Introduction Background Bursitis is inflammation of a bursa caused by repetitive use, trauma, infection, or systemic inflammatory disease.

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). These synovial-lined sacs are filled with minimal amounts of fluid to facilitate movement during muscle contraction. Deep bursae, such as the subacromial and iliopsoas bursae, are located in the fascia. Superficial bursae, such as the olecranon and prepatellar bursae, are located in the subcutaneous tissue. Humans have approximately 160 bursae. Bursitis most commonly affects the subacromial, olecranon, trochanteric, prepatellar, and infrapatellar bursae. Symptoms of bursitis may include localized tenderness, edema, erythema, and/or reduced movement. Pathophysiology Inflammation causes synovial cells to multiply and thereby increases collagen formation and fluid production. A more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. Hemorrhage may occur. One study suggests this process may be mediated by cytokines, metalloproteases, and cyclooxygenases. In septic arthritis, local trauma usually causes inoculation of bacteria into the bursa, which triggers the inflammatory process. Clinical History

History of patients with bursitis may include the following: o Localized tenderness o Decreased range of motion or pain with movement o Erythema or edema (seen in superficial bursitis) o History of repetitive movement (eg, frequent kneeling leading to prepatellar or infrapatellar bursitis) o History of inflammatory disease (eg, rheumatoid arthritis, systemic lupus erythematosus) o History of trauma

Physical There are specific bursae that are more likely to become inflamed.

Subacromial (subdeltoid) bursitis o The subacromial bursa lies between the acromion and the rotator cuff. It cushions the coracoacromial ligament from the supraspinatus muscle. When the arm is resting at the side, the bursa protrudes laterally from beneath the acromion. When the arm is abducted, it rolls medially beneath the bone. Subacromial bursitis is frequently associated with

supraspinatus tendonitis because inflammation extends from one structure to the next. o Repetitive activities with an elevated arm most frequently cause inflammation of the bursae. Examples of this include frequent pitching of a baseball or lifting luggage overhead. o Less commonly, a primary process, such as rheumatoid arthritis, gout, or tuberculosis, may lead to bursitis. o Patients often exhibit tenderness over the greater trochanter. Difficulty in abduction may occur, specifically from 70-100 degrees. Olecranon bursitis o The olecranon bursa lies posteriorly between the olecranon process and the overlying skin. Because of its superficial location, it is easily traumatized from acute blows or chronic stress. o Trauma of the skin and surrounding tissues makes the olecranon a frequent location for infectious bursitis. The risk of septic bursitis increases in those who have a history of chronic disease. Because of the higher likelihood of infection, some physicians encourage aspiration and analysis of the bursa even when tenderness and erythema are minimal. o Chronic stress from repetitive forward-leaning positions with pressure on the elbows is seen in patients on long-term hemodialysis (dialysis elbow), in patients with chronic obstructive lung disease, in students, and in those with the occupation of laying down carpet. Lunger elbow has been suggested as a term to describe this affliction. o Nontraumatic causes of olecranon bursitis most commonly include gout, followed by pseudogout, rheumatoid arthritis, and uremia. o When inflamed, the bursa is evident as fluctuant bulge posterior to the olecranon process. Pain and tenderness over the bursa may be increased in extreme flexion as tension increases. Infectious bursitis is shown in the images below.
o

Acute infectious bursitis upon presentation to an emergency department. Image courtesy of Christopher Kabrhel, MD.

Infectious bursitis. Image courtesy of Christopher Kabrhel, MD.

Iliopsoas bursitis o The iliopsoas bursa, the largest bursa in the body, lies between the iliopsoas tendon and the lesser trochanter, extending upward into the iliac fossa beneath the iliacus muscle. Ten percent of patients develop a defect in the anterior part of the hip joint capsule, allowing communication of the joint with the bursa. o Iliopsoas bursitis is often associated with hip pathology (eg, rheumatoid arthritis, osteoarthritis) or recreational injury (eg, running). Infection of this bursa is rare. o Pain from iliopsoas bursitis radiates down the anteromedial side of the thigh to the knee and is increased on extension, adduction, and internal rotation of the hip. Typically, pain worsens slowly over weeks or months, and pain may be the only symptom present. Tenderness may occur anteriorly below the middle of the inguinal ligament and lateral to the femoral artery. Occasionally, a palpable mass or visible edema may be found lateral to the femoral vessels. Pulsations from the femoral artery are sometimes transmitted through this mass. o Retroperitoneal extension can cause an abdominal or pelvic mass that causes compressive syndromes in the groin (eg, femoral vein compression, femoral neuropathy) or pelvis (eg, medial displacement of pelvic structures, superior displacement of abdominal structures). Early authors described the classic triad of a palpable mass, extrinsic pressure on adjacent structures, and radiographic changes of advanced arthritis. It is now known that this triad is not sensitive for early disease. Imaging (eg, bursography, CT scan, MRI) may assist with diagnosis. Trochanteric bursitis o The trochanteric bursa has superficial and deep components. The superficial bursa lies between the tensor fascia lata and

the skin; the deep bursa is located between the greater trochanter and the tensor fascia lata. o Patients are predominately women (male-to-female ratio of 2-4:1) in their fourth to sixth decade of life. Runners and ballet dancers may develop deep trochanteric bursitis from overuse injury. The disease is also associated with rheumatoid arthritis of the hips, osteoarthritis of the hips, lumbosacral disease, and leg-length discrepancies. o Patients experience chronic, intermittent, aching pain over the lateral hip. In 40% of cases, this radiates down to the lateral thigh. Walking or lying on the affected side exacerbates the pain. In the seated position, local tenderness is present over the greater trochanter or more posteriorly for deep bursa. Pain can be reproduced by hip adduction (superficial bursitis) or resisted active abduction (deep bursitis). More than one half of patients have pain on PatrickFabere testing (sequential flexion, abduction, external rotation, extension of the hip with the contralateral knee flexed). Range of motion of the hip joint itself should not be affected. Ischial bursitis o The ischial bursa lies between the ischial tuberosity and the overlying gluteus muscle. o Inflammation commonly arises as a result of trauma, prolonged sitting on a hard surface (weaver bottom), or prolonged sitting in the same position (spinal cord injury). o Pain may radiate down the back of the thigh and mimic sciatic nerve inflammation. In ischial bursitis, however, pain can be reproduced by pressure over the ischial tuberosity. Prepatellar bursitis o The prepatellar bursa lies between the patella and the skin. o Inflammation arises secondary to trauma or constant friction between the skin and the patella, most commonly when frequent forward kneeling is performed. Previously referred to as housemaid knee, it now is seen regularly in many other occupations, including carpet laying (carpet-layer knee), coal mining (beat knee), roofing, gardening, and plumbing. Bursitis may also develop 7-10 days after a single blow, such as a fall. Rheumatoid arthritis and gout may also be the cause of bursitis. The superficial location of the prepatellar bursa allows for easy introduction of microorganisms and predisposes to septic arthritis. Therefore, aspiration of fluid to rule out infection is highly recommended if any clinical suspicion is present. o Prepatellar bursitis is often visualized as fluctuant, wellcircumscribed warm edema over the lower pole of the patella. Knee flexion causes increased tension over the bursa and increased pain. The knee joint itself, however, is normal. Infrapatellar bursitis o The infrapatellar bursa can be divided into superficial and deep components. The superficial component lies between

the patellar ligament and the skin, while the deep component lies between the patellar ligament and the proximal anterior tibia. o Superficial infrapatellar bursitis (clergyman knee) is located more distally than prepatellar bursitis and is often caused by frequent kneeling in an upright position. It can also be seen in gout or syphilis. The differential diagnosis includes Osgood-Schlatter disease. The deep infrapatellar bursa is less frequently inflamed. o Clinically, the patient exhibits pain with flexion and extension at the extremes of the range of motion. Edema is located on both sides of the patellar tendon and is tender. Pes anserine bursitis o The anserine bursa separates the insertions of the sartorius, gracilis, and semitendinosus tendons from the tibial plateau. The name anserine originated because the edematous bursa, restrained by the 3 tendons, gives the appearance of a goose's foot. o Abnormal pull of any of the 3 tendons or an abnormal gait predisposes to repetitive friction and to bursitis. Patients with anserine bursitis are commonly obese, older females with a history of osteoarthritis of the knees. Association has also been described between this bursitis and type 2 diabetes mellitus. Other risk factors include long distance running, valgus knee alignment, and excess external rotation of the lower leg. Unlike prepatellar bursitis, anserine bursitis is almost never septic. The differential diagnosis includes medial collateral ligament strain and osteoarthritis of the medial compartment of the knee. It is helpful to ensure the medial collateral ligament is intact by performing a valgus stress maneuver. o Tenderness is present on the medial aspect of the knee 5 cm below the joint margin at the site of the tibial tubercle. Neither swelling nor warmth is present. Pain radiates along the medial joint line to the inner thigh and calf. Pain is exacerbated with stair climbing and extremes of flexion or extension. Anserine bursitis may occur bilaterally. Calcaneal bursitis o Two bursae are found 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. The calcaneal bursa can become inflamed in patients with heel spurs or in patients with poorfitting shoes (eg, high heels). Inflammation can occur secondarily from Achilles tendonitis, especially in young athletes. o Patients have tenderness to palpation of the bursa anterior to the Achilles tendon on both the medial and lateral aspects. They have pain with movement, worsened with dorsiflexion.

Causes

General bursitis: Bursal inflammation may occur from many causes, including the following: acute trauma, chronic friction (eg, overuse injuries), crystal deposition (eg, gout and pseudogout), infection, and systemic diseases (eg, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic pulmonary osteoarthropathy, idiopathic hypereosinophilic syndrome). Septic bursitis o Septic bursitis occurs from direct introduction of microorganisms through traumatic injury or through contiguous spread from cellulitis (50-70% of cases). Less commonly, infection of deep bursae is due to contiguous septic arthritis or bacteremia (10% of cases). The most common causative organism is Staphylococcus aureus (80% of cases) followed by streptococci. Other organisms include mycobacteria (both tuberculous and nontuberculous strains), fungi (Candida), and algae Prototheca wickerhamii.1 o Predisposing factors include diabetes, alcoholism, steroid therapy, uremia, trauma, and skin disease. A history of noninfectious inflammation of the bursa also increases the risk of septic bursitis. o Although septic bursitis is not diagnosed based on clinical signs alone, certain signs that favor the diagnosis of septic over sterile inflammatory bursitis include the following: Bursal tenderness/erythema Bursal warmth Peribursal cellulitis Fever

Differential Diagnoses Arthritis, Cellulitis Gout Knee Osgood-Schlatter Tendonitis Rheumatoid and Injury, Soft Pseudogout Tissue Disease

Other Problems to Be Considered Septic Ligamentous Fracture Osteoarthritis Workup Laboratory Studies

arthritis injury

Routine laboratory blood work is generally not helpful in the diagnosis of noninfectious bursitis. In cases of septic bursitis,

however, leukocyte count and erythrocyte sedimentation rate may be mildly to moderately elevated. Blood cultures may be drawn if infection of deep bursae is a concern. Imaging Studies

Plain film radiography is usually not helpful in the diagnosis of bursitis but may be helpful to exclude other suspected pathologies (eg, fractures, dislocations). Of note, the bursal walls or nearby tendons may be calcified and radiopaque in chronic bursitis. For diagnostic aspiration or treatment injections, ultrasonography may be used to elucidate the structures and to guide procedures. If needed, MRI helps depict bursal/prebursal fluid, associated abscesses, and adjacent soft tissue structures.2

Procedures

Aspiration and analysis of bursal fluid distinguishes septic bursitis from aseptic bursitis and may also be therapeutic. o Physicians should be more inclined to perform bursal fluid aspiration in the most frequently infected bursae, which are the olecranon, prepatellar, and infrapatellar bursae. o The septic bursitis white blood cell count (WBC) is lower than that of septic arthritis. A WBC count from 5,000/mm3 to 20,000/mm3 or higher may be considered indicative of infection. Gram stain accuracy varies considerably, with sensitivities between 15% and 100%. Therefore, fluid with a high WBC count but negative for Gram stain is still considered suspicious for infection. Elevated protein level and reduced glucose level are associated with infection but are not a sufficiently sensitive or specific finding to be used in isolation. Bursal fluid culture is the conclusive test for diagnosis. Culture in liquid medium has been shown to be superior to culture on solid medium. Chronic or recurrent bursitis should be sent for acid-fast staining and cultured on special media for mycobacteria, Brucella, and algae. o Fluid should also be examined for crystals. Monosodium urate crystals are seen in gout; calcium pyrophosphate crystals are seen in pseudogout; cholesterol crystals are seen in rheumatoid chylous bursitis. o Arthrocentesis should be performed if joint involvement is suspected.

Treatment Emergency Department Care

Aseptic bursitis o Most patients with bursitis are treated conservatively to reduce inflammation. Conservative treatment includes rest, cold and heat treatments, elevation, nonsteroidal anti-

inflammatory drugs (NSAIDs), bursal aspiration, and intrabursal steroid injections (with or without local anesthetic agents).3 The affected area should be placed at rest. Shoulders should not be immobilized for more than a few days because of the risk of adhesive capsulitis. After immobilization, the patient should begin graduated range of motion exercises. Educate patients who have bursitis secondary to overuse about the importance of regular periods of rest and possible alternative activities to avoid recurrence. Applying cold treatments for 20 minutes every several hours may be of value in the first 24-48 hours. This may be followed with heat treatments. Elevation is useful, particularly in lower limb bursitis. Consider site-specific therapy (eg, cushions for ischial bursitis, well-fitting padded shoes for calcaneal bursitis). NSAIDs are used as anti-inflammatory agents and for pain relief. One multicenter, double-blind, parallel study involved 372 patients with acute (ie, within 72 h) traumatic bursitis and/or tendonitis of the shoulder.4 Of those patients treated with 50 mg diclofenac bid/tid, 90% improved over 14 days, with 40-50% demonstrating at least moderate improvement. The musculoskeletal injection for bursitis can be performed in the emergency department or the outpatient setting.5 Intrabursal steroid injections (with or without local anesthetics) should not be used if infection is suspected. In overuse injuries, injections should not replace cessation or modification of the offending activity. A wide range of steroids (eg, hydrocortisone, prednisolone, methylprednisolone, triamcinolone, betamethasone, dexamethasone) has been used. No single agent is demonstrably superior. Steroids can be mixed in the same syringe with lidocaine or bupivacaine. This therapy often is reserved for those patients in whom an adequate response has not been achieved by other measures after 7-14 days. The procedural method of injection of bursae has been detailed in recent literature.6,5 One study compared the short- and long-term effectiveness of betamethasone injections (6, 12, or 24 mg with 4 mL 1% lidocaine) for trochanteric bursitis.7 Improvement in pain at 1, 6, and 26 weeks in 77%, 69%, and 61% of patients, respectively, was reported. Higher doses of steroids were significantly more effective (P <0.01).7 In a second randomized study, 42 patients with olecranon bursitis were divided after bursal aspiration into 4 treatment groups.8 The groups received intrabursal methylprednisolone (20 mg) plus naproxen (1 g/d for 10 d); intrabursal methylprednisolone without naproxen; naproxen; or placebo. The steroid injection was more successful in decreasing edema and preventing recurrence than naproxen or placebo.8

One small sample-sized study has shown that injection under ultrasonographic guidance may be more efficacious than blind injection based on anatomy.9 The potential complications of intrabursal injections include the following: infection, bleeding, allergy to injected agents, local subcutaneous atrophy, postinjection flare/pain, and tendon rupture. Postinjection pain may last several hours. Postinjection flares usually start within hours and may last up to 72 hours. Major tendons should not be injected. o Surgical excision of bursae may be required for chronic or frequently recurrent bursitis. Surgery is reserved as a last resort for patients in whom conservative treatment fails. The operation varies according to site. Septic bursitis o Patients with suspected septic bursitis should be treated with antibiotics while awaiting culture results. Superficial septic bursitis can be treated with oral outpatient therapy. Those with systemic symptoms or who are immunocompromised may require admission for intravenous antibiotics. o S aureus is the most common pathogen, accounting for more than 80% of cases. Streptococcal species (mostly group A hemolytic streptococci) account for 5-20% of cases. Other gram-positive, gram-negative, and anaerobic infections are rare. Mycobacterial, fungal, algal, and spirochetal infections are even more rare and tend to occur in unusual clinical settings (especially in those who are predisposed to infection). o An appropriate antistaphylococcal antibiotic should be started empirically. This should be a penicillinase-resistant penicillin, such as oxacillin, or a first-generation cephalosporin, such as cefazolin. In penicillin-allergic patients or in carriers of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin is an appropriate alternative treatment. o Duration of antibiotic treatment varies with the patient and clinical situation. Uncomplicated septic bursitis presenting within 7 days of infection should be treated with a minimum 10-day course.10 Aspiration should be repeated every 1-3 days while antibiotics are being administered. Antibiotics should be continued for 5 days past sterilization of bursal fluid as seen by aspiration. Aspiration also helps to decrease the bacterial load and to promote comfort. Immunocompromised patients require a longer course of treatment of at least 15 days. Deep bursae infections have higher associations with bacteremia and require more aggressive and prolonged antibiotic therapy. Surgical drainage and/or debridement often are required. o Treatment of tuberculous bursitis involves full excision of the bursae and surrounding affected tissue with concomitant antituberculous therapy for 6-12 months. Atypical mycobacteria occasionally may be successfully treated with

conservative drainage and appropriate antibiotics. Brucella bursitis is treated with excision of bursae and tetracycline with or without rifampin. Surgical intervention, such as incision and drainage with or without packing/wick placement is reserved for the following cases: failure of needle aspiration to drain the bursa adequately; bursa site inaccessible to repeated needle aspirations; abscess, necrosis, or sinus formation; need for exploration to assess the extent of infection of adjacent structures; and recurrent or refractory disease after conservative treatment.11

Consultations

General/orthopedic surgery Rheumatology

Medication The goals of pharmacotherapy are to reduce morbidity and prevent complications. Nonsteroidal anti-inflammatory agents Most commonly used for relief of mild to moderately severe pain. Although pain-relieving effects tend to be patient specific, ibuprofen is usually used for initial therapy.

Ibuprofen (Ibuprin, Advil, Motrin) DOC for mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing Interactions Contraindications Precautions

Adult 400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d Pediatric <6 months: 6 months to 12 years: >12 years: Administer as in adults

4-10

Not mg/kg/dose

established PO tid/qid

Dosing Interactions Contraindications Precautions Dosing

Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Naproxen (Anaprox, Naprelan, Naprosyn) For relief of mild to moderately severe pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Dosing Interactions Contraindications Precautions

Adult 500 mg PO initial dose, followed by 250 mg q6-8h; not to exceed 1.25 g/d Pediatric <2 years: Not >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Antibiotics

established

Therapy must cover all likely pathogens in the context of the clinical setting.

Oxacillin (Bactocill, Prostaphlin) Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Dosing Interactions Contraindications

Adult 500-1000 mg 150-200 mg/kg/d IV/IM divided q6h Pediatric 50-100 mg/kg/d PO divided 150-200 mg/kg/d IV/IM divided q6h; not to exceed 12 g/d

Precautions PO q4-6h

q6h

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Dicloxacillin (Dycill, Dynapen) Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected. Resistance to this drug results from alterations in penicillin-binding proteins.

Dosing Interactions Contraindications Precautions

Adult 125-500 mg PO qid 1-2 h ac or 2 h pc Pediatric <40 kilograms: 12.5-50 mg/kg/d PO divided qid 1-2 h ac or 2 h pc for 710 d; doses up to 50-100 mg/kg/d have been used >40 kilograms: Administer as in adults

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Dosing Interactions Contraindications Precautions

Cephalexin (Keflex, Biocef) First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.

Dosing Interactions Contraindications Precautions

Adult 250-1000 mg PO q6h; not to exceed 4 g/d Pediatric 25-50 mg/kg/d PO q6h; not to exceed 3 g/d

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Cefazolin (Ancef, Kefzol, Zolicef) First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens similar.

Dosing Interactions Contraindications Precautions

Adult 250 mg to 2 g IV/IM q6-12h depending on severity of infection; not to exceed 12 g/d Pediatric

25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Vancomycin (Vancocin) Potent antibiotic directed against gram-positive organisms and active against enterococci. Indicated for patients who cannot receive or have not responded to penicillins and cephalosporins or who have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures. May need to adjust dose in renal impairment.

Dosing Interactions Contraindications Precautions

Adult 500 mg-2g/d IV divided tid/qid 7-10 d Pediatric 40 mg/kg/d IV divided tid/qid 7-10 d Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.

Hydrocortisone (Solu-Cortef, Westcort) Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Dosing Interactions Contraindications Precautions

Adult 25-37.5 mg intrabursal; may repeat in 1-3 wk Pediatric Administer as in adults

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions (AK-Pred, Delta-Cortef, Articulose-50,

Methylprednisolone Econopred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Dosing Interactions Contraindications Precautions

Adult 20 mg intrabursal; repeat in 1-3 wk Pediatric Administer as in adults

Dosing Interactions Contraindications

Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Dexamethasone (Decadron, Dexasone) For various inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Dosing Interactions Contraindications Precautions

Adult 4-16 mg intrabursal; may repeat in 3-4 wk Pediatric Administer as in adults Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Anesthetic

Lidocaine 1-2% Local anesthetic.

Dosing Interactions Contraindications Precautions

Adult Inject 5 mL into trochanteric bursa if inflammatory trochanteric bursitis is suspected

Pediatric Not established

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Follow-up Prognosis

Mortality is very low. The prognosis of bursitis is good, with the vast majority of patients receiving outpatient follow-up and treatment.

Patient Education

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Bursitis.

Miscellaneous Medicolegal Pitfalls

Failure to diagnose and treat septic bursitis. Failure to distinguish septic bursitis from septic arthritis. Misdiagnosis of bursitis and missing other diagnoses (fracture, dislocation).