Bursitis

Definition

Inflammation of a synovial lined bursa. It is aseptic from friction, trauma or crystals, or septic from direct inoculation.

Aetiology

  • Repetitive pressure from kneeling or leaning on the elbow
  • Direct trauma with haemorrhage into the bursa
  • Gout, pseudogout and rheumatoid arthritis
  • Septic bursitis follows a skin breach, mostly from Staphylococcus aureus
  • Diabetes, alcohol excess and immunosuppression raise septic risk

Anatomy

  • Olecranon and prepatellar bursae are superficial and prone to infection
  • Trochanteric bursa lies deep to gluteus maximus and the iliotibial band
  • Pes anserinus bursa lies deep to the sartorius, gracilis and semitendinosus tendons

Clinical Features

  • Olecranon and prepatellar bursitis present as fluctuant swelling with preserved joint motion
  • Warmth, erythema, cellulitis and fever suggest septic bursitis
  • Trochanteric pain is lateral, worse lying on that side and on stairs
  • Most trochanteric pain arises from gluteal tendinopathy, see tendinopathy
  • Pes anserine pain is anteromedial, below the medial joint line
  • Pes anserine bursitis often accompanies knee osteoarthritis and obesity

Investigations

  • Aspiration for Gram stain, culture and crystals in superficial bursitis
  • Ultrasound confirms fluid and guides aspiration
  • MRI in lateral hip pain shows gluteal tendinopathy or tears
  • Radiographs exclude an olecranon spur, fracture or foreign body

Differential Diagnosis

Management

  • Activity change and padding. First line for aseptic superficial bursitis
  • Aspiration and compression. Large aseptic effusions, with frequent recurrence
  • Oral antibiotics. Antistaphylococcal cover for mild septic bursitis
  • Intravenous antibiotics and drainage. Systemic sepsis or failed oral therapy
  • Bursectomy. Recurrent or refractory bursitis, see olecranon and prepatellar bursitis
  • Education and exercise. Better than corticosteroid injection at 52 weeks in gluteal tendinopathy (LEAP trial)
  • Corticosteroid injection. Short term relief of trochanteric and pes anserine pain

Complications

  • Wound breakdown and chronic sinus after olecranon bursectomy
  • Skin atrophy after superficial corticosteroid injection

References

  1. Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis. Diagnosis and management. J Am Acad Orthop Surg. 2011, 19(6), 359-67. PubMed
  2. Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy. Prospective, single blinded, randomised clinical trial. BMJ. 2018, 361, k1662. PubMed
  3. Lormeau C, Cormier G, Sigaux J, Arvieux C, Semerano L. Management of septic bursitis. Joint Bone Spine. 2019, 86(5), 583-588. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.