Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
nonseptic bursitis
conservative management and analgesia
Conservative management involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen. In patients with olecranon bursitis there is a risk of recurrence. Because treatments like aspiration and aspiration with steroid injection can cause complications, compression bandaging and a short course of NSAIDs may offer the most appropriate balance of safety and efficacy.[19]Kim JY, Chung SW, Kim JH, et al. A randomized trial among compression plus nonsteroidal antiinflammatory drugs, aspiration, and aspiration with steroid injection for nonseptic olecranon bursitis. Clin Orthop Relat Res. 2016 Mar;474(3):776-83. http://link.springer.com/article/10.1007/s11999-015-4579-0/fulltext.html http://www.ncbi.nlm.nih.gov/pubmed/26463567?tool=bestpractice.com
Primary options
acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Secondary options
diclofenac topical: apply to the affected area(s) up to four times daily when required
Tertiary options
ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
corticosteroid injection
Corticosteroid injection is reserved for patients who have not settled with conservative management. This is a high-risk procedure in retrocalcaneal bursitis due to the risk of tendon rupture. In 36 women with trochanteric bursitis, an excellent response was reported in two-thirds and improvement was reported in the remaining third.[12]Ege Rasmussen KJ, Fano N. Trochanteric bursitis: treatment by corticosteroid injection. Scand J Rheumatol. 1985;14(4):417-20. http://www.ncbi.nlm.nih.gov/pubmed/3909381?tool=bestpractice.com
Primary options
methylprednisolone acetate: 40 mg injected into bursa as a single dose every 1-5 weeks when required
surgery
Surgery to remove the affected bursa is reserved for those cases refractory to conservative management. In particular, surgery is rarely recommended for isolated trochanteric bursitis and conservative treatment should be preferred.[28]Harper KD, Park KJ, Incavo SJ. Management of hip abductor tears and recalcitrant trochanteric bursitis in native hips. J Am Acad Orthop Surg. 2023 Oct 1;31(19):e769-77.
http://www.ncbi.nlm.nih.gov/pubmed/37647539?tool=bestpractice.com
This may be undertaken in combination with another procedure such as subacromial decompression or resection of Haglund deformity. This may be an open procedure or an endoscopic procedure. [Figure caption and citation for the preceding image starts]: Intraoperative view of an olecranon bursectomyFrom the personal collection of Nicola Maffulli, MD, MS, PhD, FRCS(Orth); used with permission [Citation ends].
septic bursitis
antibiotic therapy and aspiration of the bursa
Aspiration of the bursa provides fluid for culture to direct antimicrobial therapy and reduces the bacterial load. Repeat aspiration may be required.
Initial antimicrobial therapy should cover staphylococci and streptococci.
Cefazolin or penicillinase-resistant penicillin, such as oxacillin, is appropriate for the initial management in most patients. Gram staining and culture from bursal fluid aspirate will direct specific antibiotic therapy.[17]Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005 Dec;19(4):991-1005. http://www.ncbi.nlm.nih.gov/pubmed/16297744?tool=bestpractice.com
Duration of antibiotics is patient and region dependent and can be from 1 to 4 weeks.
Oral antibiotics are usually sufficient for a systemically well patient. If patient is systemically unwell, immunosuppressed, or requiring surgery for drainage, intravenous therapy would be recommended initially. If patient is allergic to penicillin, erythromycin and clarithromycin are oral alternatives with a similar spectrum of activity, although some bacterial species may be resistant. In the case of resistance, inpatient treatment with intravenous vancomycin is recommended. Vancomycin is the preferred antibiotic for confirmed MRSA septic bursitis.
Primary options
dicloxacillin: 125-250 mg orally every 6 hours
OR
cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours
OR
oxacillin: 500-1000 mg intravenously/intramuscularly every 6-8 hours
Secondary options
clarithromycin: 500 mg orally every 12 hours
OR
erythromycin lactobionate: 500 mg intravenously every 12 hours
Tertiary options
vancomycin: 1 g intravenously every 12 hours
More vancomycinAdjust dose according to serum vancomycin level.
conservative management and analgesia
Treatment recommended for ALL patients in selected patient group
Supportive management with activity modification and analgesia is offered alongside antibiotic therapy and following aspiration. This involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen.
Primary options
acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Secondary options
diclofenac topical: apply to the affected area(s) up to four times daily when required
Tertiary options
ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
surgical debridement and lavage
May be required if needle aspiration has not adequately drained the bursa, if an abscess is present, or if a sinus has formed. The aim is to drain the bursa and reduce the bacterial load.
antibiotic therapy
Treatment recommended for ALL patients in selected patient group
Initial antimicrobial therapy should cover staphylococci and streptococci.
Cefazolin or penicillinase-resistant penicillin, such as oxacillin, is appropriate for the initial management in most patients. Gram staining and culture from bursal fluid aspirate will direct specific antibiotic therapy.[17]Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005 Dec;19(4):991-1005. http://www.ncbi.nlm.nih.gov/pubmed/16297744?tool=bestpractice.com
Duration of antibiotics is patient and region dependent and can be from 1 to 4 weeks.
Oral antibiotics are usually sufficient for a systemically well patient. If patient is systemically unwell, immunosuppressed, or requiring surgery for drainage, intravenous therapy would be recommended initially. If patient is allergic to penicillin, erythromycin and clarithromycin are oral alternatives with a similar spectrum of activity, although some bacterial species may be resistant. In the case of resistance, inpatient treatment with intravenous vancomycin is recommended. Vancomycin is the preferred antibiotic for confirmed MRSA septic bursitis.
Primary options
dicloxacillin: 125-250 mg orally every 6 hours
OR
cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours
OR
oxacillin: 500-1000 mg intravenously/intramuscularly every 6-8 hours
Secondary options
clarithromycin: 500 mg orally every 12 hours
OR
erythromycin lactobionate: 500 mg intravenously every 12 hours
Tertiary options
vancomycin: 1 g intravenously every 12 hours
More vancomycinAdjust dose according to serum vancomycin level.
conservative management and analgesia
Treatment recommended for ALL patients in selected patient group
Conservative management involves avoiding activities that worsen symptoms and resting the affected area. Ice can be used to reduce swelling in the first 24 hours by topical application every few hours. Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. Gentle mobilization exercise is important to maintain range of movement in a joint, particularly in the shoulder.
Simple analgesia such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be given for pain relief. These agents can also be used in combination.
Topical NSAIDs may be used in preference to systemic NSAIDs if acetaminophen is insufficient. They may also be used in conjunction with acetaminophen.
Primary options
acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
Secondary options
diclofenac topical: apply to the affected area(s) up to four times daily when required
Tertiary options
ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
diclofenac potassium: 50 mg orally (immediate-release) two to three times daily when required, maximum 150 mg/day
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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