Bursitis

Definition

Bursitis is a painful inflammation of a bursa, a fluid-filled sac located near a joint.

Description

There are approximately 150 bursae (plural of bursa) throughout the body. Bursae act like air-filled bubble wrap that cushions the movement of a joint.

Located near the tendons of joints, bursae reduce friction between the bones and tendons, making joints flexible and easier to move. Bursae are not filled with air, but are filled with a clear, lubricating liquid called synovial fluid.

Bursitis occurs when the bursae become inflamed. Sometimes this inflammation causes the bursae to produce more fluid and to swell. Since bursae are located near every joint in the body, bursitis can potentially appear anywhere. The most common sites for bursitis are the shoulder, hip, elbow, knee, ankle, buttocks, and sometimes the thumb or toes. These specific areas of the body produce different types of bursitis with different symptoms and sometimes different methods of treatment and therapy.

Shoulder bursitis

Bursitis in the shoulder is called subdeltoid bursitis or subacromial bursitis and may be more complex that just having inflamed bursae. Shoulder impingement can occur at the same time. This condition happens when the rotator cuff (shoulder muscles and tendons) becomes inflamed and begins to swell between the shoulder bones. This can lead to inflamed bursae and, therefore, to shoulder bursitis.

Hip bursitis

There are two different types of hip bursitis. Trochanteric bursitis occurs on the side of the hip and thigh. Ischial bursitis (called ischiogluteal bursitis) affects the base of the hips and buttocks.

Knee bursitis

Knee bursitis can be found in two regions of the knee. Prepatellar bursitis is located in front of the kneecap. Pes anserine bursitis occurs on the inner side of the knee below the knee joint. The muscles here allow the knee to bend and facilitate crossing the legs.

Elbow bursitis

Called olecranon bursitis, this condition is found in the elbow.

Ankle bursitis

Ankle bursitis can take many forms. One of the most common presentations is called Achilles tendon bursitis. The inflammation occurs in the bursae along the Achilles tendon that runs along the back of the heel and ankle.

Demographics

Bursitis is a common condition that can affect people of any age. It is most often seen among people engaged in sports, especially runners, and people who work or take part in hobbies that require repetitive movement. Direct trauma to a joint or infection can produce bursitis at any age.

Bursitis is most frequently found in people who are middle aged or older and in people who are overweight or diabetic. Trochanteric bursitis is often seen in people over forty years old. About 85% of bursitis caused by infection occurs among men.

Causes and symptoms

Causes

The most frequent cause of bursitis is repeated movement of a joint. Trauma such as having a fall or sports injury can irritate the bursae. Rheumatoid arthritis , scoliosis, and scleroderma , can cause bursitis because of bony growth around the joints that can irritate the bursae. Gout can be a factor due to the formation of crystal deposits. In gout, the body is not able to break down uric acid, causing it to crystallize and be deposited in the joints where the bursae can become inflamed. In addition, Staphylococcus aureus or Staphylococcus epidermis bacteria can cause septic bursitis.

Keeping a joint locked in one position can cause inflammation when the joint is then exercised. For example, a person can have hip bursitis from running or marathon walking as well as from sitting at a desk without getting up and moving.

Shoulder bursitis can be caused by an injury to the shoulder from a fall or accident. It can also be caused by overuse in sports or work, such as swimming, pitching a baseball, painting a wall, or hanging wallpaper. Infection or rheumatoid arthritis can cause shoulder bursitis. Arthritis can produce bony growths on the bones of the shoulder that can rub against the tendons and the bursae, thereby inflaming them.

Trochanteric (hip) bursitis is most often caused by overuse of the joint, such as in running, climbing stairs, hiking, or bicycling. It can also be caused by sitting at a desk for extended periods without getting up and moving around. Having one leg shorter than the other can cause hip bursitis. Weak muscles around the hip and thigh can cause the bursae to become inflamed because they are overused to cushion the joint.

Ischial (hip) bursitis can be caused by standing or sitting on hard surfaces for long periods. It was commonly found among weavers who sat on a hard surface for extended periods weaving; thereby garnering the name weaver's bottom.

Prepatellar (knee) bursitis is most often caused by putting continued pressure on the front of the knee. It has often been called clergyman's knee or housemaid's knee; two occupations that were reported to require spending extended periods of time on the knees. Prepatellar bursitis is common in wrestlers from continued contact with the mat and in volleyball players who dive on their knees for the ball. Among older adults, it is most often found in gardeners who spend long hours kneeling in their gardens.

Pes anserine (knee) bursitis is found among swimmers who do the breaststroke or among soccer kickers, which is why it has been called breastroker's knee or soccer knee. It can be found among older adults who lift heavy loads from a squat position, runners, or those participating in sports that require jumping, pivoting, and squatting.

Elbow bursitis is caused by overusing the elbow. Roofers, painters, and carpenters often have elbow bursitis. Thus, it has been called carpenter's elbow and even miner's elbow because miners used to swing heavy hammers in their work. It can be caused by playing tennis or even by vacuuming.

Achilles tendon bursitis is caused by pressure on the ankle and heel. It can be caused by running on uneven paths in parks or by wearing poorly fitting shoes that rub against the heel. Ankle bursitis is also caused by overusing the ankles by running and jumping or even walking. Sometimes, it is seen in women who either are starting to wear high heels or who have worn them many years.

Symptoms

The most common symptom of bursitis is pain . If the joint is moved or pressure is applied to the surrounding area, pain is present. The affected joint may feel warm or appear red or swollen. In rare cases, infection is present and fever accompanies the pain. Besides pain, a person with bursitis may not have full range of motion in a joint.

Shoulder bursitis can be felt in the shoulder whenever it is moved, especially when reaching over the head. Pain is felt when resting the shoulder and can even wake someone from sleep. Weakness and limited range of motion may be present.

Pain in hip bursitis is usually felt on the outside of the hip and thigh (trochanteric bursitis) or in the buttocks and down the back of the thigh (ischial). Often there is stiffness and a constant ache. Some people report hearing or feeling a “pop” or “snap” when the hip is moved before the pain is felt. Erroneously, some people assume that they have thrown their hip out.

Knee bursitis causes pain and stiffness when walking, kneeling, or climbing stairs. The top or the inside of the knee may swell.

Most often people with elbow bursitis feel pain when they bend the affected arm. The entire elbow appears red and can swell to the size of a goose egg.

Symptoms of Achilles tendon bursitis are pronounced. Often, there is limping, pain in the heel, or stiffness in the ankle. Wearing shoes may become painful. The back of the heel may swell and appear red and warm.

If fever and flu-like symptoms are present, the patient should seek medical help immediately. If the bursitis has continued without relief from home care for more than a week, a medical professional should be consulted for additional treatment options.

Diagnosis

Bursitis is diagnosed by a doctor by first taking a careful history of the patient, especially what the patient was doing before pain appeared. Temperature and blood pressure are taken. The doctor examines the affected area, looking for swelling and redness. Often pressure is placed on the affected area to see if the pain is intensified when pressed. The doctor may also put the patient through a series of range of motion activities to evaluate any limited movement.

X rays are only considered if the patient has a history of disorders that produce uric crystals. If septic bursitis is suspected, the doctor may insert a needle into the affected bursae to draw a sample of synovial fluid to test for bacteria. Blood tests may be ordered to determine any underlying conditions such as diabetes, which can affect the treatment plan.

Treatment

Treatment for any form of bursitis is basically the same. The patient is asked to rest and elevate the affected area, if possible. Ice is applied for 20 minutes three or four times a day for the first day or two, then heat is applied at the same frequencies. Moist heat is most often preferred. The patient may take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium , or aspirin . Splinting or wrapping affected joints may help rest the joints. If bursitis is particularly severe or recurs often, the doctor may inject a corticosteroid drug into the bursa.

If the patient has septic busitis, antibiotics are prescribed and the bursa may be surgically drained. This may require hospitalization. Surgery to remove a bursa is rare, however, surgery may be used to remove calcium deposits.

Patients are told not to sleep on their affected side. Using a pillow between the knees when sleeping can help both knee and hip bursitis. Patients with shoulder bursitis may be asked to sleep on their backs.

ALTERNATIVE TREATMENT Some patients find additional relief through alternative therapies. Acupuncture has been effective in pain relief. Chiropractic , magnetic field therapy, body work, and applied kinesiology may also be helpful.

Nutrition/Dietetic concerns

Calcium malabsorption, magnesium deficiency, and food allergies may contribute to bursitis. Dietary changes, vitamin supplements, and herbal treatments may be beneficial for some patients.

Therapy

When pain is under control, the doctor may recommend physical therapy to stretch the joints and strengthen surrounding muscles. Yoga is often suggested for patients with hip and shoulder bursitis because yoga postures can help stretch muscles in those areas. Yoga postures that facilitate balance help to strengthen the muscles in affected areas.

Massage or ultrasound may be recommended to increase blood flow to the affected area.

Prognosis

The length of time in recovery depends on the type of bursitis present and the patient's age and general health. For example, many people take about six weeks for recovery from hip bursitis. Some patients with hip or other types of bursitis may have continued difficulty for months or years. In some cases, patients have repeated episodes of bursitis, especially if proper exercises are not continued or patients do not modify their activities.

Prevention

To prevent recurrence of bursitis, the patient should avoid repetitive activities that aggravate the bursae. If the patient does decide to participate in such activities, then the patient should take frequent breaks and be sure to warm up before using the affected joints. The patient should gradually build up strength and endurance in activities, starting with limited repetitions, time, and distance.

Stretching exercises should be continued daily and especially before any activity that uses the affected joints. The patient should take frequent breaks to move around when sitting for long periods or sit with feet elevated if standing for too long.

Proper joint positioning during activity is important to prevent bursitis. Having ergonomically correct work stations that put the body in proper alignment while working or using padding for knees or elbows can help prevent recurrence.

Patients with ankle bursitis may be asked to buy properly fitting shoes and to avoid high heels. Heel pads may be added to shoes to cushion the heel.

KEY TERMS

Bursa —A fluid-filled sac located near a joint (plural is bursae).

Diabetes —A metabolic disease caused by the body's inability to make or use insulin to process carbohydrates in the body.

Gout —A metabolic disease causing inflammation of the joints, uric deposits in and around the joints, and excessive uric acid in the blood.

Inflammation —The body's response to cellular injury.

Kinesiology —The study of the movement of the body.

Orthotics —Inserts put into shoes to support or correct muscles, joints, or skeletal parts.

Rotator cuff —The shoulder muscles and tendons.

Synovial fluid —A clear, lubricating liquid found in bursae.

Good shoes may help patients with hip bursitis. For those with one leg shorter than the other, wearing a shoe lift can bring both hips to an even height. Orthotics (shoe inserts) can align not only the feet but the spine, hips, and knees. This can help prevent bursitis.

In addition, patients who are overweight may find that losing weight eases the stress on bursae in the hips, knees, and ankles.

Caregiver concerns

Use of NSAIDs for extended periods of time should be carefully monitored by the physician since these medications can cause ulcers and other gastro-intestinal-problems.

Response to corticosteriod injections is very individual. Statistically, only about one-third of patients respond immediately from one injection. Some patients get worse, while others may require several injections. Corticosteriod injections should only be given every three months. Caution should be taken with diabetic patients because corticosteriods can elevate blood sugar. Corticosteriods are also contraindicated for septic bursitis.

It is important for the doctor to identify the underlying cause of recurrent bursitis. Undiagnosed medical problems such as diabetes, arthritis, or an autoimmune disorder may contribute to bursitis or complicate its treatment.

Resources

PERIODICALS

“Bursitis (Adult Health Advisor 2007).” Clinical Reference Systems May 31, 2007.

Rouzier, Pierre. “Pes Anserine (Knee) Bursitis.” Clinical Reference Systems—Sports Medical Advisor 2007. May 31, 2007.

Sanchez-Yamamoto, Deanna and Thomas M. Bush. “Corticosteroids Often Relieve Symptoms When Other Treatments Do Not—Injection Therapy for Bursitis and Tendonitis: Mastering the Basics.” The Journal of Musculoskeletal Medicine October 1, 2006: 720.

OTHER

“Ankle bursitis.” drugs.com. March 6, 2008 [cited April 5, 2008]. CareNotes. http://www.drugs.com/cg/ankle-bursitis.html.

Mayo Clinic Staff. “Bursitis.” MayoClinic.com. September 27, 2007 [cited April 5, 2008]. Mayo Foundation for Medical Education and Research. http://www.mayoclinic.com/health/bursitis/DS00032.

Shiel, William C. Jr. “Bursitis.” MedicineNet August 27, 2007 [cited April 5, 2008]. http://www.medicinenet.com/script/main/art.asp?articlekey=11615&pf=3&page=1.

Shiel, William C. Jr. “Cortisone Injection (Corticosteroid Injection) of Soft Tissue & Joints.” MedicineNet. April 11, 2007 [cited April 5, 2008]. http://www.medicinenet.com/script/main/art.asp?articlekey=11574&pf=3&page=1.

Steinfeldt, Jennifer L., et al. “Bursitis.

” eMedicineHealth. October 25, 2005 [April 5, 2008]. WebMD. http://www.emedicinehealth.com/bursitis/article_em.htm.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons, 6300 North River Rd., Rosemont, IL, 60018-4262, (847) 823-7186, (800) 346-2267, (847) 823-8125, http://www.aaos.org.

Arthritis Foundation, P.O. Box 7669, Atlanta, GA, 30357-0669, (404) 872-7100, (800) 283-7800, http://www.arthritis.org.

Janie F. Franz

Bursitis

Definition

Bursitis is the painful inflammation of the bursa, a padlike sac found in areas subject to friction. Bursae cushion the movement between the bones, tendons and muscles near the joints. Bursitis is most often caused by repetitive movement and is known by several common names including weaver's bottom, clergyman's knee, and miner's elbow, depending on the affected individual's occupation and area of injury.

Description

There are over 150 bursae in the human body. Usually bursae are present from birth, but they may form in response to repeated pressure. Each sac contains a small amount of synovial fluid, a clear liquid that acts as a lubricant. Inflammation causes pain on movement. The most common site for bursitis to occur is the shoulder (subdeltoid), but it also is seen in the elbows (olecranon), hips (trochanteric), knees, heels (Achilles), and toes. The affected area may be referred to as "frozen," because movement is so limited. In the knee there are four bursae, and all can become inflamed with overuse.

Causes and symptoms

The most common cause of bursitis is repeated physical activity, but it can flare up for no known reason. It can also be caused by trauma, rheumatoid arthritis, gout, and acute or chronic infection.

Pain and tenderness are common symptoms. If the affected joint is close to the skin, as with the shoulder, knee, elbow, or Achilles tendon, swelling and redness are seen and the area may feel warm to the touch. The bursae around the hip joint are deeper, and swelling is not obvious. Movement may be limited and is painful. In the shoulder, it may be difficult to raise the arm out from the side of the body. Putting on a jacket or combing the hair becomes a troublesome activity.

In acute bursitis symptoms appear suddenly; with chronic bursitis, pain, tenderness, and limited movement reappear after exercise or strain.

Diagnosis

When a patient has pain in a joint, a careful physical examination is needed to determine what type of movement is affected and if there is any swelling present. Bursitis will not show up on x-rays, although sometimes there are also calcium deposits in the joint that can be seen. Inserting a thin needle into the affected bursa and removing (aspirating) some of the synovial fluid for examination can confirm the diagnosis. In most cases, the fluid will not be clear. It can be tested for the presence of microorganisms, which would indicate an infection, and crystals, which could indicate gout. In instances where the diagnosis is difficult, a local anesthetic (a drug that numbs the area) is injected into the painful spot. If the discomfort stops temporarily, then bursitis is probably the correct diagnosis.

Treatment

Conservative treatment of bursitis is usually effective. The application of heat, rest, and immobilization of the affected joint area is the first step. A sling can be used for a shoulder injury; a cane is helpful for hip problems. The patient can take nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofin, and naproxen. They can be obtained without a prescription and relieve the pain and inflammation. Once the pain decreases, exercises of the affected area can begin. If the nearby muscles have become weak because of the disease or prolonged immobility, then exercises to build strength and improve movement are best. A doctor or physical therapist can prescribe an effective regimen.

If the bursitis is related to an inflammatory condition like arthritis or gout, then management of that disease is needed to control the bursitis.

When bursitis does not respond to conservative treatment, an injection into the joint of a long-acting corticosteroid preparation, like prednisone, can bring immediate and lasting relief. A corticosteroid is a hormonal substance that is the most effective drug for reducing inflammation. The drug is mixed with a local anesthetic and works on the joint within five minutes. Usually one injection is all that is needed.

Surgery to remove the damaged bursa may be performed in extreme cases.

If the bursitis is caused by an infection, then additional treatment is needed. Septic bursitis is caused by the presence of a pus-forming organism, usually staphylococcus aureus. This is confirmed by examining a sample of the fluid in the bursa and requires treatment with antibiotics taken by mouth, injected into a muscle or into a vein (intravenously). The bursa will also need to be drained by needle two or three times over the first week of treatment. When a patient has such a serious infection, there may be underlying causes. There could be undiscovered diabetes, or an inefficient immune system caused by human immunodeficiency virus infection (HIV).

KEY TERMS

Arthritis— Inflammation of a joint that may lead to changes in the joint's structure. It causes pain and swelling. Rheumatoid arthritis is a chronic disease that leads to crippling deformities.

Diabetes mellitus— A metabolic disease caused by a deficiency of insulin, which is essential to process carbohydrates in the body.

Gout— A hereditary metabolic disease that is a form of arthritis and causes inflammation of the joints. It is more common in men.

Inflammation— The reaction of tissue to injury.

Kinesiology— The science or study of movement.

Alternative treatment

Alternative treatments take into consideration the role of diet in causing bursitis. The faulty use of calcium by the body, magnesium deficiency, and food allergies may have a role. Diet changes and vitamin supplements may be helpful. The use of herbs, homeopathy, aromatherapy, and hydrotherapy can help relieve symptoms. Ginger is useful in reducing inflammation. Acupuncture has been proven effective in treating hip and shoulder pain caused by bursitis and other conditions. Other therapies that deal effectively with musculoskeletal problems (relating to the muscles and skeleton), may also be helpful, such as body work, magnetic field therapy, naturopathic medicine, chiropractic, and applied kinesiology.

Prognosis

Bursitis usually responds well to treatment, but it may develop into a chronic condition if the underlying cause is not corrected.

Prevention

Aggravating factors should be eliminated to prevent bursitis. Overexercising or the repetition of a movement that triggers the condition should be avoided. Doing exercises to strengthen the muscles around the joint will also help. When doing repetitive tasks, frequent breaks should be taken and the activity should be alternated with others using different parts of the body. To cushion the joints, it is a good idea to use cushioned chairs when sitting and foam kneeling pads for the knees. Leaning on the elbows, kneeling or sitting on a hard surface for a long period of time should be avoided. Not wearing high heels can help prevent bursitis in the heel, as can changing to new running shoes as soon as the old ones are worn out.

Resources

OTHER

"Bursitis." HealthAnswers.com. 1998. 〈http://www.healthanswers.com〉.

Bursitis

Definition

Bursitis is the painful inflammation of the bursa, a padlike sac of fluid found in areas of the musculoskeletal system that are subject to friction, such as joints. Bursae cushion the movement between the bones, tendons, and muscles near the joints. Bursitis is most often caused by repetitive movement performed by individuals in the course of their occupations, activities of daily living, or recreational activities.

Description

There are more than 150 bursae in the human body. Usually bursae are present from birth, but they may form in response to repeated excessive pressure. Each sac contains a small amount of synovial fluid, a clear liquid that acts as a lubricant. Inflammation causes pain on movement. The most common site for bursitis is the subdeltoid (shoulder), but it also is seen in the olecranon (elbows), trochanteric (hips), knees, heels (Achilles), and toes. The affected area may be referred to as "frozen," because movement is so limited. In the knee there are four bursae, and all can become inflamed with overuse.

Causes and symptoms

The most common cause of bursitis is repeated physical activity using excessive force, but it may also flare up for no known reason. Bursitis may be caused by trauma, proximity to inflammatory disease such as rheumatoid arthritis and gout, and it is also associated with acute or chronic infection.

Pain and tenderness are common symptoms. If the affected joint is close to the skin, as with the shoulder, knee, elbow, or Achilles tendon, swelling and redness are seen and the area over the joint may feel warm to the touch. The bursae around the hip joint are deeper, and swelling is not obvious. Movement may be limited and is painful. In the shoulder, it may be difficult for the patient to raise the arm away from the side of the body. When the shoulder is affected, patients report difficulty with activities such as putting on clothes or combing their hair.

In acute bursitis, symptoms appear suddenly. With chronic bursitis, pain, tenderness, and limited movement flare up after exercise or strain.

Diagnosis

When a patient has pain in a joint, a careful physical examination is performed to determine which type of movement is affected and if there is any swelling. Bursitis will not show up on x rays, although sometimes calcium deposits in the joint are seen. If infection is suspected, aspiration of the bursa should be performed and the fluid sent to the laboratory for cell count, gram stain and culture. In most cases, the fluid will not be clear. It can be tested for the presence of bacteria, which indicate an infection, and crystals, which could indicate gout. In instances where the diagnosis is difficult, a local anesthetic is injected into the painful spot. If the discomfort stops temporarily, then bursitis is suspected.

Treatment

Conservative treatment of bursitis is usually effective. The application of heat, rest, and immobilization of the affected joint area is the first step. A sling may be used for a shoulder injury, and a cane is helpful for patients with hip problems. Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen, obtained without a prescription, may relieve pain and inflammation. Once the pain decreases, mild to moderate exercise of the affected area may begin. If muscles proximal (near) to the affected joint have become weak or stiff because of the disease or prolonged immobility, exercises to build strength and improve movement are prescribed. A physician or physical therapist prescribes an effective exercise regimen.

If the bursitis is related to an inflammatory condition such as arthritis or gout, then management of the underlying disease is necessary to control the bursitis.

When bursitis does not respond to conservative treatment, an injection into the joint of a long-acting corticosteroid preparation, such as prednisone, may offer the patient immediate and lasting relief. The corticosteroid, which acts to reduce inflammation, is mixed with a local anesthetic and works on the joint within minutes. Usually one injection is all that is needed. It is important that the patient does not overuse the joint too soon because the pain has gone. A gradual build up to normal use is necessary.

Surgery to remove the damaged bursa may be performed in extreme cases.

If bursitis is caused by an infection, then additional treatment is needed. Septic bursitis may be caused by the presence of Staphylococcus aureus. This is confirmed by examining a sample of the fluid in the bursa and sending it for culture. Septic bursitis requires treatment with antibiotics specifically for the infection, and these antibiotics may be taken by mouth, injected into a muscle, or administered intravenously. The bursa must be drained by needle aspiration two or three times during the first week of treatment. When a patient has such a serious infection, there may be underlying causes such as previously undetected diabetes, or compromised immune system defense function, a byproduct of several diseases and some medications, e.g. chemotherapy.

Alternative treatments take into consideration the role of diet in bursitis. Dietary changes and vitamin supplements may be helpful. The use of herbs, homeopathy, aromatherapy, and hydrotherapy may help to relieve symptoms. Ginger has been used to reduce inflammation. Acupuncture has been shown to be effective treatment for hip and shoulder pain caused by bursitis and other conditions. Other therapies that deal effectively with musculoskeletal problems may also be helpful, such as osteopathy, massage, chiropractic, and applied kinesiology.

KEY TERMS

Arthritis— The collective name for approximately 100 diseases that are collagen related and inflammatory in origin. The most common are osteoarthritis and rheumatoid arthritis.

Diabetes mellitus— A metabolic disease caused by a deficiency of insulin in type 1 diabetes. Insulin is essential to process carbohydrates in the body. In type 2 diabetes, development of resistance to existing insulin levels results in inadequate blood glucose control.

Gout— A hereditary metabolic disease that is a form of arthritis and causes inflammation in the joints of the distal extremities (the feet and hands). It is more common in men.

Inflammation— The reaction of tissue to injury, or the body's immune response to disease.

Kinesiology— The science or study of movement.

Health care team roles

The diagnosis of bursitis is usually made by the primary care physician or mid-level practitioner (physician assistant or nurse practitioner). Laboratory technologists are involved in determining whether infection is present in joint fluid and radiology technologists perform radiographic or imaging studies. Nurses, physical therapists, physical therapy assistants, and exercise physiologists offer patients instruction about movements to strengthen the muscles surrounding joints and ways to prevent future injuries. For bursitis of the elbow or wrist, an occupational therapist may supervise recovery.

Prognosis

Bursitis usually responds well to treatment, but it may develop into a chronic condition if the underlying cause is not corrected.

Prevention

Aggravating factors should be eliminated if possible, to prevent recurrent bursitis. Over exercising or the repetition of a movement that triggers the condition should be avoided. Regular exercises designed to strengthen the muscles around the joint will also help. When engaging in repetitive tasks, patients should be advised to take frequent breaks and alternate activities using different parts of the body. To cushion the joints, it is advisable to use cushioned chairs when sitting and foam kneeling pads for the knees. Leaning on the elbows, and kneeling or sitting on a hard surface for a long period of time should be avoided. Avoiding high heels can help female patients avoid bursitis in the heel, and patients should be counseled to replace running shoes as soon as the alignment of the old ones deteriorates with wear.

Resources

BOOKS

Bennett, Robert M. "Bursitis, Tendinitis, Myofascial Pain, and Fibromyalgia." In Conn's Current Therapy, edited by Robert E. Rakel. Philadelphia: W. B. Saunders Co., 1998.

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1995.

Pelletier, Kenneth R. The Best Alternative Medicine What Works? What Does Not? New York: Simon & Schuster, 2000.

PERIODICALS

"Bursitis of the Hip." Mayo Clinic Health Newsletter (September 1997).

Bursitis

Definition

Bursitis is the painful inflammation of one or more bursae, which are padlike sacs found in parts of the body that are subject to friction. Bursae cushion the movements between the bones, tendons and muscles near the joints. Bursitis is most often caused by repetitive movement and is known by several common names, including weaver's bottom, clergyman's knee, housemaid's knee, and miner's elbow, depending on the area of injury.

Description

There are over 150 bursae in the human body. Usually bursae are present from birth, but they may form in response to repeated pressure. Each sac contains a small amount of synovial fluid, a clear liquid that acts as a lubricant. The bursae may become inflamed through traumatic injury, infection, or the development of arthritis. The inflammation then causes pain whenever the joint is moved. The most common site for bursitis to occur is the shoulder joint (subdeltoid), but it also is seen in the elbows (olecranon), hips (trochanteric), knees, heels (Achilles), and toes. The affected area may be referred to as "frozen," because movement is so limited. In the knee there are four bursae, and all can become inflamed with overuse.

Causes & symptoms

The most common cause of bursitis is repeated physical activity, but it can flare up for no known reason. It can also be caused by trauma, rheumatoid arthritis, gout , and acute or chronic infection.

Pain and tenderness are common symptoms of bursitis. If the affected joint is close to the skin, as with the shoulder, knee, elbow, or Achilles tendon, swelling and redness are seen and the area may feel warm to the touch. The bursae around the hip joint are deeper, and swelling is not as obvious. Movement may be limited and is painful. In the shoulder, it may be difficult to raise

the arm outward from the side of the body. Putting on a jacket or combing the hair, for example, become troublesome activities.

In acute bursitis symptoms appear suddenly; with chronic bursitis, pain, tenderness, and limited movement reappear after exercise or strain.

Diagnosis

When a patient has pain in a specific joint, a careful physical examination is needed to determine what type of movement is affected and if there is any swelling present. Bursitis will not show up on x rays, although sometimes there are also calcium deposits in the joint that can be seen. Inserting a thin needle into the affected bursa and removing (aspirating) some of the synovial fluid for examination can confirm the diagnosis. In most cases, the fluid will not be clear. It can be tested for the presence of microorganisms, which would indicate an infection, and for crystals, which could indicate gout. In instances where the diagnosis is difficult, a local anesthetic (a drug that numbs the area) is injected into the painful spot. If the discomfort stops temporarily, then bursitis is probably the correct diagnosis.

Treatment

Nutritional therapy

Naturopaths and nutritionists emphasize the role of diet as underlying causes of bursitis. They believe that the faulty use of calcium by the body, magnesium deficiencies, and food allergies may play a role. Their recommended diet may include the following:

• fresh fruits, vegetables and whole grains
• avoidance of foods that may cause allergies or digestive problems.
• multivitamin and mineral supplements
• vitamins A, C and E, selenium , and zinc supplements

Herbal therapy

Herbalists have recommended the following herbs or plant products for treatment of bursitis:

• curcumin (turmeric)
• bromelain (an enzyme found in pineapple)
• ginger
• grape-seed extract
• pine-bark extract
• citrus bioflavonoids

Homeopathy

Homeopathic remedies for bursitis include Belladonna, Bryonia and Rhus toxicodendron.

Hydrotherapy

The application of ice soon after an injury helps decrease the inflammation of acute bursitis. After two days of treatment with ice, however, heat instead of ice is more helpful. A warm heating pad or hot showers or baths can also relieve the symptoms of bursitis.

Acupuncture

Acupuncture has been proven effective in treating hip and shoulder pain caused by bursitis and other conditions.

Chiropractic

Spinal manipulation by a chiropractor may help improve movement in the affected joints by relieving some of the pressure on them.

Body work

Body work starts with adequate rest and massage of the bursitic area. Massage can increase blood circulation in the area, reducing the inflammation and pain. Following the initial phase of body work, patients may participate in yoga exercises that help to improve joint mobility and strengthen the muscles surrounding the joints.

Allopathic treatment

Conservative treatment of bursitis is usually effective. The application of heat, rest, and immobilization of the affected joint area is the first step. A sling can be used for a shoulder injury; a cane is helpful for hip problems. The patient can take nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen to relieve the pain and inflammation. Once the pain decreases, exercises of the affected area can begin. If the nearby muscles have become weak because of the disease or prolonged immobility, then exercises to build strength and improve movement are best. A doctor or physical therapist can prescribe an effective regimen.

If the bursitis is related to an inflammatory condition like arthritis or gout, then management of that disease is needed to control the bursitis.

When bursitis does not respond to conservative treatment, an injection into the joint of a long-acting corticosteroid preparation like prednisone can bring immediate and lasting relief. The drug is mixed with a local anesthetic and works on the joint within five minutes. Usually one injection is all that is needed.

Surgery to remove the damaged bursa may be performed in extreme cases.

If the bursitis is caused by an infection, then additional treatment is needed. Septic bursitis is caused by the presence of a pus-forming organism, usually Staphylococcus aureus. Septic bursitis requires treatment with antibiotics, which can be taken by mouth, injected into a muscle, or injected directly into a vein (intravenously). The bursa will also need to be drained by needle two or three times over the first week of treatment.

Expected results

Bursitis usually responds well to treatment, but it may develop into a chronic condition if the underlying cause is not corrected.

Prevention

Aggravating factors should be eliminated to prevent bursitis. Overexercising or the repetition of a movement that triggers the condition should be avoided. Doing exercises to strengthen the muscles around the joint will also help. When doing repetitive tasks, the patient should take frequent breaks and alternate the repetitive activity with others that use different parts of the body. To cushion the joints, it is a good idea to use cushioned chairs when sitting and foam kneeling pads for the knees. Leaning on the elbows, kneeling, or sitting on a hard surface for a long period of time should be avoided. Not wearing high heels can help prevent bursitis in the heel, as can changing to new running shoes as soon as the old ones are worn out.

Resources

BOOKS

Bennett, J. Claude, and Fred Plum. Cecil's Textbook of Medicine. Philadelphia: W. B. Saunders Co., 1994.

Bennett, Robert M. "Bursitis, Tendinitis, Myofascial Pain, and Fibromyalgia." In Conn's Current Therapy. Edited by Robert E. Rakel. Philadelphia: W. B. Saunders Co., 1998.

"Bursitis" In The Medical Advisor: The Complete Guide to Alternative and Medical Treatments. Richmond, VA: Time-Life Inc., 1997.

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1995.

Murray, Michael, and Joseph Pizzorno. Encyclopedia of Natural Medicine, revised 2nd ed., Rocklin, CA: Prima Health, 1998.

OTHER

Applied Medical Infomatics Inc., 1997. "Bursitis." http://www.healthanswers.com.

Mai Tran

bursitis (bursal synovitis) (ber-sy-tis) n. inflammation of a bursa, resulting from repetitive slight injury, pressure, friction, infection, or inflammatory conditions. It produces pain and sometimes restricts joint movement. See also housemaid's knee.