. Usually bursae are present from birth, but they may form in response to repeated pressure. Each sac contains a small amount of synovial fluid, a clear liquid that acts as a lubricant. Inflammation of the bursa causes pain on movement. The most common site for bursitis to occur is the shoulder (subdeltoid), but it also is seen in the elbows (olecranon), hips (trochanteric), knees, heels (Achilles), and toes. The affected area may be referred to as “frozen” because movement is so limited. There are four bursae in the knee, and all can become inflamed with overuse.
Bursitis causes about one in every 250 visits to a primary care physician in the United States. However, individuals who engage in certain types of repetitive behaviors are at a much greater risk. Individuals with jobs such as carpet or tile laying that require being on the knees for an extended time and jobs that require extended sitting are at an increased risk of developing bursitis. Many hobbies, especially very active ones, can also increase an individual's risk of bursitis. Baseball, ice skating, bicycling, and other repetitive sports can cause repeated friction, leading to bursitis. It is estimated that as many as 10% of runners have experienced bursitis.
The most common cause of bursitis is repeated physical activity, but it can flare up for no known reason. It can also be caused by trauma, rheumatoid arthritis, gout, and acute or chronic infection.
Pain and tenderness are common symptoms. If the affected joint is close to the skin, as with the shoulder, knee, elbow, or Achilles tendon, swelling and redness may be seen and the area may feel warm to the touch. The bursae around the hip joint are deeper, and swelling is not obvious. Movement may be limited and is painful. In the shoulder, it may be difficult to raise the arm out from the side of the body. Putting on a jacket or combing the hair can become a difficult activity as can throwing a ball.
In acute bursitis, symptoms appear suddenly; with chronic bursitis, pain, tenderness, and limited movement reappear after exercise or strain.
When an individual has pain in a joint, a careful physical examination is performed to determine what type of movement is affected and if there is any swelling present. Bursitis will not show up on x-rays, although sometimes there are also calcium deposits in the joint that can be seen. Inserting a thin needle into the affected bursa and removing (aspirating) some of the synovial fluid for examination can confirm the diagnosis. In most cases, the fluid will not be clear. It can be tested for the presence of microorganisms, which would indicate an infection, and crystals, which could indicate gout. In instances where the diagnosis is difficult, a local anesthetic (a drug that numbs the area) is injected into the painful spot. If the discomfort stops temporarily, then bursitis is probably the correct diagnosis.
If bursitis is related to an inflammatory condition such as arthritis or gout, then management of that disease is needed to control the bursitis.
When bursitis does not respond to conservative treatment an injection into the joint of a long-acting corticosteroid preparation, such as prednisone, can bring immediate and lasting relief. A corticosteroid drug is a hormonal substance that is the most effective drug for reducing inflammation. The drug is mixed with a local anesthetic and works on the joint within five minutes. Often one injection is all that is needed.
Surgery to remove the damaged bursa may be performed in extreme cases.
If bursitis is caused by an infection, then additional treatment is needed. Septic bursitis is caused by the presence of a pus-forming organism, usually staphylococcus aureus. Infection is confirmed by examining a sample of the fluid in the bursa. It requires treatment with antibiotics taken by mouth, injected into a muscle or into a vein (intravenously). The bursa also will need to be drained by needle two or three times over the first week of treatment. When a patient has such a serious infection, there may be underlying causes, for example undiscovered diabetes mellitus or human immunodeficiency virus infection (HIV).
Alternative treatments take into consideration the role of diet in causing bursitis. The faulty use of calcium by the body, magnesium deficiency, and food allergies may have a role. Diet changes and vitamin supplements may be helpful. The use of herbs, homeopathy, aromatherapy, and hydrotherapy can help relieve symptoms. Ginger may be useful in reducing inflammation. Acupuncture has been proven effective in treating hip and shoulder pain caused by bursitis and other conditions. Other therapies that deal effectively with musculoskeletal problems including bodywork, magnetic field therapy, naturopathic medicine, chiropractic, and applied kinesiology may be helpful.
Bursitis usually responds well to treatment, but it may develop into a chronic condition if the underlying cause is not corrected. If bursitis is caused by repetitive motion such as throwing a baseball, it may be necessary to cut back on that activity to prevent future flare-ups.
Aggravating factors should be eliminated to prevent bursitis. Overexercising or the repetition of a movement that triggers the condition should be avoided. Doing exercises to strengthen the muscles around the joint will also help. When doing repetitive tasks, frequent breaks should be taken and the activity should be alternated with others using different parts of the body. To cushion the joints, it is a good idea to use cushioned chairs when sitting and foam kneeling pads for the knees. Leaning on the elbows, kneeling, or sitting on a hard surface for a long period should be avoided. Not wearing high heels can help prevent bursitis in the heel, as can changing to new running shoes as soon as the old ones are worn out.
See also Arthritis ; Kinesiology ; Sitting .
Petty, Nicola J., ed. Principles of Neuromusculoskeleal Treatment and Management: A Guide for Therapists, 2nd ed. New York: Churchill Livingston Elsevier, 2011.
Sutton, Amy L, ed. Fitness and Exercise Sourcebook, 3rd ed. Detroit: Omnigraphics, 2007.
Rookmoneea, M., et al. “The Effectiveness of Interventions in the Management of Patients with Primary Frozen Shoulder.” Journal of Bone and Joint Surgery 92, no. 9 (September 2010): 1267–72.
“What is Frozen Shoulder?” Mayo Clinic Women's Healthsource 15, no. 1 (January 2011): 8.
“Bursitis.” PubMed Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024963 (accessed January 13, 2017).
“Bursitis.” The Mayo Clinic. August 20, 2014. http://www.mayoclinic.org/diseases-conditions/bursitis/basics/definition/con-20015102 (accessed January 15, 2017).
Arthritis Foundation, 1355 Peachtree St. NE, Ste. 600, Atlanta, GA, 30309, (404) 872-7100, (844) 571-4357, http://www.arthritis.org .
National Institute of Arthritis and Musculoskeletal and Skin Diseases, 1 AMS Circle, Bethesda, MD, 20892, (301) 495-4484, (877) 22-NIAMS (226-4267), Fax: (301) 718-6366, NIAMSinfo@mail.nih.gov, https://www.niams.nih.gov .
Karen Ericson, RN
Revised by Tish Davidson, AM