Ovid: 5-Minute Sports Medicine Consult, The

Sandeep Johar
  • May be difficult to distinguish from fractures. Suspicious joints should be immobilized, particularly in the setting of trauma.
  • Inflammation or irritation of the bursa (a sac filled with lubricating fluid, located between tissues such as bone, muscle, tendons, and skin, which decreases rubbing, friction, and irritation)
  • Potentially any bursa may be affected:
    • Subacromial (subdeltoid) bursitis: Lies between the acromion and the rotator cuff
    • Olecranon bursitis: Lies between the olecranon process and the overlying skin (usually secondary to trauma)
    • Iliopsoas bursitis: Lies between the iliopsoas tendon and the lesser trochanter (largest bursa in the body)
    • Trochanteric bursitis: Has superficial and deep components. The superficial bursa lies between the tensor fascia lata and skin; the deep bursa is located between the greater trochanter and the tensor fascia lata.
    • Prepatellar bursitis: Lies between the patella and the skin (usually secondary to trauma or frequent forward kneeling)
    • Calcaneal bursitis: 2 bursae at the level of insertion of the Achilles tendon. The superficial one is located between the skin and the tendon, and the deep one is located between the calcaneus and the tendon.
  • Bursae are flattened sacs that serve as a protective buffer between bones and overlapping muscles (deep bursae) or between bones and tendons/skin (superficial bursae). In the normal state, they contain minimal amounts of fluid to reduce friction and facilitate pain-free movement during muscle contraction.
  • Humans have ∼160 bursae.
Risk Factors
  • If you work in a profession or have a hobby that requires repetitive motion or pressure on particular bursae (ie, carpet laying, tile setting, gardening, bicycling, baseball, ice skating)
  • Rheumatoid arthritis
  • Osteoarthritis
  • Gout
  • Thyroid disease
  • Diabetes
  • Trauma (acute and chronic): Most common cause
  • Septic bursitis: Direct introduction of microorganisms through traumatic injury or through contiguous spread from cellulitis
  • Predisposing factors for septic bursitis include diabetes, alcoholism, steroid therapy, uremia, trauma, and skin disease.
  • For septic bursitis: Staphylococcus aureus causes 80%, followed by Streptococcus
  • Crystal deposition: Gout or pseudogout
  • Systemic diseases: Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic pulmonary osteoarthropathy, idiopathic hypereosinophilic syndrome
  • Full assessment of regional musculoskeletal function
  • Any suspicion of infection warrants aspiration of bursae (especially olecranon and prepatellar bursae)
  • Aspiration of hip and other deep bursae should be deferred to orthopedics or rheumatology, or may be guided in emergency department by US
Physical Exam
  • Localized tenderness
  • Decreased range of motion or pain with movement
  • Erythema or edema (seen in superficial bursitis)
  • Traumatic bursitis often follows traumatic event or overuse of related joints.
Diagnostic Tests & Interpretation
  • CBC with differential, erythrocyte sedimentation rate, serum protein electrophoresis, rheumatoid factor, serum uric acid
  • Aspiration and analysis of bursa fluid: Cell count with differential, glucose and total protein, crystal determination, gram stain, and culture
  • Normal fluid: Fluid is clear yellow with 0–200 WBCs, 0 RBCs, low protein, and glucose is same as serum.
  • Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.
  • Infective bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on gram stain.
  • P.57

  • Rheumatoid and microcrystalline inflammation: Fluid is yellow, can be cloudy, and has 1,000–40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; use polarizing microscope to identify crystals.
  • Chronic or recurrent bursitis should be sent for acid-fast staining and cultured on special media for mycobacteria, Brucella, and algae.
  • Monosodium urate crystals seen in gout; calcium pyrophosphate crystals seen in pseudogout
  • X-rays to exclude other suspected pathologies (ie, fractures, dislocations)
  • X-rays may demonstrate chronic arthritic changes or calcium deposits
  • US for diagnostic aspiration or treatment injections
  • MRI helps depict bursa/prebursa fluid, associated abscesses, and adjacent soft tissue structures.
Differential Diagnosis
  • Arthritis: Rheumatoid, septic, osteo-
  • Cellulitis
  • Gout and pseudogout
  • Fracture, tendon/ligament tear, contusion, sprain
  • Tendonitis
Ongoing Care
Follow-Up Recommendations
  • Most patients respond to therapy within 1 wk.
  • Rheumatology or orthopedic referral is recommended for patients with repetitive acute bouts, necessitating repeated joint/bursa aspirations or, eventually, surgical excision of involved bursa.
Additional Reading
Costantino TG, Roemer B, Leber EH. Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis. J Emerg Med. 2007;32(3):295–297.
Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009;35(1):45–62.
Valeriano-Marcet J, Carter JD, Vasey FB. Soft tissue disease. Rheum Dis Clin North Am. 2003;29(1):77–88, vi.
  • 726.19 Other specified disorders of bursae and tendons in shoulder region
  • 726.33 Olecranon bursitis
  • 727.3 Other bursitis disorders

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