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Understanding Bursitis What You Should Know

Bursitis: Causes, Treatment, and Symptoms

Understanding Bursitis What You Should Know

Bursitis (bur-SY-tis) is a painful condition that affects the small, fluid-filled sacs — called bursae (bur-SEE) — that cushion the bones, tendons and muscles near your joints. Bursitis occurs when bursae become inflamed.

The most common locations for bursitis are in the shoulder, elbow and hip. But you can also have bursitis by your knee, heel and the base of your big toe. Bursitis often occurs near joints that perform frequent repetitive motion.

Bursae are fluid-filled sacs found about your joints. They surround the areas where tendons, skin, and muscle tissues meet bones. The lubrication they add helps reduce friction during movement of the joint.

t is a relatively common condition, but many people treat it at home and do not see a doctor, so it is hard to know how common it is.

There are over 150 bursae in the human body. They cushion and lubricate points between the bones, tendons, and muscles near the joints.

The bursae are lined with synovial cells. Synovial cells produce a lubricant that reduces friction between tissues. This cushioning and lubrication allows our joints to move easily.

When a person has bursitis, or inflammation of the bursa, movement or pressure is painful

What Is Bursitis?

Bursitis is an inflammation of a bursa. It is a condition usually characterized by pain and sometimes by redness and swelling. A bursa is a very thin (i.e., a few cells thick), sac-like structure that is located wherever there might be friction, such as between skin and bones, between tendons and bones or between ligaments and bones. In other words, they serve to decrease the friction that occurs between hard bone and softer tissues. A good analogy is rubbing leather over the corner of a table — over time, you would rub a hole in the leather.

Skin, tendons, and ligaments would likewise wear out if there were no bursa between them and bony surfaces. As a result, there are over 150 bursae in the body, wherever there is the possibility of rubbing.

A bursa is normally very thin and does its job without notice. However, if there is too much friction, it reacts by getting inflamed or irritated. When this happens the bursa gets thicker and sometimes produces fluid to create more cushion. It goes from being very thin (like tissue paper) to thick and lumpy (like corrugated cardboard). The bursa can be very large if a lot of fluid is produced inside. Sometimes it can be colonized by bacteria, and in this case, becomes an infected bursa. It can be difficult to distinguish an inflamed bursa (irritated with no infection) and an infected bursa (irritated with infection or bacteria present).

While bursae are present all over the body, the most common areas where inflammation or irritation occurs are at the elbow, knee, and shoulder (see below). The terms “housemaid’s knee” (i.e., bursitis following domestic work done on the hands and knees), “miner’s elbow” (bursitis following work in mines performed on the hands and knees) or “student’s elbow” (bursitis following hours of studying with the elbows pressed against a table) are sometimes used to refer to bursitis in a specific group of patients due to repetitive friction.

Types Of Bursitis

Retromalleolar tendon bursitis. This type of bursitis is also called Albert disease. It’s caused by things like injury, disease, or shoes with rigid back support. These put extra strain on the lower part of the Achilles tendon. This attaches the calf muscle to the back of the heel. This can lead to inflammation of the bursa located where the tendon attaches to the heel.

Posterior Achilles tendon bursitis. This type of bursitis, also called Haglund deformity, is in the bursa located between the skin of the heel and the Achilles tendon. This attaches the calf muscles to the heel. It is aggravated by a type of walking that presses the soft heel tissue into the hard back support of a shoe.

Hip bursitis. Also called trochanteric bursitis, hip bursitis is often the result of injury, overuse, spinal abnormalities, arthritis, or surgery. This type of bursitis is more common in women and middle-aged and older people.

Elbow bursitis. Elbow bursitis is caused by the inflammation of the bursa located between the skin and bones of the elbow (the olecranon bursa). Elbow bursitis can be caused by injury or constant pressure on the elbow (for example, when leaning on a hard surface).

Knee bursitis. Bursitis in the knee is also called goosefoot bursitis or Pes Anserine bursitis. The Pes Anserine bursa is located between the shin bone and the three tendons of the hamstring muscles, on the inside of the knee. This type of bursitis may be caused by lack of stretching before exercise, tight hamstring muscles, being overweight, arthritis, or out-turning of the knee or lower leg.

Kneecap bursitis. Also called prepatellar bursitis, this type of bursitis is common in people who are on their knees a lot, such as carpet layers and plumbers.

What Are Bursitis Symptoms and Signs?

Bursitis causes pain and tenderness around the affected bone or tendon. The bursae sacs may swell, often making movement difficult. The most commonly affected joints are the shoulder, elbow, knee, and foot.

Shoulder

In the shoulder, the subacromial bursa (subdeltoid bursa) separates the supraspinatus tendon from the overlying bone and deltoid muscle. Inflammation of this bursa is usually a result of injury to surrounding structures, most commonly the rotator cuff. This limits the range of motion of the shoulder resulting in an “impingement syndrome.” The condition causes pain in the side or front of the shoulder.

Overhead lifting or reaching activities are uncomfortable.
Pain is often worse at night.
The shoulder will usually have decreased range of active motion and be tender at specific spots.

Elbow

Bursitis of the tip of the elbow, olecranon bursitis, is the most common form of bursitis.

  • The pain may increase if the elbow is bent because tension increases over the bursa.
  • This bursa is frequently exposed to direct trauma (bumping your arm) or repeated motions from bending and extending the elbow (while painting, for example).
  • Infection is common in this bursa.

Knee

Bursitis in front of the kneecap (prepatellar): Swelling on the front of the kneecap can be caused by chronic trauma (as from kneeling) or an acute blow to the knee. Swelling may occur as late as seven to 10 days after a single blow to the area, usually from a fall. Prepatellar bursitis has also been called carpet-layer’s knee, housemaid’s knee, and clergyman’s knee.

Pes anserine bursitis: The pes anserine bursa is fan shaped and lies among three of the major tendons at the inner knee.

  • This type of bursitis is most often seen in people with arthritis, especially overweight middle-aged women with osteoarthritis.
  • The pain of anserine bursitis is typically produced when the knee is bent and is particularly troublesome at night. People often seek comfort in bed by sleeping with a pillow between their thighs.
  • The pain can radiate to the inner thigh and mid-calf and usually increases on climbing stairs and at extremes of bending and extending.
  • Pes anserine bursitis also occurs as an overuse or traumatic injury among athletes, particularly long-distance runners.

Ankle

Retrocalcaneal bursitis occurs when the bursa under the Achilles tendon at the back of the heel becomes inflamed. This is commonly caused by local trauma associated with wearing a poorly designed shoe (often high heels) or prolonged walking. It can also occur with Achilles tendonitis.

Bursitis in this part of the body often occurs as an overuse injury in young athletes, ice skaters, and people starting new exercise programs, including walking or jumping. The pain is usually on the back of the heel and increases with passive extension or resisted flexion.

Buttocks

Ischiogluteal bursitis causes inflammation of the ischial bursa, which lies between the bottom of the pelvic bone and the overlying gluteus maximus muscle (one side of the buttocks). Inflammation can come from sitting for a long time on a hard surface or from bicycling. Ischiogluteal bursitis has also been called weaver’s bottom because it is common from the positioning used in this occupation.

  • The pain occurs when sitting and walking.
  • There will be tenderness over the pubic bone, which may be made worse by bending and extending the leg.
  • The pain may radiate down the back of the thigh.
  • Direct pressure over the area causes sharp pain.
  • The person may hold the painful buttock elevated when sitting.
  • The pain is worse when person is lying down and the hip is passively bent.
  • The person may have difficulty standing on tiptoe on the affected side.

Hip

The iliopsoas bursa is the largest in the body and lies in front of, and deep to, the hip joint. Bursitis here is usually associated with hip problems such as arthritis or injury (especially from running).

  • The pain of iliopsoas bursitis radiates down the front and middle areas of the thigh to the knee and is increased when the hip is extended and rotated.
  • Extension of the hip during walking causes pain so the person may limit the stride on the affected side and take a shorter step.
  • There may be tenderness in the groin area.
  • Sometimes a mass may be felt resembling a hernia. The person may also feel numbness or tingling if adjacent nerves are compressed by the inflamed bursa.

Thigh

The trochanteric bursa, at the outer thigh over the hip, can become inflamed to cause trochanteric bursitis. Trochanteric bursitis is very common and occurs most frequently in overweight, middle-aged women.

  • Trochanteric bursitis causes deep, aching hip pain along the side of the hip that may extend into the buttocks or to the side of the knee.
  • Pain is aggravated by activity, local pressure, or stretching.
  • Pain is often worse at night and can make it difficult to sleep on the involved side.

Causes

Bursitis can result from an injury, an infection, or a pre-existing condition in which crystals can form in the bursa.

Injury

An injury can irritate the tissue inside the bursa and cause inflammation. Doctors say that bursitis caused by an injury usually takes time to develop. The joints, tendons, or muscles that are near the bursa may have been overused. Most commonly, injury is caused by repetitive movements.

Some causes of bursitis include:

  • Tennis elbow: Bursitis is a common problem among tennis players and golfers. Repetitive bending of the elbow can lead to injury and inflammation.
  • Clergyman’s knee: Repeated kneeling can cause injury and swelling to the bursae in the knee area.
  • Shoulder: Repeated overhead lifting or reaching upwards can cause bursitis in the shoulder.
  • Ankle: Injury to the ankle can result from walking too much and with the wrong shoes. It is common among ice skaters and athletes.
  • Buttocks: The bursae in this area can become inflamed after sitting on a hard surface for a long time, such as on a bicycle.
  • Hips: Some runners and sprinters can develop hip bursitis.
  • Thigh: Bursitis can be caused by stretching.

Infection

Infection that causes bursitis tends to be in bursae that are nearer the surface of the skin, such as those near the elbow. A cut on the skin is an opportunity for the bacteria to get in.

Most healthy people are not affected by bacteria entering through the skin, but people with a weakened immune system are more at risk. Examples are those with diabetes or HIV/AIDS, those who are receiving chemotherapy or radiotherapy for cancer treatment, people taking steroids, and heavy consumers of alcohol.

Health conditions

People with certain health conditions are more likely to have crystals form inside the bursa. The crystals irritate the bursa and make it swell. Conditions that may cause this include gout, rheumatoid arthritis, and scleroderma.

Diagnose

Bursitis can often be diagnosed by physical exam. However, tests can also be used to diagnose this condition.

Your healthcare provider can use an X-ray or ultrasound to take images of the affected area. Blood tests and samples from the affected bursae can also be used for diagnosis.

Needle aspiration is always recommended in cases where infectious bursitis appears to be limited to the joint.

In some cases, such as when a person has olecranon bursitis, performing a needle aspiration will increase the risk of a secondary infection moving from the skin into the bursa.

Needle aspiration may not be performed then. Instead, the person with bursitis may be given antibiotics before being observed clinically. This is known as empiric therapy.

Treatment

The treatment of bursitis depends largely on the type of bursitis you have. The primary aims are to alleviate physical strain on the bursa, to decrease inflammation, and to allow ample recovery time.

Most cases will resolve with conservative treatment. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil (ibuprofen) or Aleve (naproxen) can often provide ample pain relief. In addition to rest, ice application can help reduce swelling, while short-term immobilization may be recommended if there is any evidence of connective tissue damage.

While most cases tend to improve within days or weeks, there are some that can take months. Chronic bursitis is sometimes treated with an intrabursal corticosteroid injection to quickly alleviate inflammation.6

If bursitis persists despite appropriate treatment, surgical excision may be required. The procedure, known as bursectomy, can be performed as an open surgery (with a scalpel) or arthroscopically (with a scope and keyhole incisions). Once a bursa is removed, a new one can form in its place.

Septic bursitis may be treated with oral or intravenous antibiotics depending on the severity of the infection. Surgical drainage may also be used if pus develops in and around the bursa.

Coping

Bursitis can recur in some people, particularly if it was caused by repetitive motion or a long-term sports injury. In cases like these, bursitis can flare up after activity or for no reason at all.

There are several things you can do to reduce the risk of recurrence or the severity of a flare-up:

  • Wear appropriate shoes. Bursitis of the knee or hip is often exacerbated if your foot arches are flat or the pronation (alignment) of your foot is abnormal. Getting the right pair of shoes properly fitted can significantly reduce stress on the lower extremity joints.
  • Support the affected joint. If you enjoy walking or playing tennis but are prone to bursitis in the knee or elbow, buy a neoprene orthopedic brace at your local drugstore and wear it whenever you engage in the activity.
  • Change your bad habits. If your bursitis is inflamed by the way you sit or by specific movements, take whatever steps you need to “unlearn” those habits. This may include finding alternative exercises at the gym (such as using a Smith machine instead of free weights) or switching to a chair that encourages better posture.
  • Warm-up before activity. Never launch into sports or any physical activity without first stretching and warming up the affected joints.
  • See a physical therapist. Little adjustments can sometimes correct long-standing problems with movement or posture. A physical therapist is trained to spot these issues, while an occupational therapist can provide you with the tools to help overcome them.

What Can I Do To Prevent Bursitis?

Bursitis isn’t always preventable. However, making some basic lifestyle changes can reduce your risk of developing bursitis and prevent severe flare-ups:

  • Maintain a healthy weight to avoid putting extra stress on your joints.
  • Exercise to strengthen the muscles supporting your joints.
  • Take frequent breaks when performing repetitive tasks.
  • Warm up before starting strenuous activities.
  • Practice good posture when sitting and standing.
  • Stop an activity if you experience pain.

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