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.

• Chronic overuse or repetitive use
• Traumatic injury
• Bacterial infection
• Gout, pseudogout
• Rheumatoid arthritis

Repetitive activities putting strain on the joint (e.g., athletic, occupational)

• 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)

• 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

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.

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

• Distended bursa filled with serous fluid
• In chronic cases, thickened bursal wall
• Very high white blood counts in septic bursitis

X-ray to rule out arthritic conditions.

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.

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

• 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.

Alternative therapies may be useful in reducing the pain and inflammation of bursitis while supporting healthy connective tissue.

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

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.

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

Can be helpful in resolving swelling and inflammation, especially for pain relief.

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.

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.

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.

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.

Bursitis usually resolves within one to two weeks but may recur with repeated overuse of joint. Recurring acute bursitis can progress to chronic bursitis.

Use glucocorticoids with caution in pregnancy (U.S. FDA pregnancy safety category C).

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.