From the HSS Manual of Rheumatology and Outpatient Orthopedic Disorders
- ANATOMIC CONSIDERATIONS
- DIAGNOSTIC INVESTIGATIONS
- PHYSICAL EXAMINATION
- ANATOMIC CONSIDERATIONS
A bursa is a closed sac containing a small amount of synovial fluid and lined with a cellular membrane similar to synovium. Bursae are present in areas where tendons and muscles move over bony prominences; they facilitate such motion. Approximately 160 formed bursae are present in the body, and others may form in response to irritative stimuli. Descriptions of the clinically important bursae follow.
- The subacromial bursa lies between the acromion and the rotator cuff.
- The subdeltoid bursa lies between the deltoid muscle and the rotator cuff.
- The subcoracoid bursa lies at the attachment of the biceps, coracobrachialis, and pectoralis minor tendons to the coracoid process.
- The olecranon bursa lies over the olecranon process.
- The radiohumeral bursa lies between the common wrist extensor tendon and the lateral epicondyle.
- The iliopsoas bursa may communicate with the hip joint and lies between the hip capsule and the psoas musculotendinous unit.
- The trochanteric bursa surrounds the gluteal insertions into the greater trochanter.
- The ischiogluteal bursa separates the gluteus maximus from the ischial tuberosity.
- The prepatellar bursa lies between the skin and the patellar tendon.
- The infrapatellar bursa lies deep to the insertion of the patellar ligament.
- The popliteal bursae are numerous. The largest lies between the semimembranous muscle and the medial head of the gastrocnemius muscle.
- The pes anserine bursa lies between the medial collateral ligament and the sartorius, gracilis, and semitendinosus tendons
- The Achilles bursa separates the Achilles tendon insertion from the posterior aspect of the calcaneus.
- The subcalcaneal bursa is located at the insertion of the plantar fascia into the medial tuberosity of the calcaneus.
- Direct trauma to a bursal area may lead to an inflammatory response in the bursa with its attendant hyperemia and the exudation of fluid and leukocytes into the bursal sac. Bursal fluid can be clear, hemorrhagic, or xanthochromic.
- Chronic overuse or irritation of a bursal area.
- A systemic disorder, such as rheumatoid arthritis or gout. Here the bursal fluid can by cloudy or purulent, depending upon the level of inflammation.
- Septic bursitis may occur secondary to puncture wounds from trauma or an overlying rash such as psoriasis, a surrounding cellulitis, or after a local therapeutic injection. The organisms most frequently responsible are staphylococci (S. aureus, S. epidermidis) and streptococci.
- DIAGNOSTIC INVESTIGATIONS
- Localized pain is the presenting complaint, with radiation into the involved limb as an occasional feature.
- Swelling is common in olecranon bursitis but is usually not seen in subdeltoid bursitis.
- Erythema may be present and does not necessarily indicate sepsis.
- Tenderness is always present.
- Pain is usually elicited when the patient is asked to execute a maneuver that stresses the involved motor unit; for example, abduction of the hip against gravity will cause pain in trochanteric bursitis.
- Radiographs may, on occasion, demonstrate deposits of calcium in the region of the bursae. Calcific bursitis and calcific tendinitis may be indistinguishable, both clinically and radiographically.
- The region should be immobilized for 7 to 10 days.
- The patient should be told to discontinue activities that aggravate the symptoms for 1 to 2 weeks. An ergonomic assessment of the office or home work areas can be helpful in defining those activities that lead to irritative inflammatory bursal reactions.
- Ice compresses to the acutely inflamed area reduce swelling and provide relief from pain.
- Anti-inflammatory medications
- For mild to moderate symptoms, 600 mg of ibuprofen oral three times daily with food or other NSAIDs are helpful. .
- For severe symptoms, 25 mg of indomethacin PO four times daily with food. This treatment should not be continued for more than 5 to 7 days.
- Swollen subcutaneous bursae, such as the olecranon bursa, should be aspirated. Reaccumulation is common, and it is not unusual for two or three aspirations to be required to resolve the problem. The fluid should be cultured and a crystalline evaluation performed. Incision of the bursa may lead to prolonged drainage or infection but is rarely indicated.
- Injection of the offending bursa with 3 mL of 1% lidocaine mixed with 40 mg of methylprednisolone acetate (Depo-Medrol) is usually successful in relieving symptoms.
- Surgery to excise a bursa is rarely necessary. However, if the procedures outlined in A through E have been repeatedly unsuccessful and the disability is significant, surgery may provide relief.
- If infection is suspected (i.e., red, warm bursa yielding cloudy or purulent fluid associated with a cellulitis and/or fever) the bursa must be aspirated and the fluid smeared for direct Gram’s stain and sent for microbiologic culture. Pending results, patients with mild symptoms may be treated as outpatients with 500 mg of dicloxacillin or cefalexin orally four times daily. Patients who demonstrate no improvement or worsening on oral antibiotics with bursal aspirations, have more severe infections or who are markedly symptomatic should be hospitalized and treated with nafcillin or cefalexin IV. In chronic cases refractory to antibiotics, bursectomy may be indicated.
Tendinitis is a general term used to describe any inflammation associated with a tendon. The inflammation may occur within a substance of the tendon (intratendinous lesion) or be associated with the tenosynovial sheath (tenosynovitis). Because bursae are often located near tendons, the terms tendinitis and bursitis are often used interchangeably to represent the same affliction (see preceding discussion of bursitis). Together, these entities are the most common causes of soft-tissue pain.
- Intratendinous lesions occur primarily later in life as the vascularity of the tendon diminishes. They are usually associated with repetitive motion and are felt to represent microtrauma or limited macrotrauma short of rupture within the substance of the tendon. Local signs and symptoms of inflammation are caused by the reparative process of vascular infiltration with acute and chronic cellular responses. During the reparative process, calcium salts, which are visible on radiographs, may be deposited in degenerated portions of the tendon—hence the term calcific tendinitis. Tennis elbow, calcific tendinitis in the supraspinatus, and trochanteric tendinitis are examples of intra-tendinous lesions.
- Acute or chronic para-tendinous inflammation or tenosynovitis may have several etiologies.
- Repetitive motion with injury is by far the most common etiology. Synovial tendon sheaths are located in areas where tendons pass over bony surfaces and where large tendon excursions are found, most commonly above the wrist and ankle. Repetitive motion causes inflammation with edema and a decrease in the fine tolerances already present in these gliding areas. The result is decreased excursion and painful motion of the affected tendon, often with signs of mechanical blocking, such as may be seen with de Quervain’s disease and trigger finger.
- These paratendinous inflammations may also be triggered by direct or microtraumatic intra-tendinous injuries and result from the reparative process initiated in the tenosynovium.
- Systemic inflammation disorders such as RA may be associated with prominent tenosynovitis of the hands and feet.
- Acute tenosynovitis may also be of septic origin. Most commonly, this disorder involves a direct wound contaminating the sheath. Alternatively, it may result from a generalized sepsis, especially in a compromised host, and may be multifocal. Neisserial organisms such as gonorrhea typically can cause this type of inflammation. Because vascular supply is poor, infection due to non-gonococcal organisms is not well controlled with antibiotics alone, and surgical drainage is usually necessary.
- PHYSICAL EXAMINATION
- The classic sign of inflammation within the tendon or tendon sheath is pain on motion, especially with passive stretch or contraction of the affected motor tendon unit against resistance.
- Local swelling, warmth, and tenderness are usually present. Tenderness may be palpated along the course of the tendon. On deep structures, such as the supraspinatus or gluteus medius tendons, deep-point tenderness in a specific and reproducible location may be elicited.
- Erythema may or may not be present, depending on the depth of the structure and the acuteness of the process. Because most tendons cross joints, tendinitis must be distinguished from acute inflammatory or septic arthritis. In the latter case, range of motion will be more severely restricted. Systemic signs may be present, and capsular tenderness should be distinguished from tenderness directly over the tendon. In doubtful cases, diagnostic arthrocentesis will resolve the matter.
- The treatment of tendinitis is similar to that of bursitis.
- Immobilization is the most important therapy. Methods are as follows:
- A splint or cast for the affected region in the distal upper and lower extremities.
- A sling for lesions of the proximal upper extremity.
- Crutches for lesions of the proximal lower extremity.
- Gentle physical therapy within the limits of pain should be started as the inflammation resolves to avoid permanent stiffness.
- Local heat is helpful in relieving symptoms and in alleviating painful muscle spasm associated with tendinitis. Hot packs, warm soaks, skin counterirritants (e.g., balms, ultrasound), or hot wax treatments are equally effective and should be utilized.
- Anti-inflammatory medications
- Nonsteroidal anti-inflammatory medications in appropriate doses are used for acute inflammation.
- Corticosteroids, given systemically or locally as injections with a local anesthetic, can also be beneficial in certain cases. The injected area should be cooled with ice for 24 hours after injection, and adequate analgesics should be prescribed to counteract the pain experienced when the local anesthetic wears off. The use of a long-acting local anesthetic such as bupivacaine can minimize the pain associated with corticosteroid injection. A suspension of 20 to 40 mg of methylprednisolone acetate is the most frequently used preparation. No more than three weekly injections should be administered. Steroid preparations are contraindicated in the presence of infection. At times, ultrasound-guided steroid injections can be quite helpful in cases previously unresponsive to “blind” injections.
- Surgery is the treatment of choice when non-operative therapy has failed. It involves repair of a degenerative tendon, as in tennis elbow; release of fibro-osseous tunnels, as in de Quervain’s disease; and tenosynovectomy for chronic wrist tenosynovitis, a common manifestation of rheumatoid arthritis.
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