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What is Bursitis?
Bursitis is a disorder that affects a bursa, a small, fluid-filled sac located beneath the skin, typically near a joint, that acts as a cushion between tendons, muscles, and bones, allowing them to glide smoothly over one another during movement. There are more than 150 bursae distributed throughout the human body, each one strategically placed at points where friction between moving structures would otherwise occur.
The main symptoms of bursitis are:
- pain in the affected area;
- swelling;
- irritation and tenderness of the overlying tissue.
Bursitis can technically occur in any bursa in the body, but it most commonly affects the joints that are subjected to frequent and repetitive movement, such as:
- the shoulders;
- the elbows;
- the knees (a form so classically associated with kneeling that it is often nicknamed “housemaid’s knee”);
- the hips.
Other areas can also be affected, including:
- the ankles;
- the feet;
- the Achilles tendon region (the large tendon connecting the calf muscle to the heel bone), where a specific bursa can become inflamed and cause heel pain.
Treatment usually involves resting the affected joint and protecting it from further strain or trauma. In most cases, pain resolves within a few weeks of appropriate treatment, but recurrent episodes of bursitis are, unfortunately, far from uncommon, particularly when the underlying trigger, such as a repetitive occupational movement, is not modified.
Causes
Bursitis can develop for three main reasons:
- trauma, meaning physical injury or repetitive mechanical stress;
- infection, when bacteria enter the bursa;
- as a consequence of a pre-existing health condition, such as an underlying inflammatory or metabolic disease.
Trauma
Following an injury, the internal tissue lining of a bursa (the small fluid-filled sac surrounding a joint) can become irritated and inflamed, a process that underlies the characteristic swelling seen in bursitis.
In most cases, the injury results not from a single traumatic event but from repeated stress over time, when nearby joints, muscles, and tendons are subjected to overuse. Repetitive movements are, by far, the most typical risk factors for this type of injury. Some common examples include:
- for the shoulder: repeatedly raising the arm or reaching for objects placed at height;
- repeatedly bending and straightening the elbow;
- repetitive knee movements or frequent kneeling (knee bursitis is commonly known as “housemaid’s knee” precisely for this reason);
- walking excessively, especially in unsuitable footwear, or practicing activities such as ice skating that place strain on the ankle;
- for the hips: running, particularly on hard or uneven surfaces;
- resting the elbows on hard surfaces for prolonged periods, or kneeling directly on hard flooring without protection.
A bursa can also become damaged following a sudden impact, such as bumping the elbow against a hard surface or falling heavily onto the knees.
Infection
Bursae located close to the surface of the skin, such as those near the elbow, can become infected when bacteria penetrate through a nearby wound, cut, or abrasion. Bursitis caused by infection is referred to as septic bursitis.
The immune system, the body’s natural defense system against injury and disease, normally prevents this type of infection from taking hold. As a result, septic bursitis tends to occur predominantly in individuals whose immune systems are compromised or weakened. The immune system can be weakened by chronic conditions such as:
- HIV infection or AIDS;
- the use of certain medications, such as corticosteroids or chemotherapy drugs, both of which suppress normal immune function.
Additionally, alcoholism, diabetes, and certain chronic kidney diseases also significantly increase the risk of developing an infection within a bursa.
Underlying Health Conditions
Several underlying health conditions can directly cause inflammation of a bursa, even in the absence of any specific injury or infection. These include:
- Gout and pseudogout, conditions caused by the accumulation of uric acid crystals (or calcium pyrophosphate crystals, in pseudogout) within the joints and surrounding tissues;
- Rheumatoid arthritis, an autoimmune condition in which the immune system mistakenly attacks the lining of the joints;
- Scleroderma, a disease that causes progressive hardening and thickening of the skin and connective tissue;
- Ankylosing spondylitis, a form of chronic inflammatory arthritis that primarily affects the spine and sacroiliac joints;
- Systemic lupus erythematosus, a complex and still incompletely understood autoimmune condition that can affect a wide range of tissues and organs throughout the body.
Risk Factors
Several factors are known to increase an individual’s likelihood of developing bursitis:
- Age: Bursitis occurs more frequently in middle-aged and older adults, likely due to cumulative wear and tear on the joints over time, along with age-related changes in tendon and bursa tissue.
- Being overweight: Excess body weight places additional mechanical stress on weight-bearing joints, particularly the hips and knees, increasing the risk of bursitis in these areas.
- Occupation or hobbies: Individuals whose work or leisure activities involve repetitive movements or sustained pressure on a particular bursa, such as carpet layers, gardeners, plumbers, musicians, or athletes, face a substantially higher risk of developing bursitis over time.
Symptoms
The severity of bursitis depends largely on the extent of inflammation affecting the bursa, but the most common symptoms include:
- pain;
- inflammation;
- swelling;
- stiffness;
- redness;
- warmth of the affected area.
The pain associated with bursitis is typically described as dull and aching in character, and it is generally worsened by movement or by direct pressure on the affected area. It may become painful to bear weight on the affected limb, or, in the case of hip bursitis, it may become uncomfortable to lie down on the affected side, often disrupting sleep.
Septic Bursitis
This particular form of bursitis is caused by an underlying infection and can therefore present with additional symptoms beyond the typical local signs, including:
- an elevated body temperature (fever, generally defined as a temperature of 38°C/100.4°F or higher);
- chills;
- infection extending into the deeper layers of the skin, known as cellulitis;
- visible skin lesions or breaks in the skin overlying the infected bursa.
When to Call a Doctor
It is advisable to consult your doctor or a specialist if any of the following situations occur:
- the joint pain is disabling and/or has persisted for more than two weeks;
- the affected area shows
- significant swelling,
- redness,
- or pronounced bruising;
- the pain appears suddenly and is sharp or stabbing, particularly when performing physical exercise or placing strain on the affected joint;
- despite following the prescribed treatment, there is no improvement after two weeks;
- you develop a fever.
It is particularly important to seek medical attention promptly if symptoms of bursitis are accompanied by fever, since this combination is highly suggestive of an underlying infection (septic bursitis), which requires prompt antibiotic treatment to prevent the infection from spreading further.
Diagnosis
The diagnostic process for bursitis typically begins with a thorough clinical evaluation. The physician examines the affected area, looking for characteristic signs such as swelling, localized warmth, redness, and any limitation in the joint’s normal range of motion. Taking a detailed clinical history is fundamental at this stage, as it helps identify recent trauma, repetitive occupational or sporting activities, and any underlying systemic diseases that might be contributing to the condition.
Imaging Studies
Although the diagnosis of bursitis is often made on clinical grounds alone, current medical guidelines recommend the use of imaging studies to support the diagnosis in cases that are unclear, atypical, or persistent despite initial treatment:
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Musculoskeletal ultrasound: This represents the first-line imaging test for suspected bursitis, thanks to its ability to visualize, in real time, thickening of the bursa walls and any accumulation of fluid within the bursa itself. Ultrasound is also relatively inexpensive, widely available, and does not involve any radiation exposure, making it particularly suitable for this purpose.
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Magnetic Resonance Imaging (MRI): This more detailed imaging technique is used specifically to evaluate deep bursitis, such as that affecting the iliopsoas muscle or the deep structures of the hip, or to rule out associated injuries involving nearby tendons or soft tissues that might not be well visualized on ultrasound.
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X-ray (radiography): While a standard X-ray cannot directly visualize an inflamed bursa, since bursae are composed of soft tissue and fluid rather than bone, this test remains useful for ruling out other potential causes of joint pain, such as fractures, bone abnormalities, or calcifications that might be contributing to or perpetuating the inflammatory process.
Fluid Analysis and Laboratory Tests
If the physician suspects that the bursitis may have a metabolic or infectious underlying cause, further diagnostic testing may be performed:
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Arthrocentesis (bursal aspiration): Using a thin needle, a sample of fluid is withdrawn directly from the affected bursa. Laboratory analysis of this fluid allows physicians to distinguish between simple inflammatory bursitis, microcrystalline bursitis (typically associated with gout), and septic bursitis (caused by a bacterial infection). This distinction is crucial, as it directly determines the most appropriate treatment approach.
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Blood tests: Tests such as the white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) help confirm the presence of an infectious or inflammatory process, while testing for specific autoantibodies can help identify an underlying autoimmune condition, such as rheumatoid arthritis or other systemic rheumatic diseases, as the root cause of recurrent bursitis.
Treatment
The modern therapeutic approach to bursitis aims to relieve pain, resolve inflammation, and restore full function to the affected joint, while simultaneously working to prevent future recurrences. The choice of treatment depends largely on the severity of symptoms and on the specific underlying cause that has been identified, whether traumatic, septic, or metabolic in nature.
Conservative Approach and Lifestyle Measures
In the initial stages, conservative management represents the gold standard of treatment for most cases of bursitis. The generally recommended protocol includes:
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Functional rest: Avoiding the specific activities that triggered the condition, while at the same time avoiding complete immobilization of the joint, which could otherwise lead to unwanted stiffness and loss of mobility.
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Cryotherapy (ice application): Applying ice packs to the affected area for approximately 15 to 20 minutes, several times per day, remains one of the most effective and readily accessible remedies for reducing swelling and local congestion, particularly in the acute phase.
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Compression and elevation: The use of elastic compression bandages, combined with positioning the affected limb above the level of the heart when possible, helps promote the reabsorption of excess fluid and reduces swelling.
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Weight management: In cases of bursitis affecting the lower limbs, particularly the hip and knee, achieving and maintaining a healthy body weight represents a determining factor for long-term recovery and for preventing future recurrences.
Pharmacological Therapy
Medications are commonly employed to manage the acute phase of bursitis:
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Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Medications such as ibuprofen, ketoprofen, diclofenac, or naproxen can be used either orally or in topical formulations, such as gels or medicated patches applied directly over the affected area.
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Analgesics: Paracetamol (acetaminophen) is recommended for pain control in individuals who cannot take NSAIDs, for example due to gastrointestinal conditions or kidney disease, although it provides a comparatively weaker anti-inflammatory effect. Aspirin may occasionally be prescribed, with appropriate caution, depending on the patient’s overall clinical picture and any contraindications.
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Antibiotics: These are absolutely essential in cases of confirmed septic bursitis. Treatment must be started promptly and completed strictly according to medical instructions in order to fully eliminate the responsible bacteria and prevent the infection from spreading to surrounding tissues or, in rare cases, into the bloodstream.
Specialized Treatments and Injections
When home remedies and initial conservative measures are not sufficient to resolve symptoms, physicians may turn to minimally invasive procedures:
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Drainage (aspiration): The removal of excess fluid from the bursa using a needle provides immediate relief by reducing internal pressure and pain. This procedure is frequently performed under ultrasound guidance, which allows for greater precision and reduces the risk of complications.
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Corticosteroid injections: A local injection of corticosteroid medication directly into the affected bursa provides a powerful and rapid anti-inflammatory effect. This treatment is generally reserved for cases that are resistant to more conservative measures, since repeated corticosteroid injections carry a risk of weakening the surrounding tendons if performed too frequently.
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Physical therapy: Once the acute phase has resolved, a personalized exercise program becomes essential for strengthening the supporting muscles around the affected joint, improving overall joint biomechanics, and preventing the bursitis from becoming a chronic, recurring problem.
Surgery
Surgical removal of the bursa, known as a bursectomy, is considered a last-resort treatment option. It is generally proposed only when chronic inflammation seriously compromises the patient’s quality of life, or in cases of persistent infection that fail to respond adequately to drainage combined with intensive antibiotic therapy. Fortunately, many of these surgical procedures can today be performed using minimally invasive or arthroscopic techniques, which generally allow for a faster recovery compared to traditional open surgery.
Prevention
There are several common-sense precautions that can be followed to help prevent the development of bursitis.
Protect Your Joints
If your work requires prolonged periods of kneeling, such as carpet fitting or flooring installation, wearing protective knee pads will help shield your knees from repetitive strain and direct pressure.
If you walk or run regularly, make sure you are wearing appropriate footwear, in the correct model and size for your foot type and activity. If you are purchasing running or walking shoes for the first time, consider buying them from a specialty sports shoe store, where experienced staff can often perform useful assessments, including a gait analysis, to recommend the most suitable type of shoe for your individual biomechanics.
If you continue to experience problems related to footwear, specialized healthcare professionals such as podiatrists can provide expert guidance and conduct a more comprehensive analysis of the overall biomechanics of your lower limbs.
Take Regular Breaks
Take regular breaks during activities that involve repetitive movements. This simple measure helps prevent excessive, cumulative strain on any single part of the body. It can also be helpful to vary your physical activities by incorporating different types of exercise that do not always involve the same joints and muscle groups repeatedly.
Warm Up Before Exercise
Perform a proper warm-up lasting at least six minutes before engaging in exercise. This should include some moderate aerobic activity, such as brisk walking or light jogging, before progressing to more vigorous forms of exercise. It is also worthwhile to educate yourself about proper pre-exercise warm-up techniques and appropriate post-activity stretching or cool-down routines to help the body recover.
Build Muscular Strength
If a particular joint has previously been affected by bursitis, strengthening the muscles surrounding that joint can help protect it against future injury. However, it is important to remember not to begin strengthening exercises until the bursitis has completely resolved, as exercising too soon during the active inflammatory phase can worsen symptoms and delay recovery.
Frequently Asked Questions
What is bursitis?
Bursitis is the inflammation of a bursa, a small, sac-like anatomical structure filled with fluid that helps reduce friction during the movement of a joint. The most common sites affected by bursitis include the elbow, hip, knee, and shoulder.
How is bursitis treated?
The cornerstone of bursitis treatment is a conservative approach that includes rest, ice application, elevation of the joint above the level of the heart, and compression bandaging. Anti-inflammatory medications can be particularly helpful for reducing pain. In cases of severe bursitis, more invasive treatments may be required, such as corticosteroid injections and/or aspiration of the excess fluid from the affected bursa.
How can I help reabsorb and reduce swelling from bursitis?
In most cases, following the RICE protocol (Rest, Ice, Compression, and Elevation of the joint) is sufficient to promote healing, although complete recovery can sometimes take several weeks. In more severe cases, when swelling is particularly pronounced, a doctor may consider aspirating the excess fluid directly from the bursa to provide faster relief.
Is it normal for the elbow to remain swollen after bursitis?
Persistent swelling of the elbow following an episode of bursitis can be considered normal, particularly if only a few weeks have passed since the initial inflammation. However, if swelling persists beyond several weeks or continues to worsen, it is advisable to consult a doctor for further evaluation.
What treatment options are available if anti-inflammatory medications do not work for bursitis?
If anti-inflammatory medications do not prove effective in relieving symptoms, it is important to consult your doctor again for further evaluation. Additional treatment approaches may need to be explored, such as physical therapy, corticosteroid injections, or, in rare and more severe cases, surgical intervention.
Sources and Bibliography
- NHS, licensed under the Open Government Licence (OGL)
- Mayo Clinic. Bursitis: Symptoms and causes
- American Academy of Orthopaedic Surgeons (AAOS). Bursitis
- Cleveland Clinic. Bursitis: Causes, Symptoms, and Treatment
- Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis: diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons. 2011;19(6):359-367.
- Williams CH, Sternard BT. Bursitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
