Bursitis a common cause of painful hips, knees, heels and elbows: Most conditions can be managed with simple, nonsurgical techniques

Bursitis occurs when the bursae become irritated or infected, often causing pain on movement. When infection is involved, medical intervention is necessary to fight the underlying infection and prevent it from spreading; when infection is not involved, prompt medical attention can prevent the condition from becoming worse over time.

Four of the most common types of bursitis, affecting the hips (trochanteric bursitis), knees (prepatellar bursitis), elbows (olecranon bursitis) and heels (retrocalcaneal bursitis), are examined in a new review article published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

"Bursitis is a common cause of musculoskeletal pain and often prompts orthopaedic consultation," said study author Daniel Aaron, MD, a clinical instructor in the department of orthopaedics at Brown University in Providence, R.I. "One of the challenges facing clinicians is to differentiate bursitis from conditions with similar symptoms, including arthritis, tendinitis, fracture, tendon or ligament injury and tumor. Additionally, bursitis arises from infectious and noninfectious causes, and distinguishing between the two can be challenging.

"A thorough history and physical examination is required for accurate diagnosis, and in some cases, medical tests also may be used to help the clinician identify bursitis and determine whether or not infection is involved," he added.

Trauma or infection is usually the root cause of all four types of bursitis, Dr. Aaron said.

"Hip and heel bursitis usually result from 'overuse' syndromes involving underlying structures related to the tendons," he noted. "Elbow and knee bursitis can be traumatic, due to either chronic low-level trauma or acute trauma, or infectious. Other inflammatory conditions can lead to bursitis as well."

Typical symptoms of bursitis include:

• pain with or without joint movement;
• swelling of the area surrounding the joint;
• redness of the skin near the joint;
• warmth of the area near the joint; or
• pain or tenderness when the bursa is touched.

Dr. Aaron noted not all types of bursitis will involve the same kinds of symptoms. For instance:

• Hip bursitis may involve pain on the side of the hip, often radiating to the thigh. The hip area may be painful to the touch. Although range of motion of the hip may appear normal during the physical exam, the symptoms of trochanteric bursitis may be exacerbated by lying on your side, walking (especially uphill), climbing stairs and standing up from a seated position.
• Knee bursitis may be due to specific predisposing factors, including a history of trauma to the area, such as repetitive or prolonged kneeling, immune system disorders, alcoholism, chronic obstructive pulmonary disease (COPD), kidney failure, prior use of local corticosteroid medication and previous inflammation of the bursa. Pain with movement is uncommon, except when the joint is significantly flexed.
• Elbow bursitis typically involves a history of minor or repetitive local trauma. Although swelling is often involved in patients with olecranon bursitis, usually this swollen area is only tender when infection is involved.
• Heel bursitis often involves pain surrounding the Achilles tendon and heel areas, which are often tender when squeezed. This type of bursitis is typically associated with overuse and is especially common in runners, especially those who regularly train on inclines.

All types of bursitis often can be successfully managed non-surgically, and possible treatments include:

• use of ice packs or compressive dressings;
• activity modification that may reduce stress or irritation;
• administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or antibiotics;
• corticosteroid injections (knee and elbow);
• stretching exercises; and/or
• change of footwear (heel).

Surgery may be required in patients whose symptoms remain following these treatments and in certain situations when infection is involved.

Dr. Aaron said in most cases, the best way to prevent bursitis is to vary physical activity, avoiding repetitive activities that may increase stress and trauma on the joints. Padding surrounding the knee or elbow joints may help prevent repetitive trauma which could lead to bursitis in those areas. Finally, losing extra weight which may be causing stress on joints, particularly of the hips and knees, is also recommended.

"By recognizing the presence of bursitis and determining whether or not infection is involved, clinicians can identify the best mode of treatment which will resolve symptoms and help the patient regain mobility," Dr. Aaron said.