Bursitis is the inflammation of one or more bursae (small sacs) of synovial fluid in the body. They are lined with a synovial membrane that secretes a lubricating synovial fluid. There are more than 150 bursae in the human body. The bursae rest at the points where internal functionaries, such as muscles and tendons, slide across bone. Healthy bursae create a smooth, almost frictionless functional gliding surface making normal movement painless. When bursitis occurs, however, movement relying on the inflamed bursa becomes difficult and painful. Moreover, movement of tendons and muscles over the inflamed bursa aggravates its inflammation, perpetuating the problem. Muscle can also be stiffened.
|Example of Olecranon bursitis|
Bursitis commonly affects superficial bursae. These include the subacromial, prepatellar, retrocalcaneal, and pes anserinus bursae of the shoulder, knee, heel and shin, etc. (see below). Symptoms vary from localized warmth and erythema to joint pain and stiffness, to stinging pain that surrounds the joint around the inflamed bursa. In this condition, the pain usually is worse during and after activity, and then the bursa and the surrounding joint becomes stiff the next morning.
There can be several concurrent causes. Trauma, auto-immune disorders, infection and iatrogenic (medicine-related) factors can all cause bursitis. Bursitis is commonly caused by repetitive movement and excessive pressure. Shoulders, elbows and knees are the most commonly affected. Inflammation of the bursae may also be caused by other inflammatory conditions such as rheumatoid arthritis, scleroderma, systemic lupus erythematosus, and gout. Immune deficiencies, including HIV and diabetes, can also cause bursitis. Infrequently, scoliosis can cause bursitis of the shoulders; however, shoulder bursitis is more commonly caused by overuse of the shoulder joint and related muscles.
Traumatic injury is another cause of bursitis. The inflammation irritates because the bursa no longer fits in the original small area between the bone and the functionary muscle or tendon. When the bone increases pressure upon the bursa, bursitis results. Sometimes the cause is unknown. It can also be associated with various other chronic systemic diseases.
The most common examples of this condition:
It is important to differentiate between infected and non-infected bursitis. People may have surrounding cellulitis and systemic symptoms include a fever. The bursa should be aspirated to rule out an infectious process.
Bursae that are not infected can be treated symptomatically with rest, ice, elevation, physiotherapy, anti-inflammatory drugs and pain medication. Since bursitis is caused by increased friction from the adjacent structures, a compression bandage is not suggested because compression would create more friction around the joint. Chronic bursitis can be amenable to bursectomy and aspiration. Bursae that are infected require further investigation and antibiotic therapy. Steroid therapy may also be considered. In cases when all conservative treatment fails, surgical therapy may be necessary. In a bursectomy the bursa is cut out either endoscopically or with open surgery. The bursa grows back in place after a couple of weeks but without any inflammatory component.
Achilles bursitis is bursitis (inflammation of synovial sac) of bursa situated above the insertion of tendon to calcaneus. It results from overuse and wearing of tight shoes.Baker's cyst
A Baker's cyst, also known as a popliteal cyst, is a type of fluid collection behind the knee. Often there are no symptoms. If symptoms do occur these may include swelling and pain behind the knee, or knee stiffness. If the cyst breaks open, pain may significantly increase with swelling of the calf. Rarely complications such as deep vein thrombosis, peripheral neuropathy, ischemia, or compartment syndrome may occur.Risk factors include other knee problems such as osteoarthritis, meniscal tears, or rheumatoid arthritis. The underlying mechanism involves the flow of synovial fluid from the knee joint to the gastrocnemio-semimembranosus bursa, resulting in its expansion. The diagnosis may be confirmed with ultrasound or magnetic resonance imaging (MRI).Treatment is initially with supportive care. If this is not effective aspiration and steroid injection or surgical removal may be carried out. Around 20% of people have a Baker's cyst. They occur most commonly in those 35 to 70 years old. It is named after the surgeon who first described it, William Morrant Baker (1838–1896).Bunion
A bunion is a deformity of the joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.The exact cause is unclear. Proposed factors include wearing overly tight shoes, family history, and rheumatoid arthritis. Diagnosis is generally based on symptoms and supported by X-rays. A similar condition of the little toe is referred to as a bunionette.Treatment may include proper shoes, orthotics, or NSAIDs. If this is not effective for improving symptoms, surgery may be performed. It affects about 23% of adults. Females are affected more often than males. Usual age of onset is between 20 and 50 years old. The condition also becomes more common with age. It was first clearly described in 1870.Bursectomy
A bursectomy is the removal of a bursa, which is a small sac filled with synovial fluid that cushions adjacent bone structures and reduces friction in joint movement. This procedure is usually carried out to relieve chronic inflammation (bursitis) or infection, when conservative management has failed to improve patient outcomes.Calcific bursitis
Calcific bursitis refers to calcium deposits within the bursae. This most occurs in the shoulder area. The most common bursa for calcific bursitis to occur is the subacromial bursa. A bursa is a small, fluid-filled sac that reduces friction, and facilitates movements between its adjacent tissues (i.e., between tendon and bone, two muscles or skin and bone). Inflammation of the bursae is called bursitis.Crepitus
Crepitus is grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue.
Various types of crepitus that can be heard in joint pathologies are:
Bone crepitus: This can be heard when two fragments of a fracture are moved against each other.
Joint crepitus: This can be obtained when the affected joint is passively moved with one hand, while the other hand is placed on the joint to feel the crepitus.
Crepitus of bursitis: This is heard when the fluid in the bursa contains small, loose fibrinous particles.
Crepitus of tenosynovitisGreater trochanteric pain syndrome
Greater trochanteric pain syndrome (GTPS), is inflammation of the trochanteric bursa, a part of the hip.
This bursa is at the top, outer side of the femur, between the insertion of the gluteus medius and gluteus minimus muscles into the greater trochanter of the femur and the femoral shaft. It has the function, in common with other bursae, of working as a shock absorber and as a lubricant for the movement of the muscles adjacent to it.Occasionally, this bursa can become inflamed and clinically painful and tender. This condition can be a manifestation of an injury (often resulting from a twisting motion or from overuse), but sometimes arises for no obviously definable cause. The symptoms are pain in the hip region on walking, and tenderness over the upper part of the femur, which may result in the inability to lie in comfort on the affected side.More often the lateral hip pain is caused by disease of the gluteal tendons that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles.Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis. It may also coexist with low back pain, arthritis, and obesity.Iliopsoas bursitis
Iliopsoas bursitis is inflammation of a bursa (synovial sac) lying between iliopsoas muscle and hip joint, lateral to femoral vessels. Pain is experienced over the same area and made worse by extension of hip joint.Infrapatellar bursitis
Infrapatellar bursitis is the inflammation of one or both of the infrapatellar bursa, which are located just below the kneecap. Symptoms of bursitis commonly include swelling and knee pain. Bursitis often develops gradually over a period of days to even months but may develop more rapidly, especially in the event of trauma or infection.
Bursitis affecting the superficial infrapatellar bursa is an occupational hazard of persons whose work involves kneeling on hard surfaces. Depending on the occupation affected, it is known by a variety of nicknames, most commonly floor layer's knee, but also plumber's knee, clergyman's knee, hoe's knee, parson's knee, vicar's knee, and housewife's knee (prepatellar bursitis).
The deep infrapatellar bursa occasionally also become inflamed, swollen, and painful. Bursitis in the deep infrapatellar bursa usually develops from chronic overuse of the knee extensor tendon (patellar tendon) as can occur with repetitive flexing of the knee under pressure in work duties or exercise. Examples might include climbing stairs, jumping, or deep knee bends.Ischial bursitis
Ischial bursitis (also known as weaver's bottom) is inflammation of the synovial bursa located between gluteus maximus muscle and ischial tuberosity.It is usually caused by prolonged sitting on a hard surface.Knee effusion
Knee effusion occurs when excess synovial fluid accumulates in or around the knee joint. It has many common causes, including arthritis, injury to the ligaments or meniscus, or fluid collecting in the bursa, a condition known as prepatellar bursitis.Olecranon bursitis
Olecranon bursitis is a condition characterized by swelling, redness, and pain at the tip of the elbow. If the underlying cause is due to an infection, fever may be present. The condition is relatively common and is one of the most frequent types of bursitis.It usually occurs as a result of trauma or pressure to the elbow, infection, or certain medical conditions such as rheumatoid arthritis or gout. Olecranon bursitis is associated with certain types of work including plumbing, mining, gardening, and mechanics. The underlying mechanism is inflammation of the fluid filled sac between the olecranon and skin. Diagnosis is usually based on symptoms.Treatment involves avoiding further trauma, a compression bandage, and NSAIDs. If there is concern of infection the fluid should be drained and tested and antibiotics are typically recommended. The use of steroid injections is controversial. Surgery may be done if other measures are not effective.Pes anserine bursitis
Pes anserine bursitis is an inflammatory condition of the medial (inner) knee at the anserine bursa, a sub muscular bursa, just below the pes anserinus.Pes anserinus (leg)
Pes anserinus ("goose foot") refers to the conjoined tendons of three muscles that insert onto the anteromedial (front and inside) surface of the proximal extremity of the tibia. The muscles are the sartorius, gracilis and semitendinosus sometimes referred to as the guy ropes. The name "goose foot" arises from the three-pronged manner in which the conjoined tendon inserts onto the tibia.Prepatellar bursitis
Prepatellar bursitis is an inflammation of the prepatellar bursa at the front of the knee. It is marked by swelling at the knee, which can be tender to the touch and which generally does not restrict the knee's range of motion, or extremely painful and disabling as long as the underlying condition persists.
Prepatellar busitis is most commonly caused by trauma to the knee, either by a single acute instance or by chronic trauma over time. As such, the condition commonly occurs among individuals whose professions require frequent kneeling.
A definitive diagnosis can usually be made once a clinical history and physical examination have been obtained, though determining whether or the inflammation is septic is not as straightforward. Treatment depends on the severity of the symptoms, with mild cases possibly only requiring rest and localized icing and options for presentations with severe septsis including intravenous antibiotics, surgical irrigation of the bursa, and bursectomy.Retrocalcaneal bursitis
Retrocalcaneal bursitis is an inflammation of the bursa located between the calcaneus and the anterior surface of the Achilles tendon. It commonly occurs in association with rheumatoid arthritis, spondyloarthropathies, gout, and trauma.
The pain is usually on the back of the heel and swelling appears on lateral or medial side of the tendon.Shoulder surgery
Shoulder surgery is a means of treating injured shoulders. Many surgeries have been developed to repair the muscles, connective tissue, or damaged joints that can arise from traumatic or overuse injuries to the shoulder.Subacromial bursitis
Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.
Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain.Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions such as rheumatoid arthritis; crystal deposition disorders such as gout or pseudogout; calcific loose bodies, and infection. More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury.In 1983 Neer described three stages of impingement syndrome. He noted that "the symptoms and physical signs in all three stages of impingement are almost identical, including the 'impingement sign'..., arc of pain, crepitus, and varying weakness". The Neer classification did not distinguish between partial-thickness and full-thickness rotator cuff tears in stage III. This has led to some controversy about the ability of physical examination tests to accurately diagnose between bursitis, impingement, impingement with or without rotator cuff tear and impingement with partial versus complete tears.
In 2005, Park et al. published their findings which concluded that a combination of clinical tests were more useful than a single physical examination test. For the diagnosis of impingement disease, the best combination of tests were "any degree (of) a positive Hawkins–Kennedy test, a positive painful arc sign, and weakness in external rotation with the arm at the side", to diagnose a full thickness rotator cuff tear, the best combination of tests, when all three are positive, were the painful arc, the drop-arm sign, and weakness in external rotation.