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Overview |
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Definition |
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Bursitis is the inflammation of a bursa, a sac lined by a synovial membrane,
filled with fluid, and located between bones and tendons or muscles. Commonly
affected bursae are the subdeltoid, olecranon, prepatellar, trochanteric,
iliopsoas, ischial, anserine, Achilles, calcaneal, and radiohumeral. Bursae
exist where joint friction occurs, helping lubricate and cushion the joint.
Bursitis seldom occurs in patients before adulthood and is more common in middle
and old age. Bursitis can be acute or chronic. Septic bursitis is an infection
of the bursa. |
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Etiology |
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- Chronic overuse or repetitive use
- Traumatic injury
- Bacterial infection
- Gout, pseudogout
- Rheumatoid arthritis
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Risk Factors |
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Repetitive activities putting strain on the joint (e.g., athletic,
occupational) |
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Signs and Symptoms |
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- Localized pain aggravated by movement
- Abrupt onset of pain in acute bursitis
- Localized swelling
- Localized tenderness
- Erythema
- Fever, swelling, and increased temperature of the overlying skin
(septic bursitis)
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Differential
Diagnosis |
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- Arthritis
- Gout or pseudogout
- Tendinitis
- Sprain or strain
For shoulder pain:
- Referred cardiac pain
- Referred cervical nerve root compression
- Referred gallbladder pain
- Injury to the rotator cuff
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Diagnosis |
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Physical Examination |
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Physical signs of bursitis are pain or tenderness and swelling that can be
localized to the bursa rather than the entire joint, except in cases of deep
bursae. |
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Laboratory Tests |
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For infection:
- White blood count
- Gram stain and culture of bursal fluid
To rule out gout:
- Analysis of bursal fluid for crystals
To rule out rheumatic and connective tissue disease:
- CBC
- ESR
- Serum protein electrophoresis
- Rheumatoid factor
- Serum uric acid
- Calcium
- Phosphorus
- Alkaline phosphatase
- VDRL
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Pathology/Pathophysiology |
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- Distended bursa filled with serous fluid
- In chronic cases, thickened bursal wall
- Very high white blood counts in septic
bursitis
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Imaging |
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X-ray to rule out arthritic conditions. |
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Other Diagnostic
Procedures |
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Bursitis can often be diagnosed by the history and physical assessment. The
absence of pain on passive motion may help differentiate bursitis from
arthritis. A swollen, inflamed bursa should be aspirated to rule out infection;
crystals in the fluid usually indicate gout. EKG if necessary to rule out
referred cardiac pain. |
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Treatment Options |
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Treatment Strategy |
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In most cases of nonseptic bursitis, conservative treatment with rest is
sufficient to allow the inflammation to resolve. Rarely, in severe chronic cases
is surgical excision of the bursa necessary.
Acute bursitis:
- Rest the joint, and elevate if possible
- Ice application
- Immobilization and/or compression of the joint
- Ultrasound therapy helpful in some cases
- NSAIDs for pain
- In more severe cases, local anesthetic and corticosteroid injected
into the bursa
- Oral corticosteroids
- Rarely, aspiration is indicated
Septic bursitis:
- Drain bursal fluid
- Antibiotics
Chronic bursitis:
- Repeated corticosteroid injections with physical therapy to restore
joint function
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Drug Therapies |
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- Nonsteroidal anti-inflammatory drugs for pain; continue four to five
days to prevent recurrence; side effects include gastrointestinal bleeding,
abdominal pain, nausea, vomiting, possible renal damage with chronic
use.
- Corticosteroids and local anesthetic, such as a combination of 2 to 3
ml of 1% to 2% lidocaine with 20 to 40 mg of a depoglucocorticoid (Celestone,
Aristocort, Kenalog), by injection of 1 to 3 ml using a 22-gauge needle for more
severe acute and chronic inflammation; wait two weeks before repeat injection to
rule out iatrogenic sepsis; side effects of corticosteroids include blurred
vision, frequent urination, increased thirst.
- Antibiotics for septic bursitis; the drug of choice depends on the
results of the Gram stain and culturing; most cases caused by Staphylococcus
aureus.
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Complementary and Alternative
Therapies |
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Alternative therapies may be useful in reducing the pain and inflammation of
bursitis while supporting healthy connective tissue. |
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Nutrition |
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Minimize pro-inflammatory foods, especially arachidonic acid from saturated
fats (dairy and animal products). Include anti-inflammatory oils such as found
in cold-water fish, nuts, and seeds.
- Glucosamine sulfate (500 mg bid to tid), for connective tissue
support
- Omega-3 oils (1,000 mg bid to tid), such as flaxseed oil, for
anti-inflammatory support
- Vitamin C with flavonoids (1,000 mg tid), for connective tissue
repair
- Proteolytic enzymes such as bromelain (250 mg bid), to reduce
inflammation
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas
should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20
minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in
combination as noted.
- Anti-inflammatory herbs include meadowsweet (Filipendula ulmaria),
white willow (Salix alba), Jamaica dogwood (Piscidia piscipula),
and turmeric (Curcuma longa). A tincture of one, or a combination of
these, may be taken at 15 drops every 15 minutes up to four doses for acute pain
relief, or 30 drops qid. Turmeric helps potentiate the effects of
bromelain.
- For concurrent muscle spasm, add valerian (Valeriana
officinalis).
- For chronic bursitis, add hawthorn (Crataegus monogyna) to
help restore the integrity of the connective
tissue.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arnica gel applied topically (as directed) gives excellent
short-term pain relief.
Acute remedies to be considered include the following.
- Arnica for post-trauma bursitis
- Ruta graveolons for rheumatic pains in the joint
- Bellis perennis for injury with much bruising
- Rhus toxicodendron for pain that is relieved with
movement
- "Traumeel" injections as an alternative to
corticosteroids
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Acupuncture |
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Can be helpful in resolving swelling and inflammation, especially for pain
relief. |
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Massage |
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Contraindicated in septic bursitis. Otherwise, massage (especially myofascial
release therapy) can be used for general relaxation and to reduce discomfort
from holding patterns secondary to pain and compensating for an injured
part. |
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Patient Monitoring |
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Monitor the patient for rare allergic reaction to corticosteroids. Educate
the patient to discontinue use of NSAIDs as soon as possible to reduce the risk
of side effects. If the pain does not resolve within two weeks, have the patient
return for reexamination and, if necessary, a second corticosteroid
injection. |
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Other
Considerations |
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Prevention |
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Most acute and chronic bursitis can be prevented by avoiding overuse of the
joint, by resting between periods of activity, and by adequately warming up and
stretching before strenuous activity. |
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Complications/Sequelae |
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Infection or inflammation at the injection site; instruct patient to report
redness or swelling that occurs at this site. Atrophy may occur if the injection
enters the skin. Possible motion or activity restrictions in chronic
cases. |
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Prognosis |
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Bursitis usually resolves within one to two weeks but may recur with repeated
overuse of joint. Recurring acute bursitis can progress to chronic
bursitis. |
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Pregnancy |
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Use glucocorticoids with caution in pregnancy (U.S. FDA pregnancy safety
category C). |
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References |
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Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine.
3rd ed. Philadelphia, Pa: WB Saunders Co; 1993.
Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine.
4th ed. Baltimore, Md: Williams & Wilkins; 1995:885-894.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Lippincott Williams & Wilkins; 1999.
Murray MT. The Healing Power of Herbs: The Enlightened Person's Guide to
the Wonders of Medicinal Plants. 2nd ed. Rocklin, Calif: Prima Publishing;
1998.
Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year
Book; 1994:2400-2404. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. |