New Treatments for Bursitis

Posted by Alex

When inflammation of a bursa is superficial, such as of the shoulder, knee, elbow, or Achilles tendon, the diagnosis of bursitis is easily accomplished. Deep bursae, such as those around the hip joint and the ischial tuberosity, do not present with obvious swelling; a diagnosis must be inferred from local tenderness and exacerbation of pain by activation of the associated muscles. In difficult cases, the temporary elimination of pain after the local instillation of an anesthetic is a useful diagnostic tool. Bursitis seldom shows up on plain radiographs, and expensive imaging studies are not routinely advocated. If possible, one should aspirate the bursa because the finding of synovial fluid helps confirm the diagnosis of bursitis. If the fluid is not clear (as is the case in most instances of “irritated” bursitis), it should be sent for culture and examined for the presence of crystals.

TABLE 3 – Commonly Involved Sites of Myofascial Pain

Location of Trigger Point	Symptom
Trapezius (most commonly upper portion)	Shoulder and neck pain, often headache
Sternomastoid (often multiple trigger points)	Atypical facial pain, headache
Masseter	Temporomandibular pain syndrome
Suboccipital	Headache-occipital, retro-orbital, forehead
Levator scapulae	Stiff neck
Gluteus medius (upper portion)	Pain in low back and buttock
Muscles inserting into greater trochanter	Lateral hip and thigh pain
Tensor fasciae latae	Lateral thigh pain
Muscles inserting into upper border of patella	Knee pain

Noninfective bursitis is treated as follows. The involved areas should be rested (e.g., the provision of a sling for subdeltoid bursitis or instruction in the use of a cane in the contralateral hand for trochanteric bursitis). The quickest and usually most complete relief is obtained by an appropriately placed corticosteroid injection. After the bursa is aspirated, a mixture of 1% procaine (about 3 mL) containing 1 to 2 mL of a long-acting corticosteroid preparation, such as triamcinolone hexacetonide (Aristospan Intralesional [into the bursa, not the joint]), prednisolone tebutate (Hydeltra-TBA), betamethasone acetate (Celestone Soluspan), methylprednisolone acetate (Depo-Medrol), or dexamethasone acetate (Decadron-LA), can be instilled. Prompt amelioration of discomfort within about 5 minutes of giving this injection (due to the effect of the local anesthetic) gives some reassurance that the injection has been accurately placed and the diagnosis is correct.

In some cases, the injection of a long-acting corticosteroid preparation, which is usually microcrystalline, provokes an acute inflammatory response akin to gout. This is almost always averted if the patient is prescribed concomitant nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., indomethacin [Indocin SR], 75 mg twice daily), ibuprofen (Motrin or Rufen, 800 mg three times daily), ketoprofen (Orudis, 75 mg twice daily), naproxen (Naprosyn, 500 mg twice daily), or nabumetone (Relafen, 500 mg twice daily). Therapy with NSAIDs should be continued for approximately 1 week after all symptoms have subsided and the patient has embarked on a program of gentle return to normal activity. If aggravating factors have been eliminated, the patient seldom needs repeated injections.

A recurrence of the bursitis within 7 days of injection should arouse concern regarding possible septic bursitis, and a reaspiration should be performed. Septic bursitis is usually caused by Staphylococcus aureus, which is often penicillin resistant. The physician should always consider the possibility of the patient’s having undiagnosed diabetes, being an intravenous drug abuser, or being immunocompromised with human immunodeficiency virus infection. It is important to note that septic bursitis is not treated with local antibiotics. In many patients, systemic treatment with oral dicloxacillin (Dynapen, 500 mg four times a day for 10 days) is an effective regimen.

Patients who have a serious underlying illness should be treated more vigorously with intravenous antibiotics, such as oxacillin (Prostaphlin), 2 grams four times a day for 7 days, followed by oral dicloxacillin. In patients who are allergic to beta-lactams, the appropriate antibiotic is dictated by the culture report. At the initiation of therapy, it is most important that the bursal contents be drained through a 16- to 18-gauge needle. This drainage often has to be repeated two or three times over the course of the first week of treatment. In those rare cases in which reaccumulation of infected bursal fluid is recurrent, despite appropriate antibiotics, the possibility of open surgical drainage should be discussed with an orthopedic surgeon.