Bursitis is an acute, subacute or chronic inflammation of the synovial sac, which is accompanied by abundant formation and accumulation of exudate (inflammatory fluid) in its cavity. It is clinically manifested by an increase in body temperature, malaise, pain, swelling and redness in the area of the affected synovial sac, moderate restriction of movements in the joint. The basis of diagnosis is examination of the affected area, puncture and bacteriological examination of the punctate, MRI and radiography of the joint. Treatment includes rest of the affected limb, ice compresses, painkillers and anti-inflammatory drugs. Chronic bursitis is often an indication for surgical treatment.
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Bursitis is an acute, subacute or chronic inflammatory process in the synovial sac (bursa). The disease is accompanied by an increase in bursa due to the accumulation of exudate in it. The cause of development may be acute trauma, permanent mechanical irritation or salt deposition in some rheumatoid diseases. About 85% of all cases of this disease are observed in men. The first place in prevalence is occupied by ulnar bursitis.
Acute infected bursitis usually develops as a result of a small injury (small wound, hematoma, abrasion) or purulent inflammation (bedsore, osteomyelitis, carbuncle, furuncle, erysipelas). In the area of damage, pyogenic microbes multiply, which are then transferred through the lymphatic pathways to the area of the bag, infecting its contents.
It is also possible to transfer the infection through the blood or direct entry of microbes into the cavity of the bag with damage to soft tissues. Most often, direct infection occurs with cuts and abrasions in the elbow area (for example, as a result of a fall from a bicycle). The cause of the development of infected bursitis in this case is usually epidermal or Staphylococcus aureus.
The probability of bursitis in direct contact with microorganisms increases with a decrease in immunity, alcoholism, diabetes, taking steroids, some kidney diseases. In addition, the cause of bursitis may be some diseases (scleroderma, gout, rheumatoid arthritis). In this case, bursitis occurs due to the deposition of salts in the synovial sac.
Chronic bursitis occurs due to constant, prolonged mechanical irritation of the corresponding area. Usually its occurrence is due to the peculiarities of professional or sports activities. For example, miners often have bursitis of the elbow joint, housewives and housekeepers have bursitis of the knee joint, etc.
A synovial bag is a slit-like cavity lined with a shell and containing a small amount of synovial fluid. The bags are located near the protruding areas of the bones and perform a cushioning function, protecting soft tissues (muscles, tendons, skin and fascia) from excessive friction or pressure.
There are the following types of synovial bags: axillary (located under the muscles), subfascial (located under the fascia), subcutaneous (lying under the tendons) and subcutaneous (located on the convex surface of the joints, directly in the subcutaneous tissue).
In surgery, traumatology and orthopedics, there are several classifications of bursitis:
- Taking into account the localization (elbow, knee, shoulder joint, etc.) and the name of the affected bursa.
- Taking into account the clinical course: acute, subacute and chronic bursitis.
- Taking into account the pathogen: specific (bursitis in syphilis, tuberculosis, brucellosis, gonorrhea) and nonspecific bursitis.
- Taking into account the nature of the exudate: serous (plasma with an admixture of a small amount of shaped blood elements), purulent (microorganisms, destroyed cells, decayed leukocytes), hemorrhagic (fluid with a large number of red blood cells) and fibrinous (with a high content of fibrin) bursitis.
In addition, in clinical practice, aseptic (uninfected) and infected bursitis are often isolated.
With acute inflammation, a painful, limited, elastic swelling of a rounded shape is formed in the area of the bag. There is redness of the skin and a slight swelling of the soft tissues. The patient is concerned about pain in the affected area. Sometimes the patient complains of malaise and fever. Palpation determines the fluctuation confirming the presence of fluid. Movements in the joint are moderately limited.
With the further development of the inflammatory process, edema and hyperemia increase, significant hyperthermia is observed (up to 39-40 °C) and severe pain syndrome. In severe cases, purulent soft tissue damage with the development of phlegmon is possible. As a result of treatment, acute bursitis disappears. Sometimes recovery cannot be achieved, and acute bursitis turns into subacute, and then into a chronic form.
With chronic bursitis, a soft, limited swelling of a rounded shape is determined in the area of the bag. There is no redness, swelling of the surrounding tissues and soreness during palpation. Movements in the joint are preserved in full. With secondary chronic bursitis, a recurrent course is possible. In this case, isolated areas of destroyed tissues remain in the cavity of the bag, which, with a decrease in immunity or a small injury, can become a favorable ground for the re-development of the inflammatory process.
The diagnosis of bursitis is made on the basis of the clinical picture. To clarify the nature of the inflammatory fluid and determine the sensitivity of microorganisms to antibiotics, a puncture is performed. In the process of diagnosis, it is necessary to exclude specific infections (spirochetes, gonococci, etc.), therefore, if the specific nature of the disease is suspected, bacteriological studies and serological reactions are performed.
Differential diagnosis with arthritis is carried out on the basis of clinical signs: with bursitis, unlike arthritis, the volume of movements in the joint is slightly reduced or preserved. X-ray diagnostics and joint MRI are an auxiliary diagnostic method for superficial bursitis and are of greater practical importance in the recognition of deep bursitis, which are less accessible for direct clinical examination.
In acute aseptic lesions, the limbs are provided with rest, ice compresses, anti-inflammatory and painkillers are prescribed. In some cases, bursa puncture is performed to remove fluid and/or administer corticosteroids.
When an infection is attached, antibiotic therapy is performed, if necessary, repeated removal of the inflammatory fluid or drainage with washing of the bursa cavity with solutions of antibiotics and antiseptics is performed. In severe cases, surgical excision of the bursa is sometimes required. In the future, treatment is carried out as usual for purulent wounds, healing can take a long period of time.
Treatment of chronic aseptic form depends on the localization. In many cases, the most reliable way to get rid of bursitis forever is a surgical operation – excision of the bag. Removal of uninfected bursa is carried out as planned, in a clean operating room. The wound heals by primary tension within 10 days. Recurrences of bursitis when using this method of treatment are observed in 2-2.5% of patients. Purulent bursitis can be complicated by fistulas, osteomyelitis, arthritis or sepsis.
Bursitis of the elbow joint
As mentioned above, the most common type of bursitis is bursitis of the elbow joint, more precisely, the ulnar subcutaneous sac located in the area of the ulnar process. Acute ulnar bursitis develops as a result of injury, infection or metabolic disorders. The cause of the development of acute and chronic bursitis may be the peculiarities of work or sports load (except for miners, this disease sometimes affects people who have to constantly lean their elbows on the table while working, as well as wrestlers – due to pressure and friction of elbows on the carpet).
Initially, a small swelling occurs in the area of the ulnar process, which often goes unnoticed. With acute bursitis, the swelling increases, the skin above it turns red, movements in the joint become painful. Local temperature rise is possible. During palpation, an elastic fluctuating formation is determined. With the further development of the infection, weakness appears, symptoms of general intoxication.
Surgeons are engaged in the treatment of acute bursitis. Therapy includes standard methods used for all types of bursitis: rest, compresses, anti–inflammatory and painkillers, sometimes – punctures and the introduction of corticosteroids. With purulent bursitis, antibiotics are prescribed, fluid is removed through a small incision, followed by washing and drainage of the cavity. In advanced cases, surgical intervention is performed – an autopsy followed by drainage.
With chronic bursitis, the swelling also continues to increase, however, in this case, neither redness nor an increase in temperature is observed. The only unpleasant symptoms may be a feeling of awkwardness in the elbow area and pain when bending due to the tension of the bursa.
In the absence of treatment, bursa can reach significant sizes and significantly limit joint mobility. When performing any work, the patient is forced to take breaks due to pain during movements. The swelling can be both elastic and tense, and flabby, soft. Sometimes, during palpation, cartilage density seals and scar strands are determined.
Chronic aseptic bursitis is managed by orthopedic traumatologists. Punctures of the bag in this case are not shown, because after removal, the fluid usually accumulates again. Surgery is recommended. Surgical intervention is performed in a hospital setting. The bag is peeled off from the skin and bone, and then removed, the wound is drained, a tight bandage is applied to the joint area. The graduate is removed for 2 or 3 days, the stitches are usually removed 10 days after the operation.
It should be remembered that with ulnar bursitis, there is a fairly high risk of secondary infection. In addition, with long-standing chronic bursitis, scarring changes occur in and around the bag, which makes it difficult to perform surgery. Therefore, you need to see a doctor early, without waiting for complications.
Bursitis of the knee joint
Most often, the subcutaneous sac located on the anterior surface of the joint (the first place in prevalence) and the infrapatellar sac located under the kneecap and a large tendon are affected. Prepatellar bursitis is an inflammation of the subcutaneous sac located on the anterior surface of the knee. It ranks first in prevalence among knee joint bursitis.
The disease usually occurs after an injury (falling on the kneecap, bruising or impact) or after prolonged kneeling, usually due to professional activity (roofer’s knee, housewife’s knee). In addition, the cause of bursitis may be the deposition of salts in pseudopodagra, gouty arthritis or rheumatoid arthritis.
There is swelling, redness of the skin, unpleasant sensations in the knee area. The pain is usually less pronounced than with arthritis, the movements are slightly limited or preserved in full. There may be some stiffness when walking. When the fluid in the bursa cavity is infected, the pain increases, the volume of movements decreases, there is an increase in regional lymph nodes and an increase in body temperature. Treatment – as with other types of bursitis.
Infrapatellar bursitis develops as a result of inflammation of the infrapatellar bursa located under a large tendon, which, in turn, lies under the kneecap. Usually the cause of bursitis is a jump injury (jumper’s knee). Treatment includes rest of the affected limb, ice compresses, as well as taking painkillers and anti-inflammatory drugs.
Goose bursitis is an inflammation of the goose bursa located on the posterior surface of the knee joint. It develops more often in overweight women. It is accompanied by pain, which increases when climbing and descending stairs.
Conservative treatment is standard, performed by surgeons. With chronic aseptic bursitis of the goose sac, which is also called Becker’s cyst, surgical intervention is recommended – excision of the bursa. The operation is performed by traumatologists or orthopedists in a hospital setting. As in the case of ulnar bursitis, a rubber graduate is placed in the postoperative wound for 1-2 days. The stitches are removed on the tenth day.
Bursitis of the shoulder joint
Most often, there is inflammation of bags that are not associated with the cavity of the shoulder joint – subacromial, subcutaneous and subcutaneous acromial. There is pain, which increases with the rotation of the limb. The pain syndrome is especially pronounced with bursitis of the subcutaneous sac. The area of the shoulder joint increases slightly in volume, the contours of the muscles are smoothed. When the subcutaneous sac is affected, the deltoid muscle looks enlarged, in some cases there is swelling on the outer surface of the joint.
The iliac-scallop sac, deep and superficial sac of the large trochanter are most often affected. These types of bursitis are characterized by a severe course. Acute bursitis is accompanied by a significant increase in temperature and severe pain, which sharply increases with rotation, extension and removal of the hip. There is a forced position of the limb: the hip is withdrawn, bent and slightly turned outward. A painful swelling is detected above the inguinal ligament on the anterior-inner surface of the thigh.
In some cases, hip bursitis must be differentiated from purulent arthritis. Unlike arthritis, bursitis is characterized by the presence of local swelling, absence of pain with axial load on the limb, reduction and flexion of the hip.
Bursitis of the ankle joint
Most often, bursitis of the subcutaneous calcaneal sac, located between the Achilles tendon and the calcaneal tubercle, occurs in this area. The cause of the occurrence is an injury (for example, rubbing shoes) or the transfer of infection through lymphatic or blood vessels. Sometimes in cases of achillobursitis it is necessary to carry out differential diagnosis with the inflammatory process caused by traumatization of tissues by the heel spur.
Prognosis and prevention
The prognosis of bursitis is favorable. Miners and people of other professions associated with an increased risk of bursitis should, if possible, protect synovial bags from permanent injury (for example, using protective bandages). To prevent the development of acute bursitis, it is necessary to carefully treat wounds in the joints, properly and timely treat pustular diseases.
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- Pes Anserine Bursitis. Mohseni M, Mabrouk A, Graham C. 2022 Nov 23. link
- Anatomy, Skin Bursa. Mercadante JR, Marappa-Ganeshan R. 2022 Oct 8. link