Bursitis

Symptoms

Bursitis is inflammation and swelling of a bursa. A bursa is a fluid-filled sac which forms under the skin, usually over the joints, and acts as a cushion between the tendons and bones.

The main symptoms of bursitis are pain, swelling and tenderness in the affected area.

Any bursa can become inflamed, but bursitis most commonly occurs in the:

shoulder
elbow
knee (known as housemaid's knee)
hip

Other areas affected can include the ankle, foot and Achilles tendon (the large tendon that attaches the heel bone to the calf muscle).

Bursitis causes pain, inflammation and tenderness in the affected area of the body.

The severity of bursitis depends on how inflamed the bursa is. It can cause swelling and stiffness and the affected area may also be warm and red.

The pain of bursitis usually feels like a dull ache made worse by movement or pressure. Supporting your body weight may be painful. For example, if you have bursitis in your hip, you may find it difficult to lie on the affected side.

Septic bursitis

Septic bursitis is bursitis caused by infection. This can cause additional symptoms, such as:

a high temperature (fever) of 38C (100.4F) or above
feeling shivery
an infection of the deeper layers of the skin (cellulitis)
broken skin over the affected area

When to seek medical advice

See your GP if you have symptoms of bursitis and a fever as it's likely you have an infection.

Otherwise, see your GP if your symptoms don't improve after two weeks.

Your GP will usually be able to diagnose bursitis by examining the affected body part and asking about your symptoms.

You may be asked whether you have recently fallen on the joint, or whether you have a job or hobby that involves repetitively using the affected area of your body.

Fluid sample

If you have a fever – a temperature of 38C (100.4F) or above – you may have a small sample of fluid taken from the affected bursa.

The fluid is removed using a needle during a procedure known as aspiration. The sample is then sent to a laboratory to be tested for bacteria, which indicates a bacterial infection (septic bursitis). The sample may also be checked for crystals, which can develop because of conditions such as gout.

Following aspiration, a dressing is placed over the area and you will need to avoid strenuous activity for a couple of days.

Further testing

Further tests are usually only required if your symptoms do not respond to treatment. If this is the case, it will be necessary to rule out other conditions that may be responsible for your symptoms.

Further tests may include:

blood tests – to rule out conditions such as rheumatoid arthritis
magnetic resonance imaging (MRI) – to rule out tissue damage, such as a torn tendon (tendons are the cords that join bones to muscles)

What causes bursitis?

A bursa can become inflamed through injury or repetitive movement.

Your risk of developing bursitis is increased if you regularly take part in physical activities that involve a lot of repetitive movement, for example running (bursitis in the ankle) or playing darts (bursitis in the elbow).

People who spend a lot of time kneeling, such as carpet fitters and gardeners, also have an increased risk of developing bursitis in their knee.

Less commonly, bursitis can develop as a result of an infection or as a complication of certain conditions, such as gout or rheumatoid arthritis.

Bursitis can develop in three main ways. It can be caused by an injury or infection, or as the result of a pre-existing health condition.

Injury

If a bursa (the small fluid-filled sac which forms around the joints) is injured, the tissue inside it can become irritated, leading to inflammation (swelling).

In most cases, the injury develops over time because joints, muscles and tendons near the bursae are overused. Repetitive movement is a particular risk for this type of injury.

Ways that the bursa can be injured include:

lifting or reaching overhead can damage the shoulder
repeatedly bending and straightening the elbow, or falling on it
repeatedly moving the knee or kneeling on it (bursitis of the knee is known as "housemaid's knee")
excessive walking (particularly if you are not wearing suitable walking shoes) or activities such as ice skating or athletics can damage the ankle
running can injure the hips
leaning your elbows or kneeling on hard surfaces

A bursa can also be injured following a sudden impact, such as banging your elbow or by falling heavily on to your knees.

Infection

Bursae near the surface of your skin, such as those near your elbow, can become infected if bacteria find their way into cuts and grazes and then move into a bursa. Bursitis caused by an infection is known as septic bursitis.

The immune system (the body's natural defence against injury and illness) usually prevents this type of infection, so septic bursitis tends to only occur in people with a weakened immune system. This can be because of a long-term condition, such as HIV or AIDS, or taking certain medication, such as corticosteroids or chemotherapy. Alcoholism, diabetes and some kidney conditions can also put people at a higher risk.

Health conditions

A number of health conditions can sometimes cause a bursa to become inflamed. These include:

gout and pseudogout – a condition caused by a build-up of uric acid in the blood
rheumatoid arthritis – where the immune system attacks the linings of the joints
scleroderma – a condition that causes hardening of the skin
ankylosing spondylitis – a type of long-term arthritis that affects parts of the spine
systemic lupus erythematosus – a poorly understood condition that affects many of the body's tissues and organs
being overweight can also cause bursitis

Treating bursitis

Most cases of bursitis can be treated at home. Resting the affected area, using an ice pack (a frozen bag of vegetables wrapped in a tea towel works well) to reduce inflammation, and taking painkillers such as aspirin, paracetamol and ibuprofen will help relieve your symptoms and speed up your recovery.

The pain usually improves within a few weeks, but the swelling may take longer to completely disappear.

See your GP if your symptoms do not improve after two weeks.

Most cases of bursitis can be treated at home with self-care techniques and over-the-counter painkillers.

The pain usually improves within a few weeks, but the swelling may take longer to completely disappear.

Exactly how long it takes to recover may depend on where the bursitis is and whether it is caused by an infection (septic bursitis).

Self-care

There are a number of things you can do yourself to reduce the swelling in the affected joint. Rest the joint until your symptoms improve and avoid strenuous activities that are likely to cause additional pain, such as running.

Wearing padding may help protect the joint from further injury. For example, knee pads may help if you have bursitis in your knee joints.

Ice packs are also a good way of reducing inflammation and pain. Wrap an ice pack (or a bag of frozen vegetables) in a towel and apply it to the affected area for 10-20 minutes. Repeat this every few hours.

While sleeping, avoid lying on the side that has bursitis. If possible, raising the body part above the level of your heart may help reduce the inflammation. For example, you can prop your foot up on a pillow to raise your ankle.

If your knees, ankles or hips are affected, try to avoid long periods of standing up. Standing on a soft surface can help, as can placing a pillow between your knees when lying on your side. Being overweight can also cause bursitis, so losing weight may help.

Painkillers such as aspirin, paracetamol or ibuprofen can help to relieve the pain. Ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen or diclofenac, can also be used to help reduce swelling.

Always read the patient information leaflet that comes with the medicine to check that it is suitable for you and that you are taking the correct dose.

Aspiration

If the swelling caused by bursitis is particularly severe, you may want to consider having the fluid drained out. This procedure, known as aspiration, can relieve the pain and improve the range of movement in your joint.

During aspiration, a needle is used to draw out the fluid before the area is covered with a dressing. You'll need to avoid strenuous activity for about two days afterwards.

Corticosteroids

If your bursitis symptoms are severe or they do not respond to treatment, corticosteroid injections are another possible treatment option. Corticosteroids contain steroids, a type of hormone, and can be used to reduce inflammation.

Your GP can inject corticosteroids directly into the affected area. Possible side effects include the surrounding tissue wasting away and discolouration of the skin around the injection site.

You will not be able to have a corticosteroid injection if you have septic bursitis, and cannot have more than three corticosteroid injections a year in the same area.

Antibiotics

Your GP will prescribe antibiotics if tests confirm that you have septic bursitis. These may include:

These will usually be taken as tablets or capsules two or four times a day for seven days. After seven days, your GP should check how well you're responding to the antibiotics. If you still have signs of infection, you may need to take antibiotics for another seven days.

If you're prescribed antibiotics, it's important that you finish the entire course, even if your symptoms improve. This will help to prevent the infection returning.

Referral

If your symptoms do not improve with treatment after a couple of months, your GP may refer you to a specialist. This may be:

a rheumatologist – a specialist in conditions that affect the bones, muscles and joints
an orthopaedic surgeon – a specialist in the surgical treatment of conditions that affect the bones, muscles and joints

You may also be referred if you have infected bursitis that does not get better or reoccurs.

Surgery

In some cases, surgery may be recommended to remove the affected bursa, particularly where septic bursitis does not respond to antibiotics.

Surgery either involves removing the bursa completely, or making an incision in your skin and draining the fluid out of the bursa (incision and drainage).

Preventing bursitis

Taking precautions, such as wearing knee pads when kneeling and warming up properly before exercise, may help reduce your risk of getting bursitis.

There are a number of commonsense precautions you can take to prevent getting bursitis.

Protect your joints

If your job involves a lot of kneeling, such as carpet fitting, wearing a pair of knee pads will help protect your knees.

If you run or walk regularly, make sure your walking or running shoes fit properly.

You should go to a specialist running shop if you are buying running shoes for the first time. A trained member of staff will be able to carry out a number of tests, including a gait analysis, and give you advice about the type of shoes that are best for you.

If you continue having problems with your shoes, a podiatrist (a foot specialist) will be able to provide a more expert opinion and look at your overall lower limb biomechanics.

Find a podiatrist in your area.

Regular breaks

Take regular breaks while carrying out tasks that involve repetitive movements. This will help avoid placing excess strain on one particular area of your body.

You can also vary your patterns of physical activity by carrying out different tasks or exercises that do not all involve using the same part of your body.

Warm up before exercising

Make sure you warm up for at least six minutes before exercising. Do some light aerobic exercise, such as walking or easy jogging, before starting to exercise more vigorously.

Strengthen your muscles

If one of your joints has previously been affected by bursitis, strengthening the muscles around it will provide protection from further injury. However, only try to strengthen the muscles after your bursitis symptoms have cleared up.

Read more about strength and flexibility training.