Version October 2024
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BURSITIS OVERVIEW — A bursa is a sac filled with lubricating fluid located in and around joints. Bursae (the plural of "bursa") act like "cushions" or "shock absorbers"; they reduce friction between moving parts in the body, such as bones, joints, tendons, and skin. The major bursae are found in the shoulders, elbows, hips, and knees. Some of them are close to the skin (ie, superficial bursae), while others are farther below the skin (ie, deep bursae).
When a bursa becomes irritated or inflamed, this is called "bursitis." Bursitis may cause pain, redness, and swelling. It can be mistaken as pain coming from the joint itself.
CAUSES OF BURSITIS
Mechanical causes — Bursitis is most commonly caused by a variety of mechanical stresses on the bursa and nearby structures. Examples include the following:
●Injury
●Strenuous activity or overuse (ie, repeatedly doing the same movement or activity)
●Prolonged pressure over the bursa (eg, spending a lot of time kneeling or leaning on an elbow)
●Mechanical imbalance (eg, favoring one side of the body over the other due to pain or weakness)
Infection — Bacterial infections can cause "septic" bursitis. This usually happens when bacteria spread to the bursa from a nearby infection, such as the skin (ie, cellulitis), or if there is direct trauma to the bursa that introduces bacteria. Less commonly, it may be related to bacteria in a nearby joint (ie, septic arthritis) or in the bloodstream (ie, bacteremia).
Other medical conditions — Bursitis can also be caused by some medical conditions, including forms of inflammatory arthritis (eg, rheumatoid arthritis, psoriatic arthritis) or gout. Other conditions also increase the risk of developing bursitis, including diabetes and thyroid disease.
SYMPTOMS
Common symptoms — The most common symptoms of bursitis are pain and tenderness over the affected area. There may be swelling and/or redness of the overlying skin, especially when the bursa is superficial. People with bursitis usually have a normal range of motion in the nearby joints; however, the range can be reduced when there is significant swelling.
Most cases of bursitis are acute, meaning symptoms are temporary and resolve over several days or weeks with proper treatment. Less commonly, bursitis can become a recurrent or chronic problem. Over time, this can lead to reduced range of motion in the nearby joints, including contractures (joint deformities caused by hardening of the surrounding tissue) and weakness of the surrounding muscles.
People may have other symptoms when bursitis is caused by specific condition. As examples, people with bursitis caused by a bacterial infection may develop a fever, while those with bursitis related to gout may have widespread joint pain and swelling and develop "tophi" (small deposits of urate crystals) in the bursa or surrounding tissues.
Bursitis syndromes — Symptoms of bursitis depend on the location of the bursa. Some common types of bursitis are described below.
Shoulder
●Subacromial/subdeltoid bursitis – Subacromial/subdeltoid bursitis can cause pain in the front of the shoulder and upper arm (figure 1). Pain is often worse when raising the arm or lying on the affected side. Depending on a person's symptoms and examination, imaging tests may be needed to help exclude other causes of shoulder pain (such as rotator cuff tear).
●Subscapular bursitis – Subscapular bursitis usually causes pain in the back of the shoulder that is worse with reaching the arm up. It may be associated with a popping or clicking sound when moving the shoulder.
Elbow — The olecranon bursa sits on top of the bony prominence of the elbow (the olecranon) (figure 2). People with olecranon bursitis usually have very prominent swelling that may look like a golf ball. It is often more comfortable to extend the elbow and more painful to flex it; this pattern can help distinguish olecranon bursitis from problems inside the elbow joint.
Hip and pelvis
●Ischiogluteal bursitis – Ischiogluteal bursitis is associated with prolonged sitting (the condition is sometimes called "weaver's bottom") and repetitive movements of the gluteus maximus muscle (eg, from cycling). It can cause pain in the upper thigh or buttocks and, less commonly, symptoms similar to sciatica (eg, pain that radiates from the buttock down into the leg).
●Greater trochanteric pain syndrome – Greater trochanteric pain syndrome (formerly known as "trochanteric bursitis") is a common cause of pain in the side of the hip (figure 3) and is often worsened by lying on the affected hip. This condition was reclassified as a "syndrome" instead of a bursitis since the main source of pain is irritation of the muscle tendons. It is commonly associated with mechanical stress, including being overweight, and pain in nearby areas, including low back pain and pain in the opposite knee.
Knee
●Prepatellar and superficial infrapatellar bursitis – Prepatellar and superficial infrapatellar bursitis can cause pain and swelling over the patella and its tendon (figure 4) and is most commonly caused by infection, repetitive pressure or trauma (eg, kneeling), or gout. It is often more comfortable to extend the knee and more painful to flex it; this pattern can help distinguish bursitis from problems inside the knee joint.
●Pes anserinus pain syndrome – Pes anserinus pain syndrome (previously known as "anserine bursitis") can cause pain in the inside of the knee and upper and is not always associated with actual bursitis (figure 5). Pain is often worsened by standing up, going up or down stairs, and/or lying on one's side with the knees touching each other (which may disturb sleep).
Heel — Retrocalcaneal bursitis can cause pain at the base of the heel, near the Achilles tendon (figure 6). It may be caused by repetitive activities (eg, running, jumping) or poor-fitting shoes and can also be seen in people with certain types of inflammatory arthritis.
DIAGNOSIS — In most cases of bursitis, a complete medical history and physical examination is usually all that is needed to make the diagnosis. However, your health care provider may order tests to rule out other conditions. These may include:
●Blood tests – These may be done to look for an infection.
●Aspiration – This is a procedure that involves using a thin needle to take fluid from a swollen bursa. Fluid is sent to check for signs of infection and gout crystals. Sometimes a provider may need to use imaging to guide the needle, such as ultrasound or computed tomography (CT).
●Imaging tests – Imaging may be needed when there is a history of trauma or injury, when a provider needs guidance to remove fluid from or inject medications into a bursa, and/or when pain could be caused by a different medical condition that requires specific treatment. As an example, people with a complete tear of their rotator cuff may have shoulder pain that mimics shoulder bursitis; ultrasonography or magnetic resonance imaging (MRI) may therefore be required to help identify the true cause of pain.
TREATMENT — All people with bursitis are treated with supportive care, including the following:
●Rest – Rest your joints and avoid activities that cause repetitive pressure or movement of the painful area. Think about what activities involve repetitive movements or positions that worsen your symptoms.
●Supportive devices – Splints, braces, or cushions may be needed to promote joint rest and help relieve pressure on the affected bursa. People with bursitis in the legs are sometimes referred to podiatry to consider orthotics or other adjustments to their shoes.
●Ice – Apply a bag of ice or a cold gel pack covered in a thin towel on the painful area for about 15 minutes every few hours. This can be especially helpful after you do an activity that brings on the pain.
●Medications for pain and inflammation – Talk with your health care provider about the best type of medicine to take to relieve pain and inflammation due to bursitis. If you have pain but do not have much swelling and redness, you can try acetaminophen (sample brand name: Tylenol). If you have more pain and swelling or your pain does not go away, your provider may recommend you substitute or add a nonsteroidal antiinflammatory drug (NSAID). NSAIDs are a group of medicines that includes ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand names: Naprosyn). People who have certain medical conditions, including kidney disease and stomach ulcers, or who are taking certain medications like anticoagulants (blood thinners) should not take NSAIDs. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Other types of treatment for bursitis depend on the type and/or cause of bursitis:
●Treatment of septic bursitis – People with an infected bursa (septic bursitis) are treated with antibiotics. Typically, antibiotics can be taken by mouth, but for severe infections, people may need to be admitted to the hospital for intravenous (IV) antibiotics. People sometimes need repeated aspiration of the bursa and, rarely, surgical drainage and removal (bursectomy) of the infected bursa.
●Steroid injections for deep bursitis – An injection with antiinflammatory steroids (glucocorticoids) may occasionally be needed to temporarily relieve the pain and swelling from bursitis when the bursa is deep below the skin. Steroid injections are not used for people with septic bursitis and are generally avoided for people with superficial bursitis due to an increased risk of complications. When they are used, they typically act quickly (within a few days) and last for several weeks.
●Physical therapy for mechanical causes of bursitis – When bursitis is caused or worsened by repeated pressure over a bursa or repetitive movements of the surrounding area, people may benefit from evaluation by a physical therapist (exercise expert). The therapist can assess how your body is moving and teach you strengthening and stretching exercises and other strategies to help avoid stress on the affected bursa.
●Treatment of gout or rheumatoid arthritis – People with bursitis due to an underlying condition (eg, gout, rheumatoid arthritis) require targeted therapy for their related condition. (See "Patient education: Gout (Beyond the Basics)" and "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)".)
PREVENTING RECURRENT BURSITIS — Most people with bursitis will get better over the course of days to weeks. Less commonly, people may develop chronic (ongoing) bursitis or intermittent flares of recurrent bursitis. To try to reduce the risk of developing another episode of bursitis, you can try the following measures:
●Take breaks when doing repetitive movements.
●Use a cushion for areas that are prone to constant or repetitive pressure. As an example, people who have knee bursitis may benefit from wearing knee pads when kneeling on the floor.
●Work with a physical therapist to identify repetitive movements and weak muscles that might be contributing to your bursitis and to develop a plan with strengthening, stretching, and activity modification to address these.
●Practice good posture. This includes improving ergonomics and positioning at home or at work, or even when you do recreational activities.
●Wear proper, supportive footwear and consider seeing a podiatrist for orthotics.
WHEN TO CALL THE DOCTOR — Call your health care provider if you have any of the following:
●Pain that does not go away despite treatment
●Limited movement of a joint
●Worsening swelling (eg, a prominent bump or bulge) and/or redness of the painful area
●Fevers or chills
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Bursitis (The Basics)
Patient education: Shoulder pain (The Basics)
Patient education: Hip pain in adults (The Basics)
Patient education: Knee pain (The Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (The Basics)
Patient education: Gout (The Basics)
Patient education: Rheumatoid arthritis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Knee pain (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: Gout (Beyond the Basics)
Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their providers are reading.
Overview of soft tissue musculoskeletal disorders
Bursitis: Clinical manifestations, diagnosis, and management
Septic bursitis
Knee bursitis
Greater trochanteric pain syndrome (formerly trochanteric bursitis)
NSAIDs: Therapeutic use and variability of response in adults
Nonselective NSAIDs: Overview of adverse effects
Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/healthtopics.html)
●National Institute of Arthritis and Musculoskeletal and Skin Disease
●American College of Rheumatology
●Arthritis Foundation
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