• Bursitis is inflammation or irritation of the bursa (a fluid-filled sac between layers of tissue to decrease friction and facilitate movement).
• Caused by infection (septic bursitis), direct trauma, overuse/prolonged pressure, or systemic illness like gout, ankylosing spondylitis, and rheumatoid or psoriatic arthritis.
• Over 140 bursae in the body, however examples of some sites of bursitis include the following:

Focused History and Physical Examination

• Pain (especially with movement), bursal enlargement, and tenderness.
• Need to differentiate between septic and noninfectious acute bursitis.
  • Noninfectious bursitis: Warmth and erythema are less prominent, and the skin is intact.
  • Septic bursitis: more abrupt onset with rapid progression over hours. The bursa is hot and erythematous, breaks in the overlying skin, +/- fever.
• Radiographic studies and ultrasound imaging not required unless concern for fracture.
• If considering infection, aspirate the bursa fluid: Gram stain, culture, cell count and crystals.
  • Aspiration is both diagnostic and therapeutic.

Further lab work rarely indicated unless septic, want to rule in/out systemic illness.

Pitfalls

• Failure to recognize that a patient with less obvious bursitis: deeper and more chronic forms of bursitis can have no erythema or visible swelling.
• Failure to consider systemic conditions.
• Failure to aspirate the bursa when infectious process is a consideration.
• Failure to consider underlying septic joint.

• Bursitis is usually self-limited, therefore the goals of treatment include symptom management, preventing disability and treating any underlying etiology if present.
• Superficial infectious bursitis = antibiotics for skin & soft tissue infection and drained via aspiration (some choose initial incision or drainage rather than aspiration).
• Arthrocentesis of the affected joint should be undertaken if signs of septic arthritis. (ex. Iliopsoas bursitis).
• Inflammatory bursitis should be treated with ice, rest, NSAIDs.
  • Avoid further irritation or trauma to the bursa.
• Not typical ED treatment options:
  • Corticosteroid injections have been shown to have similar long-term outcomes to physical therapy and lack high quality evidence demonstrating any acute benefits.
  • Platelet-rich plasma injection (PRP) lacks high-quality evidence supporting its use and is therefore not recommended as part of the standard of care for bursitis.
• If there is an underlying systemic condition, treating the condition while advising conservative management is advised.

1. Bursitis: An overview of clinical manifestations, diagnosis, and management – UpToDate [Internet]

   
   

2. Walls R., Hockerberger R., & Gausche-Hill M. (eds) Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9^th Philadelphia, PA: Elsevier; 2018.

   
   

1. Podcast – CRACKCast E117 – Tendinopathy & Bursitis.

   
   

2. Video – Septic Bursitis Aspiration (EM:RAP).