Bursitis
Anatomy and Role of Bursae
Understanding the structure and function of bursae helps to grasp why their inflammation can cause such sharp and debilitating pain:
- A serous bursa is a potential cavity lined with a synovial membrane and containing a few milliliters of synovial fluid under normal conditions.
- Superficial bursae are located directly beneath the skin, overlying a bony prominence, and protect against repeated skin trauma (elbow, kneecap, heel).
- Deep bursae are located between tendons and bones, facilitating tendon gliding during joint movements (subacromial in the shoulder, trochanteric in the hip).
- In case of irritation, the synovial membrane reacts with an overproduction of fluid: the bursa distends, compresses adjacent structures, and generates characteristic pain.
- Chronic inflammation can lead to thickening of the bursa wall and the formation of calcifications in advanced cases.
Causes and risk factors
Bursitis most often results from repeated mechanical stress on the bursa, but several other mechanisms can be involved:
| Mechanism | Causes and associated situations | Preferred locations |
|---|---|---|
| Repeated mechanical surcharge | Repetitive professional or sports movements that strain the same joint for prolonged periods, carrying heavy loads, maintaining awkward postures | Shoulder (subacromial), elbow (olecranon), hip (trochanteric), knee (prepatellar, pes anserinus) |
| Direct trauma | Single shock on a bony prominence, fall on the knee or elbow, prolonged pressure on a hard surface | Superficial bursae: prepatellar (housemaid's knee, tailor's bottom), olecranon (miner's elbow), retrocalcaneal (heel) |
| Bacterial infection (septic bursitis) | Skin penetration by bacteria through wounds, scratches, insect bites, or injections; hematogenous spread of a distant infection | Mainly the superficial bursae: olecranon and prepatellar, directly accessible to skin trauma |
| Systemic inflammatory diseases | Rheumatoid arthritis, gout (urate deposits in the bursa), pseudogout (calcium pyrophosphate), spondyloarthropathies | Variable by disease; often multiple bursae are affected simultaneously in systemic diseases |
| Tendinous calcifications associated | Calcium hydroxyapatite deposits in adjacent tendons, secondary inflammatory reaction of the bursa by contiguity | Shoulder, especially (supraspinatus tendon), hip (greater trochanter) |
| General facilitating factors | Obesity (joint overload), diabetes (increased susceptibility to infections and inflammation), advanced age (degeneration of periarticular tissues), immunosuppression | All locations; diabetes particularly increases the risk of septic bursitis |
Most frequent locations
While bursitis can theoretically affect any bursa in the body, certain locations are significantly more common in clinical practice, often with popular names that evoke the activities or postures that favor them:
| Location | Stock market hit | Common name | Usual context |
|---|---|---|---|
| Shoulder | Subacromial (subdeltoid) bursa | Subacromial bursitis | Repetitive overhead movements, painting, throwing sports, swimming; often associated with rotator cuff tendinopathy |
| Elbow | Olecranon bursa | Miner's elbow, student's elbow | Prolonged pressure of the elbow on a hard surface, direct trauma; superficial bursa very exposed to infections |
| Hip | Trochanteric bursa (greater trochanter) | Trochanteric bursitis | Running, leg length discrepancy, hip osteoarthritis, iliotibial band syndrome |
| Knee – anterior aspect | Pre-rotulian scholarship | Tiler's knee, cleaner's knee | Prolonged kneeling on hard surfaces; frequently infected superficial bursa |
| Knee – medial aspect | Pes anserinus bursitis | Pes anserinus bursitis | Obesity, medial knee osteoarthritis, diabetes; characteristic pain on the inner side of the knee, 3 to 5 cm below the joint line |
| Talon | Retrocalcaneal bursa or retro-Achilles bursa | Heel bursitis, Haglund's deformity | Ill-fitting shoes compressing the Achilles tendon, intensive running, bony deformity of the calcaneus (Haglund's exostosis) |
| Butt | Ischial bursa | Weaver's bursitis | Prolonged sitting on hard surfaces, sports activities that strain the hamstrings |
Distinction between aseptic bursitis and septic bursitis
This distinction is fundamental because it entirely conditions the management. An unrecognized septic bursitis can rapidly evolve into septic arthritis or extensive cellulitis:
| Features | Aseptic bursitis | Septic bursitis |
|---|---|---|
| Cause | Mechanical, traumatic, microcrystalline, or systemic inflammatory | Bacterial infection, most often Staphylococcus aureus (80 % of cases), Streptococcus |
| Fever | Absent or very moderate | Present in 70 % of cases, sometimes high with chills |
| Local aspect | Moderate swelling, heat, and redness; erythema limited to the scrotum | Intense redness, marked heat, swelling extending beyond the scrotum; wound or entry point sometimes visible |
| Pain | Pain on pressure and movement, variable intensity | Intense pain even at rest, exquisite to the touch |
| Fluid analysis | Clear or slightly cloudy liquid, white blood cells less than 2,000/mm³ | Purulent or cloudy fluid, white blood cells over 10,000/mm³, positive bacterial culture |
| Treatment | Rest, anti-inflammatories, physiotherapy, injection if necessary | Urgent systemic antibiotic therapy; surgical drainage if an abscess has formed |
Symptoms
The symptoms of bursitis vary depending on its location, cause, and stage of development, but some cardinal signs are found in most forms:
- Pain localized in the vicinity of a joint, worsening with direct pressure on the bursa and during movements that stress the affected area.
- Visible or palpable swelling in the form of a soft, resilient, and sometimes fluctuating lump, directly superimposed on the relevant bony prominence.
- Local redness and heat, more pronounced in infectious and microcrystalline forms
- Limitation of joint motion, often painful in a specific range of motion rather than in all directions
- Nocturnal pain disturbing sleep, particularly common in subacromial bursitis of the shoulder when lying on the affected side.
- Fever, chills, and general malaise in case of infectious bursitis
- In chronic forms: progressive induration of the bursa, palpable calcifications, recurrent painful episodes interspersed with periods of remission
Diagnosis
The diagnosis of bursitis is mainly based on clinical examination, supplemented by targeted investigations depending on the location and suspected cause:
- Detailed medical history: occupation, sports or leisure activities, recent trauma, history of gout or rheumatological disease, fever, recent skin wound
- Clinical examination: precise location of pain, assessment of active and passive range of motion, palpation of the bursa, check for skin entry points or associated cellulitis
- Standard radiography: excludes fracture, underlying bone pathology, and visualizes periarticular calcifications
- Musculoskeletal ultrasound: confirms bursitis diagnosis, assesses bursa size and content (simple fluid, heterogeneous, purulent), guides diagnostic and therapeutic aspiration
- Articular MRI: reserved for atypical or complex forms, particularly for evaluating tendinopathy or a rotator cuff tear associated with subacromial bursitis.
- Bursa aspiration with fluid analysis: essential in case of suspected septic bursitis (direct examination, culture, antibiogram) or microcrystalline bursitis (search for urate or pyrophosphate crystals)
- Biological assessment if infectious or inflammatory condition is suspected: complete blood count, CRP, ESR, blood uric acid, blood cultures if fever.
Treatments
The management of bursitis is closely guided by its cause, location, and severity. The vast majority of aseptic bursitis cases respond well to well-managed conservative treatments:
| Treatment | Terms and conditions | Indications and remarks |
|---|---|---|
| Relative repository and modification of activities | Temporary eviction of triggering movements or postures; maintenance of moderate activity within painless ranges | First systematic measure; complete rest contraindicated as it promotes stiffness and functional loss |
| Cryotherapy | Apply ice pack wrapped in a cloth for 15 to 20 minutes, 3 to 4 times a day for the first few days | Reduces local inflammation and pain in the acute phase; do not apply directly to the skin |
| Nonsteroidal anti-inflammatory drugs (NSAIDs) | Ibuprofen 400 to 600 mg every 6 to 8 hours, naproxen 500 mg twice a day, for 7 to 14 days | Reduce pain and inflammation; take with food; contraindicated in cases of kidney failure, gastroduodenal ulcer, or pregnancy |
| Physical therapy and physiotherapy | Targeted stretches, peri-articular muscle strengthening, manual therapies, therapeutic ultrasound, iontophoresis | Fundamental treatment of chronic or recurrent forms; correction of muscular imbalances and biomechanical defects that favor recurrence |
| Corticosteroid infiltration | Ultrasound-guided long-acting corticosteroid (methylprednisolone, triamcinolone) intra-bursal injection with or without local anesthetic | Fast and often spectacular efficacy on pain; maximum of 2 to 3 injections per site per year to avoid local side effects (skin atrophy, tendon weakening); do not inject if infection is suspected |
| Aspiration biopsy | Aspiration of inflammatory fluid under ultrasound guidance | Immediate relief for a very swollen and painful bursa; often combined with corticosteroid injection in the same session |
| Antibiotic therapy (septic bursitis) | Cefazoline IV in hospital if severe forms, or amoxicillin-clavulanate PO for mild to moderate forms; duration of 10 to 14 days depending on the evolution | Prioritize coverage for Staphylococcus aureus; adapt based on the puncture fluid antibiogram; surgical drainage if abscess or no response to 48-72 hours of antibiotic therapy |
| Surgical bursectomy | Excision of the bursa via arthroscopy or open surgery, depending on location | Reserved for chronic forms refractory to all conservative treatments after 6 to 12 months, for recurrent septic bursitis, or when an underlying bony exostosis (Haglund's deformity) maintains the mechanical conflict. |
| Treatment of the underlying cause | Gout treatment (colchicine, allopurinol), rheumatoid arthritis, correction of a biomechanical malocclusion, orthopedic insoles | Indispensable for preventing recurrences in bursitis of microcrystalline or rheumatic origin |
Possible complications
Untreated or inadequately managed bursitis can lead to local or general complications depending on its nature:
| Complication | Description | Contributing factors |
|---|---|---|
| Chronicization | Progressive thickening of the bursal wall, fibrosis, and intra-bursal calcifications, leading to recurrent bursitis that is resistant to usual treatments. | Continuation of aggravating activities, insufficient or delayed treatments, uncorrected underlying cause |
| Septic arthritis | Extension of the infection from the bursa to the adjacent joint, orthopedic emergency with risk of rapid joint destruction | Unpurulent bursitis or one caused by a virulent germ, immunosuppression, deep location of the bursa (hip) |
| Extensive cellulite | Spread of bacterial infection to the peribursal soft tissues, which can progress to necrotizing fasciitis in extreme cases | Virulent germ, immunosuppression, diabetes, delayed treatment |
| Cutaneous fistula | Spontaneous opening of an infected bursitis through the skin, with chronic purulent discharge that is difficult to treat without surgery. | Superficial infected bursa under tension, insufficient antibiotic treatment |
| Amyotrophy and joint stiffness | Muscle loss and persistent functional limitation due to prolonged immobilization or chronic pain inhibiting movement | Prolonged excessive repos, absence of early physiotherapy |
Prevention and practical advice
The prevention of bursitis relies on reducing repeated mechanical strain on the bursae and ergonomically adapting daily and professional tasks.
- Use protective knee pads for prolonged kneeling work on hard surfaces (tiling, gardening, cleaning).
- Adapt the workstation to prevent repeated pressure on the elbows during office work or manual labor.
- Progressively warm up joints before sports activities and plan for stretching at the end of the session
- Gradually increase the intensity and volume of sports training to respect the adaptive capacities of periarticular tissues.
- Choose shoes that are well-suited to the type of activity and the foot's morphotype, with a firm heel counter that is not traumatizing for heel bursitis.
- Maintain a healthy weight to reduce mechanical stress on the knees and hips
- Promptly treat any superficial wounds or abrasions on the bursae (elbow, knee) to prevent infection.
- Effectively control gout and maintain a target serum uric acid level to prevent recurrent microcrystalline bursitis
Certain clinical presentations associated with bursitis require immediate medical evaluation: fever with intense redness, heat, and rapid swelling of a superficial bursa suggesting infectious bursitis; rapid spread of redness beyond the bursa into surrounding tissues; presence of a visible wound or skin entry point at the inflamed bursa; or intense joint pain with complete functional impairment, raising concern for associated septic arthritis. These situations require emergency diagnostic aspiration and prompt antibiotic therapy to prevent serious complications.
In the presence of a high fever, chills, or a general worsening of condition associated with bursitis, call 911 immediately or go to the nearest emergency room without delay. For any painful bursitis without signs of infection, a consultation at Clinique Omicron allows for a rapid evaluation and appropriate management.
Consult at Clinique Omicron
Clinique Omicron provides assessment and management of musculoskeletal pain, including bursitis, at several service points across Quebec. A physician or a nurse practitioner (NP) can examine the affected area, order appropriate investigations including musculoskeletal ultrasound, initiate anti-inflammatory treatment, and, if indicated, perform or coordinate an ultrasound-guided diagnostic puncture or corticosteroid injection. Referrals to a physiatrist, rheumatologist, or orthopedist are arranged based on the complexity of the clinical presentation. In-person and telemedicine consultations are available. To book an appointment in Montreal, on the South Shore, or at one of our other service points in Quebec, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and is not intended to replace the advice of a qualified healthcare professional. Consult a physician for any symptoms, questions or decisions you may have regarding your health.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.