Common Superficial Bursitis

 

Am Fam Physician. 2017 Feb 15;95(4):224-231.

  Patient information: See related handout on bursitis of the elbow, knee, and heel, written by the author of this article.

Author disclosure: No relevant financial affiliations.

Superficial bursitis most often occurs in the olecranon and prepatellar bursae. Less common locations are the superficial infrapatellar and subcutaneous (superficial) calcaneal bursae. Chronic microtrauma (e.g., kneeling on the prepatellar bursa) is the most common cause of superficial bursitis. Other causes include acute trauma/hemorrhage, inflammatory disorders such as gout or rheumatoid arthritis, and infection (septic bursitis). Diagnosis is usually based on clinical presentation, with a particular focus on signs of septic bursitis. Ultrasonography can help distinguish bursitis from cellulitis. Blood testing (white blood cell count, inflammatory markers) and magnetic resonance imaging can help distinguish infectious from noninfectious causes. If infection is suspected, bursal aspiration should be performed and fluid examined using Gram stain, crystal analysis, glucose measurement, blood cell count, and culture. Management depends on the type of bursitis. Acute traumatic/hemorrhagic bursitis is treated conservatively with ice, elevation, rest, and analgesics; aspiration may shorten the duration of symptoms. Chronic microtraumatic bursitis should be treated conservatively, and the underlying cause addressed. Bursal aspiration of microtraumatic bursitis is generally not recommended because of the risk of iatrogenic septic bursitis. Although intrabursal corticosteroid injections are sometimes used to treat microtraumatic bursitis, high-quality evidence demonstrating any benefit is unavailable. Chronic inflammatory bursitis (e.g., gout, rheumatoid arthritis) is treated by addressing the underlying condition, and intrabursal corticosteroid injections are often used. For septic bursitis, antibiotics effective against Staphylococcus aureus are generally the initial treatment, with surgery reserved for bursitis not responsive to antibiotics or for recurrent cases. Outpatient antibiotics may be considered in those who are not acutely ill; patients who are acutely ill should be hospitalized and treated with intravenous antibiotics.

A bursa is a fluid-filled synovial pouch that can be deep or superficial and functions as a cushion to reduce friction between structures such as tendons, bone, or skin.1 Superficial bursae are located in the subcutaneous tissue between bone and overlying skin. There are many superficial bursae in the body, but only olecranon, prepatellar, superficial infrapatellar, and subcutaneous (superficial) calcaneal bursitis have been reported. Historically, enlargement of a bursa has been called bursitis, although in many cases no true inflammatory process exists.2 This article reviews the causes, locations, presentation, diagnosis, and management of superficial bursitis.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bursal aspiration with fluid analysis should be performed in patients with suspected septic superficial bursitis.

C

3, 4, 8, 9, 16, 17, 3032

Initial management of superficial bursitis caused by microtrauma should consist of conservative measures such as padding, ice, elevation, and analgesics (only for pain).

B

35, 8, 9, 21, 35, 39

Septic superficial bursitis should be treated empirically with systemic antibiotics covering Staphylococcus aureus and Streptococcus pyogenes. The antibiotic regimen can be modified, if needed, after culture andsensitivity results from the aspirated bursal fluid are available.

B

3, 4, 8, 9, 1619, 30, 35, 48, 49


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bursal aspiration with fluid analysis should be performed in patients with suspected septic superficial bursitis.

C

3, 4, 8, 9, 16, 17, 3032

Initial management of superficial bursitis caused by microtrauma should consist of conservative measures such as padding, ice, elevation, and analgesics (only for pain).

B

35, 8, 9, 21, 35, 39

Septic superficial bursitis should be treated empirically with systemic antibiotics covering Staphylococcus aureus and Streptococcus pyogenes. The antibiotic regimen can be modified, if needed, after culture andsensitivity results from the aspirated bursal fluid are available.

B

3, 4, 8, 9, 1619, 30, 35, 48, 49


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Causes and Locations

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The Author

MORTEZA KHODAEE, MD, MPH, is an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine, Aurora.

Address correspondence to Morteza Khodaee, MD, MPH, University of Colorado School of Medicine, AFW Clinic, 3055 Roslyn St., Denver, CO 80238 (e-mail: morteza.khodaee@ucdenver.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Hudson K, Delasobera BE. Bursae. In: Birrer RB, O'Connor FG, Kane SF, eds. Musculoskeletal and Sports Medicine For The Primary Care Practitioner 4th ed Boca Raton, Fla: CRC Press, Taylor & Francis Group; 2016:111–116....

2. Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011;19(6):359–367.

3. Baumbach SF, Lobo CM, Badyine I, Mutschler W, Kanz KG. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg. 2014;134(3):359–370.

4. Reilly D, Kamineni S. Olecranon bursitis. J Shoulder Elbow Surg. 2016;25(1):158–167.

5. Chard MD, Walker-bone K. The elbow. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. Rheumatology. 6th ed. Philadelphia, Pa.: Mosby; 2015:611–617.

6. Morrey BE. Bursitis. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders. 4th ed. Philadelphia, Pa.: Saunders/Elsevier; 2009: 1164–1173.

7. Blackwell JR, Hay BA, Bolt AM, Hay SM. Olecranon bursitis: a systematic overview. Shoulder Elbow. 2014;6(3):182–190.

8. Laupland KB, Davies HD; Calgary Home Parenteral Therapy Program Study Group. Olecranon septic bursitis managed in an ambulatory setting. Clin Invest Med. 2001;24(4):171–178.

9. McAfee JH, Smith DL. Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med. 1988;149(5):607–610.

10. Senécal L, Leblanc M. Olecranon bursitis in chronic haemodialysis patients. Nephrol Dial Transplant. 2001;16(9):1956–1957.

11. Chhabra A, Cerniglia CA. Bursae, cysts and cyst-like lesions about the knee. J Am Osteopath Coll Radiol. 2013;2(4):2–13.

12. Kamper L, Haage P. Images in clinical medicine. Infrapatellar bursitis [published correction appears in N Engl J Med. 2009;360(17):1797]. N Engl J Med. 2008;359(22):2366.

13. Campanelli V, Piscitelli F, Verardi L, Maillard P, Sbarbati A. Lower extremity overuse conditions affecting figure skaters during daily training. Orthop J Sports Med. 2015;3(7):2325967115596517.

14. Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician. 2002;65(9):1805–1810.

15. Cordts S. Nontender elbow nodules. Am Fam Physician. 2016;94(5):375–376.

16. Abzug JM, Chen NC, Jacoby SM. Septic olecranon bursitis. J Hand Surg Am. 2012;37(6):1252–1253.

17. Zimmermann B III, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. 1995;24(6):391–410.

18. Cea-Pereiro JC, Garcia-Meijide J, Mera-Varela A, Gomez-Reino JJ. A comparison between septic bursitis caused by Staphylococcus aureus and those caused by other organisms. Clin Rheumatol. 2001;20(1):10–14.

19. Perez C, Huttner A, Assal M, et al. Infectious olecranon and patellar bursitis: short-course adjuvant antibiotic therapy is not a risk factor for recurrence in adult hospitalized patients. J Antimicrob Chemother. 2010;65(5):1008–1014.

20. Maxwell DM. Nonseptic olecranon bursitis management. Can Fam Physician. 2011;57(1):21.

21. Harris-Spinks C, Nabhan D, Khodaee M. Noniatrogenic septic olecranon bursitis: report of two cases and review of the literature. Curr Sports Med Rep. 2016;15(1):33–37.

22. Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. 2009;37(3):269–272.

23. Wingert NC, DeMaio M, Shenenberger DW. Septic olecranon bursitis, contact dermatitis, and pneumonitis in a gas turbine engine mechanic. J Shoulder Elbow Surg. 2012;21(5):e16–e20.

24. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases. Arch Intern Med. 1989;149(7):1581–1585.

25. Greenhill D, Haydel C, Rehman S. Management of the Morel-Lavallée lesion. Orthop Clin North Am. 2016;47(1):115–125.

26. Shmerling A, Bravman JT, Khodaee M. Morel-Lavallée lesion of the knee in a recreational frisbee player. Case Rep Orthop. 2016;2016:8723489.

27. Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006;27(6):568–571.

28. Bellon EM, Sacco DC, Steiger DA, Coleman PE. Magnetic resonance imaging in “housemaid's knee” (prepatellar bursitis). Magn Reson Imaging. 1987;5(3):175–177.

29. Floemer F, Morrison WB, Bongartz G, Ledermann HP. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. 2004;183(1):29–34.

30. Shell D, Perkins R, Cosgarea A. Septic olecranon bursitis: recognition and treatment. J Am Board Fam Pract. 1995;8(3):217–220.

31. Stell IM. Management of acute bursitis: outcome study of a structured approach. J R Soc Med. 1999;92(10):516–521.

32. Choudhery V. The role of diagnostic needle aspiration in olecranon bursitis. J Accid Emerg Med. 1999;16(4):282–283.

33. Pullen RL Jr. Administering medication by the Z-track method. Nursing. 2005;35(7):24.

34. Ho G Jr, Tice AD. Comparison of nonseptic and septic bursitis. Further observations on the treatment of septic bursitis. Arch Intern Med. 1979;139(11):1269–1273.

35. Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg. 2014;134(11):1517–1536.

36. Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. 1984;43(1):44–46.

37. McFarland EG, Gill HS, Laporte DM, Streiff M. Miscellaneous conditions about the elbow in athletes. Clin Sports Med. 2004;23(4):743–763, xi–xii.

38. Conway R, O'Shea FD, Cunnane G, Doran MF. Safety of joint and soft tissue injections in patients on warfarin anticoagulation. Clin Rheumatol. 2013;32(12):1811–1814.

39. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med. 1989;149(11):2527–2530.

40. Herrera FA, Meals RA. Chronic olecranon bursitis. J Hand Surg Am. 2011;36(4):708–709.

41. Kim JY, Chung SW, Kim JH, et al. A randomized trial among compression plus nonsteroidal antiinflammatory drugs, aspiration, and aspiration with steroid injection for nonseptic olecranon bursitis. Clin Orthop Relat Res. 2016;474(3):776–783.

42. Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. 2006;72(4):400–403.

43. Kerr DR, Carpenter CW. Arthroscopic resection of olecranon and prepatellar bursae. Arthroscopy. 1990;6(2):86–88.

44. Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. 2000;16(3):249–253.

45. Stewart NJ, Manzanares JB, Morrey BF. Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg. 1997;6(1):49–54.

46. Khanna D, Khanna PP, Fitzgerald JD, et al.; American College of Rheumatology. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447–1461.

47. Baumbach SF, Michel M, Wyen H, Buschmann CT, Kdolsky R, Kanz KG. Current treatment concepts for olecranon and prepatellar bursitis in Austria [published correction appears in Z Orthop Unfall. 2013;151(2): e4]. Z Orthop Unfall. 2013;151(2):149–155.

48. Ho G Jr, Tice AD, Kaplan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med. 1978;89(1):21–27.

49. Stell IM. Septic and non-septic olecranon bursitis in the accident and emergency department—an approach to management. J Accid Emerg Med. 1996;13(5):351–353.

50. Pien FD, Ching D, Kim E. Septic bursitis: experience in a community practice. Orthopedics. 1991;14(9):981–984.

51. Raddatz DA, Hoffman GS, Franck WA. Septic bursitis: presentation, treatment and prognosis. J Rheumatol. 1987;14(6):1160–1163.

52. Ho G Jr, Su EY. Antibiotic therapy of septic bursitis. Its implication in the treatment of septic arthritis. Arthritis Rheum. 1981;24(7):905–911.

 

 

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