DOCUMENT 11
FOI-24/25-0120
Research – Bursitis: Evidence Based Treatments
Brief
Evidence based treatments for
Bursitis.
Date
January 20, 2021
Requester(s)
Alicia s47F - personal privacy (Senior Technical Advisor (TAB/AAT))
Researcher
Craig
(
s47F - persona Tactical Research Advisor (TAB?AAT)
Cleared
Janes47F - personal priva (Research Team Leader (TAB)
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These
are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on
access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of
these matters.
1 Contents
2
Summary ......................................................................................................................................... 2
3
What is Bursitis?.............................................................................................................................. 2
4
Symptoms of Bursitis ...................................................................................................................... 2
5
Causes of Bursitis ............................................................................................................................ 3
6
Types of Bursitis .............................................................................................................................. 3
7
Treatment and Management .......................................................................................................... 3
7.1
Overview ................................................................................................................................. 3
7.2
Prepatellar Bursitis .................................................................................................................. 4
7.3
Olecranon Bursitis ................................................................................................................... 4
7.4
Trochanteric Bursitis ............................................................................................................... 4
7.5
Retrocalcaneal Bursitis ............................................................................................................ 5
8
References ...................................................................................................................................... 5
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2 Summary
• Bursitis can often be treated at home, especially if the patient can avoid the activity that
might have triggered it
• Most patients respond to nonsurgical management, including ice, activity modification, and
nonsteroidal anti-inflammatory drugs
• Treatment will depend on the cause of the bursitis, and aims to relieve the symptoms as
much as possible while the healing process takes place
• When a bursa is infected, it is known as "septic bursitis". When not infected it is known as
"aseptic bursitis"
• There are four types of bursa each requiring different treatment
• Depending on the type and severity of the bursa, anti-inflammatory medications or
injections of corticosteroids may be required, and surgical excision (a definitive option) of
the bursal sac may be necessary.
3 What is Bursitis?
Bursitis is an inflammation or irritation of the small, fluid-filled ‘cushions’ that protect a tendon
where it touches a bone. These cushions are called bursae (or bursa (singular) if there’s just one).
Muscles in our bodies are connected to the bones via strong white fibrous cords called tendons.
Wherever these tendons cross bones and joints, the body creates a small cushion filled with fluid,
which is known as a bursa.
When a bursa becomes irritated or inflamed, it swells with fluid and the swelling can be painful and
restrict movement [1].
Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology [2].
When a bursa is infected, it is called septic bursitis. Septic bursitis typically affects bursae located at
the knee and elbow joints. Unlike aseptic (non-infectious) bursitis, septic bursitis is a potentially
serious medical condition and prompt medical attention is advisable [3].
4 Symptoms of Bursitis
Joint pain can be experienced when the patient moves and is often the first symptom of bursitis. The
area may also have swelling, feel warm or look red. As bursitis progresses, the patient might even
feel pain when at rest.
The swollen bursa can make the joint stiff and its movement might be restricted [1].
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5 Causes of Bursitis
Bursitis is commonly caused by overuse of a joint, especially by doing repetitive movements. The
movements might be through work, such as kneeling to clean or garden, or through sport, such as
playing tennis.
Bursitis can also be caused by an injury to the joint, and by conditions that cause swelling such as
gout and rheumatoid arthritis. It is most common in the knee and shoulder, but also occurs in the
hip, elbow, wrist, ankle and heel [1].
6 Types of Bursitis
The Common types of bursitis include [2]:
• Pre-patellar
• Olecranon
• Trochanteric
• Retro-calcaneal
7 Treatment and Management
7.1
Overview
Bursitis can often be treated at home, especially if the patient can avoid the activity that might have
triggered it [1].
Treatment will depend on the cause of the bursitis, and aims to relieve the symptoms as much as
possible while the healing process takes place. Treatment options may include [4]:
• Pain-relieving medications
• Cold packs
• Gentle mobilising exercises and rest
• Anti-inflammatory medications or injections of corticosteroids may be used in cases of
severe pain
Most patients respond to nonsurgical management, including ice, activity modification, and
nonsteroidal anti-inflammatory drugs [2].
If infection is present, as well as pain and swelling of the affected area, other symptoms may
develop, such as a raised temperature. Treatment with an appropriate antibiotic is necessary [4].
If the bursitis was triggered by a particular form of overuse, it‘s important to avoid that activity, or
modify how you perform that activity. An occupational therapist can help you find solutions to this
problem [4].
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7.2
Pre-patellar Bursitis
Bursitis arises from many inflammatory phenomena, but infection is the primary concern.
Approximately 80% of cases of septic pre-patellar bursitis are caused by Staphylococcus aureus.
Local corticosteroid injection may be used in the management of pre-patellar bursitis.
Management of septic pre-patellar bursitis is controversial. Recommendations range from oral
antibiotics alone to surgical excision of the bursal sac. The primary decision in developing a
treatment algorithm is whether to initiate nonsurgical or surgical management. Most patients
respond to nonsurgical treatment. Surgery is a definitive option that is associated with
complications. Management of aseptic pre-patellar bursitis typically consists of rest, compression,
and nonsteroidal anti-inflammatory drugs (NSAIDs). It may also include local corticosteroid injection
[2, 5].
7.3
Olecranon Bursitis
Olecranon bursitis is the most common superficial bursitis [2, 6]. Fluid collection within and
inflammation around the bursa are caused by traumatic, inflammatory, and infectious processes.
Olecranon bursitis is typically non-infectious in origin; septic bursitis accounts for approximately 20%
of all acute cases [2, 7].
Management of olecranon bursitis is dictated by its aetiology. Acute traumatic or idiopathic
olecranon bursitis typically resolves with nonsurgical management. Ice, compressive dressings, and
avoidance of aggravating activity are sufficient in most patients [2, 8]. When a patient does not
improve as expected, aspiration should be performed to rule out infection. Alternatively, in the
patient in whom fluid collection is bothersome at presentation, aspiration with or without
concurrent corticosteroid injection may be done [2, 9]. In a study of 47 patients with traumatic
bursitis who underwent aspiration, 90% recovered in 6 months [2, 10]. Intrabursal corticosteroid
injection is associated with complications, including infection, skin atrophy, and chronic pain [2, 10].
7.4
Trochanteric Bursitis
Patients with trochanteric bursitis typically present with lateral hip pain, which may radiate to the
buttock, groin, or low back. Symptoms may be exacerbated by ambulation, walking uphill, stair
climbing, and rising from a seated position [2].
Initial management consists of physical therapy and oral NSAIDs. If symptoms persist, local
glucocorticoid injection is performed [2, 11, 12]. Most patients respond to nonsurgical management
[2].
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7.5
Retrocalcaneal Bursitis
Inflammation of the retrocalcaneal bursa can limit function and cause pain. The Achilles tendon and
its bony insertion may be involved in severe cases. This spectrum of disease has been given many
names, including Haglund syndrome, Albert disease, calcaneus altus, pump bump, winter heel, and
achillodynia [13].
Management of these causes of posterior heel pain begins with ice, activity modification, NSAIDs,
and orthoses. Shoe wear modification to prevent irritation of the posterior heel by the shoe counter
should be considered, as well. Manoeuvres that stretch the local Achilles tendon may aid in
attenuating the symptoms [2].
Surgical intervention is warranted for retrocalcaneal bursitis that does not resolve with nonsurgical
management. Accurate clinical diagnosis guides surgical management. For refractory cases
associated with Haglund deformity, open procedures include resection of the calcaneal prominence
proximal to the Achilles insertion, debridement of Achilles tendinopathy, and complete excision of
the retrocalcaneal bursa [14-16]. Alternatively, dorsal closing wedge osteotomy may be considered
to rotate the posterior calcaneus to a lesser prominence [17]. Complications of open procedures
include skin breakdown, Achilles tendon avulsion, altered sensation, and painful scar formation [2,
13, 18].
8 References
1.
Healthdirect. Bursitis 2021 [Available from: https://www.healthdirect.gov.au/bursitis.
2.
Daniel LA, Amar P, Stephen K, Ryan C. Four Common Types of Bursitis: Diagnosis and
Management. J Am Acad Orthop Surg [Internet]. 2011; 19(6):[359-67 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/21628647/.
3.
Arthritis Health. Septic Bursitis 2019 [Available from: https://www.arthritis-
health.com/types/bursitis/septic-bursitis.
4.
Better Health Channel. Bursitis: Department of Health & Human Services: State Government
of Victoria; 2020 [Available from:
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bursitis.
5.
Langford CA, BC G. Periarticular disorders of the extremities, in Fauci AS, Braunwald E,
Kasper DL, et al, eds: Harrison's Principles of Internal Medicine, 17e.
6.
Pien FD, Ching D, Kim E. Septic bursitis : experience in a community practice. Orthopedics
[Internet]. 1991; 14(9):[981-4 pp.]. Available from: https://europepmc.org/article/med/1946062.
7.
Jaffe L and Fetto JF. Olecranon bursitis. Contemp Orthop1984.
8.
J J Canoso. Idiopathic or traumatic olecranon bursitis. Clinical features and bursal fluid
analysis. Arthritis Rheum [Internet]. 1977; 20(6):[1213-6 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/901595/.
9.
BF Morrey. (in) The Elbow and its Disorders (ed 4). Philadelphia: Saunders; 2009. p. 1164-73.
10.
Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for
traumatic olecranon bursitis. Annals of the rheumatic diseases [Internet]. 1984; 43(1):[44-6 pp.].
Available from: https://pubmed.ncbi.nlm.nih.gov/6696516/.
11.
M I Shbeeb 1 and E L Matteson. Trochanteric bursitis (greater trochanter pain syndrome).
Mayo Clin Proc [Internet]. 1996; 71(6):[565-9 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/8642885/.
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12.
Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Arch Phys
Med Rehabil [Internet]. 1986; 67(11):[815-7 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/3778178/.
13.
Leitze Z, Sella, Enzo, Aversa, John. Endoscopic Decompression of the Retrocalcaneal Space. J
Bone Joint Surg Am [Internet]. 2003 18/01/21; 85(8):[1488-96 pp.]. Available from:
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftf&NEWS=N&AN=00004623-
200308000-00009.
14.
P Angermann. Chronic retrocalcaneal bursitis treated by resection of the calcaneus. Foot
Ankle [Internet]. 1990; 10(5):[285-7 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/2341100/.
15.
Pauker M, Katz K, Yosipovitch Z. Calcaneal ostectomy for Haglund disease. Foot Surg
[Internet]. 1992; 31(6):[588-9 pp.]. Available from: https://pubmed.ncbi.nlm.nih.gov/1469219/.
16.
Schneider W, Niehus W, Knahr K. Haglund's syndrome: disappointing results following
surgery -- a clinical and radiographic analysis. Foot Ankle Int [Internet]. 2000; 21(1):[26-30 pp.].
Available from: https://pubmed.ncbi.nlm.nih.gov/10710258/.
17.
AE Miller and TA Vogel. Haglund's deformity and the Keck and Kelly osteotomy: a
retrospective analysis. J Foot Surg [Internet]. 1989; 28(1):[23-9 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/2654263/.
18.
Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the
retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot &
ankle international [Internet]. 2007; 28(2):[149-53 pp.]. Available from:
https://pubmed.ncbi.nlm.nih.gov/17296130/.
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