JAAOS article reviews diagnostic, treatment options

Bursitis is a common cause of pain of the knee (prepatellar), elbow (olecranon), hip (trochanteric), and heel (retrocalcaneal). The diagnosis must differentiate bursitis from arthritis, tendinitis, fracture, tendon or ligament injury, infection, and neoplasm. Bursitis may be septic or nonseptic, and distinguishing between the two forms can be challenging.

The June 2011 issue of the Journal of the AAOS included a review of the “Four Common Types of Bursitis,” by Daniel L. Aaron, MD; Amar Patel, MD, Stephen Kayiaros, MD, and Ryan Calfee, MD.

According to the authors, adjunct tests may be helpful in determining the diagnosis of bursitis after a thorough history and physical examination is conducted. Most patients with bursitis can be successfully treated nonsurgically, although surgical options include open bursectomy, arthroscopic bursal excision, and partial excision of the involved bony processes.

Prepatellar bursitis
Bursitis arises from many inflammatory phenomena, but infection is the primary concern. Approximately 80 percent of cases of septic prepatellar bursitis are caused by Staphylococcus aureus. Other organisms, including Streptococcus, Mycobacterium, Brucella, other Staphylococcus, and fungal species, have been implicated in the pathogenesis of prepatellar bursitis. Noninfectious etiologies of bursitis include trauma, gout, sarcoid, idiopathic calcification, and CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia).

The subcutaneous prepatellar bursa and the superficial infrapatellar bursa are the two main bursae about the knee joint, collectively referred to as the prepatellar bursa. The subcutaneous prepatellar bursa lies between the skin and the patella, and the superficial infrapatellar bursa lies between the skin and the tibial tubercle.

The clinical indications of septic prepatellar bursitis are swelling, pain, erythema, and warmth. Local tenderness to palpation is a hallmark of the condition. Pain with joint range of motion is atypical except for discomfort at extreme flexion, which compresses the inflamed bursa. Diagnosis of septic prepatellar bursitis is based on clinical presentation and risk factors and may require aspiration of the bursa.

Recommendations for management of septic prepatellar bursitis range from oral antibiotics alone to surgical excision of the bursal sac. Although most patients respond to nonsurgical treatment, surgery is a definitive option that is associated with complications. Management of aseptic prepatellar bursitis typically consists of rest, compression, nonsteroidal anti-inflammatory drugs (NSAIDs), and possibly local corticosteroid injection.

Olecranon bursitis
Olecranon bursitis (Fig. 1) is the most common superficial bursitis and is typically noninfectious in origin. Patients generally have unilateral swelling over the proximal olecranon and a history of minor or repetitive local trauma. Aseptic traumatic bursitis is characterized by a nontender fluctuant mass over the olecranon.

If the physical examination is insufficient to establish a diagnosis, bursal fluid analysis and skin temperature measurements may be used for confirmation.

Management of olecranon bursitis is dictated by its cause. Acute traumatic or idiopathic olecranon bursitis typically resolves with nonsurgical management—ice, compressive dressings, and avoidance of aggravating activity. Management of septic bursitis ranges from drainage of collected fluid, mechanical rest, and systemic antibiotics to serial aspiration or open incision and drainage.

Trochanteric bursitis
Tendinosis of the gluteus medius and/or minimus tendons is increasingly viewed as the primary pathology of trochanteric bursitis, giving rise to the term “greater trochanter pain syndrome” as a more accurate description.

Patients with trochanteric bursitis typically report 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. Although the patient may have normal range of motion, he or she may also have tenderness over the lateral aspect of the greater trochanter, pain with resisted abduction and internal rotation, and pain elicited with the Ober and flexion, abduction, and external rotation (FABER) tests.

MRI is a reliable diagnostic modality, and standard hip radiographs can be used to evaluate for concomitant arthritic disease of the hip joint and prior trauma to the trochanter.

Initial nonsurgical management is usually successful and consists of physical therapy and oral NSAIDs, followed by a local glucocorticoid injection if symptoms persist. For patients who need surgery, reattachment of the abductor tendons into the bone has been described to manage tendinosis or partial or complete tear of the gluteus medius—the so-called rotator cuff tear of the hip.

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.

Pain anterior to the Achilles tendon and just superior to the calcaneus is the hallmark of retrocalcaneal bursitis. Patients often have a positive two-finger squeeze test—that is, pain when pressure is applied with two fingers placed medially and laterally anterior to the Achilles insertion.

Retrocalcaneal bursitis is particularly common in runners, especially those who regularly train on inclines, due to the increased stress on the bursa. Persons with hindfoot varus as well as those with a rigid plantarflexed first ray are also susceptible to retrocalcaneal bursitis. A diagnosis of bilateral retrocalcaneal bursitis is suggestive of inflammatory arthritis.

Management begins with ice, activity modification, NSAIDs, and orthoses. Shoe wear modification to prevent irritation of the posterior heel by the shoe counter should also be considered. Maneuvers that stretch the local Achilles tendon may ease symptoms.

If the condition does not resolve with nonsurgical management, surgery—including resection of the calcaneal prominence proximal to the Achilles insertion, débridement of Achilles tendinopathy, and complete excision of the retrocalcaneal bursa—should be considered.

Recovery time is based in part on the cause of symptoms and may be considerably longer in patients who have pre-existing calcific tendinitis.

In general, said Dr. Aaron, steps the patient may take to help prevent recurrence of bursitis include padding of bony prominences about the knee and elbow and attempting to vary physical activity as opposed to considtent and repeated stresses.

Disclosure information: Dr. Aaron—Orthopaedic Research and Reviews (electronic journal); Dr. Patel—no conflicts; Dr. Kayiaros—no data; Dr. Calfee—Medartis, American Society for Surgery of the Hand.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org