You may have heard the word bursitis spoken by the elderly, but as physiotherapists we hear it quite often. Most likely to develop in older adults, bursitis results in pain, swelling, and tenderness around a joint.
As physiotherapists we specialize in helping to eliminate, or decrease a patient’s pain. We understand how pain can affect your day-to-day life, which is why we are dedicated to finding a unique solution for all our patients.
Wherever skin, muscles, or tendons need to slide over the bone is home to bursae. A bursa (singular) is a sac made of thin, slippery tissue. They could be compared to a blister as they are lubricated with a small amount of fluid inside their outer layer. A healthy bursa helps reduce friction created from the sliding parts, such as between tendon and bone.
Bursitis is the inflammation of a bursa. An inflamed bursa, or bursae, can cause the patient pain, swelling, and tenderness around a joint with bursitis. This pain can be mild and bothersome to acute and very problematic. Although it is more common in older adults, the younger population can be affected too.
Bursitis can be developed in many areas, but the focus of this article touch on knee, elbow, hip, and heel bursitis.
Bursitis diagnosis is based on patient history, symptoms, special clinical tests in the physiotherapist’s office and at times radiological procedures such as ultrasound imaging. Symptoms of bursitis are much like the ones that can occur with tumors, arthritis, certain fractures, tendinitis, and at times referred nerve pain. As such, careful observations must be made to arrive at an accurate diagnosis.
Physiotherapists use special movement tests and positions which can compress the bursa. When the bursa is compressed, the symptoms are reproduced allowing the physiotherapist to pinpoint the source. Each specific location of pain (elbow, knee, hip, heel) have special tests the physiotherapist performs to confirm bursitis.
Ultrasound imaging is a relatively accessible and inexpensive imaging procedure and can be useful to determine inflammation in a bursa such as the subacromial bursa in the shoulder and the retro achilles bursa. X-rays are taken to rule out arthritis and fractures. On occasion an MRI study will be ordered, but this expensive study and difficult to access test is not typically required for the diagnosis and treatment of bursitis.
Symptoms and patient history is usually a clear indicator of the problem. However, physiotherapists are challenged with determining the cause of the bursitis. In order to do so, a physician may need to aspirate the bursa.
Aspiration is a way of removing some of the bursa fluid for analysis. The physician inserts a very thin needle into the bursa to suction out some of the fluid.
Bursitis can be caused by trauma, inflammation from overuse or directly related to a disease process such as rheumatoid arthritis, and less commonly infection.
When trauma is the cause of bursitis, a direct blow or fall onto the knee, elbow, hip, or heel may result in damages to the bursa. With trauma, the blood vessels in the tissues that make up the bursa are damaged and torn causing bleeding into the bursa sac.
When this happens, blood filling the bursa sac will cause it to swell up like a balloon filled with water. The blood in the bursa causes an inflammatory reaction. This is much unlike our skin where simply a bruise would form.
When inflamed, the bursa becomes thickened and tender and remains that way even after the blood has been absorbed by the body. Bursitis refers to the thickening and swelling of the bursa.
Bursae can become irritated and inflamed in ways other than trauma. Prepatellar bursitis in the knee can be from repeated injury that has lead to irritation and thickening of the bursa over time.
For example, a person who works on their knees can repeatedly injure the prepatellar bursa. This injury over time will lead to the irritation and thickening of the bursa, thus resulting in bursitis. In the past this condition was referred to as “housemaid’s knee”, and it has also been frequently associated with trades such as carpet installers.
Bursitis caused by infection is usually from staph or strep infection. Bacteria enters the body close to the affected joint through means such as a cut or small opening in the skin.
Minor infections of the skin over the bursa can spread down into the bursal sac. When this occurs, instead of blood or inflammatory fluid filling the bursa, pus does. The area around the bursa then becomes hot, visibly red, and very tender. This condition requires antibiotic treatment and typically resolves very well.
It is believed that infectious bursitis cannot be caused by bacteria traveling to the joint through the bloodstream because there isn’t much blood supply to the bursa.
Conservative, nonsurgical care is almost always the treatment for bursitis. Initial treatments can include rest from pain provoking movements, activity/sport modification, and medications. Medications include anti-inflammatories for pain and swelling, or antibiotics for infections.
Physiotherapy treatment is very important in the treatment of bursitis. Modalities such as ice, ultrasound, interferential current and acupuncture can help reduce pain and inflammation. Biomechanics of the affected limb are evaluated to identify contributing influences such as postural problems and habits, muscle tightness, muscle weakness and footwear problems. Patient involvement is required as stretching, strengthening and movement retraining exercises are almost always prescribed to improve the function about the joint that has the painful bursitis. Sometimes, a change in shoe or additional arch support such as an orthotic may be required in the case of heel bursitis.
On occasion, a cortisone injection into the bursa is ordered by the doctor to “kick start” the improvement cycle, but this tends to be the exception rather than the rule. For the most part, very good results are seen with time and disciplined adherence to activity modifications, exercise prescriptions and physiotherapy treatments.
Patients who do not respond to nonoperative care may choose surgery to remove the bursa, or bursae. This process is referred to as bursectomy. With surgery there is always a risk of additional problems or complications. As such, it is not the first step in treatment but more of a last resort.
Depending on the location of the bursa other surgical techniques may be required. For example, the hip area may require a portion of the bone to be removed.
In the heel, an osteotomy of the bone may help change the patient’s alignment and remove pressure off the bursa. This process involves the removal of a tiny wedge-shaped piece of bone in the heel in order to rotate it just enough to eliminate pressure from the bone on the bursa.