Bursae • Progressive Sports Medicine
Bursitis
Everyone has bursae, and an enlarged one on a scan is often completely normal. The skill is working out whether your bursa is the problem, a reaction to a problem, or an innocent bystander, because each answer leads to a very different treatment.
Introduction
What is a bursa, and what is bursitis?
A bursa is a “potential space” which develops between two layers of tissue that move across each other that would otherwise create friction. Usually they are microscopically thin, but they can fill with fluid, either as a normal process to protect from friction, or due to problems such as inflammation or infection.
Everyone has bursae throughout their body. The knee has at least 6 and sometimes up to 13 bursae around it. Some bursae exist in everyone, like the one that protects the rotator cuff in the shoulder. Others can develop as a protective response to friction (like in the front of the foot) or as a response to infection or injury.
There are approximately 160 bursae in the body. Only a handful of them usually cause bursitis.
Bursitis is also commonly known as housemaid’s knee, student’s elbow and tailor’s bottom, to name a few, all named for the repetitive pressure that produced them.
Where it happens
Common sites of bursitis
The most common bursa sacs that cause bursitis are found in the knee, shoulder, elbow and hip. Less frequently, bursitis may also occur in the heel, wrist, buttocks, back and big toe.
Because bursae and tendons work side by side, deep bursitis rarely travels alone. It commonly coexists with tendon problems, which is why these pages are worth reading together:
Read this before your scan report worries you
An enlarged bursa is not automatically the answer
Firstly, there is no absolute consensus on “normal” bursa sizes. An enlarged bursa can be a completely painless and normal process to protect from friction. An example is that swimmers have large bursae in their shoulders to protect them from repetitive shoulder movements.
Seeing an enlarged bursa on a scan does not mean the cause of the pain has been found.
An enlarged bursa can mean:
A normal response to abnormal friction
An injury, a bone spur or weakness leading to the extra friction. Here the bursa is the messenger, and the friction is the message.
A response to direct trauma
Typically at the knee and elbow bursae, where the sac sits just under the skin over a bony point.
A pathological process
Such as infection or even gout. These change the treatment completely, and are the reason an accurate assessment matters.
This is why treatment aimed only at the bursa so often disappoints. In the shoulder and hip especially, the bursa is usually reacting to the mechanics and tendon health around it, so lasting relief comes from addressing that driver.
Causes
What brings bursitis on
Bursitis may result from one or more of the following events: trauma or injury to the point of a bone, including falling, bumping, or lying for an extended period on the area; repetitive friction from work or sport; direct pressure from kneeling or leaning; and underlying inflammatory or crystal conditions such as gout.
Diagnosis is clinical first: the history of the loading or trauma, and an examination that separates the bursa from the tendon, joint and bone beneath it. Point-of-care ultrasound confirms fluid within the bursa and, more usefully, assesses the surrounding tendons for the friction driving it. Where infection or gout is suspected, aspirating the bursa and analysing the fluid is the definitive test.
Don’t sit on this one
Infected (septic) bursitis
Superficial bursae at the elbow and knee sit directly under the skin, so bacteria entering through a cut, scrape or graze can infect them. Septic bursitis behaves differently from ordinary bursitis and is treated differently: with aspiration of the fluid and antibiotics.
Seek prompt medical assessment if a swollen bursa shows:
- Marked redness and heat over the swelling
- Severe tenderness, or rapidly increasing swelling
- Fever, chills, or feeling generally unwell
- A recent cut, graze or skin break over the area
This is not a wait-and-see situation, and it should not be treated with a corticosteroid injection until infection has been excluded.
Treatment
Treating bursitis properly
Superficial bursitis(elbow, kneecap), usually from direct trauma or pressure, settles with protection of the area, avoiding the pressure that caused it (kneeling pads, elbow protection), a compression bandage, ice for comfort in the first days, and simple analgesia. Aspiration is used when the swelling is tense or when fluid analysis is needed.
A note on cortisone at the elbow. For aseptic olecranon bursitis, corticosteroid injection has been shown to increase complications, including skin atrophy, without improving the outcome. It is therefore used sparingly and selectively, not as a routine first step.
Deep bursitis(shoulder, hip) is where the real work lies, because the bursa is usually reacting to the mechanics around it. The evidence here is strong and consistent with how we treat tendon problems generally: in gluteal tendinopathy with trochanteric bursitis, a programme of load management education plus exercise produced better global improvement and pain outcomes than a corticosteroid injection or a wait and see approach, both at 8 weeks and at 52 weeks. Cortisone bought early relief; exercise produced lasting change.
So the plan is to correct the driver: restoring rotator cuff or gluteal tendon capacity and control with a progressive programme, guided by our exercise physiology team, alongside activity and load modification. Where pain is genuinely blocking that rehabilitation, a corticosteroid injection delivered under ultrasound guidance can open a window to get started, and shockwave therapy is a useful option for stubborn trochanteric cases.
Surgery is rarely needed. In olecranon bursitis, non-surgical management has been shown to be significantly more effective and safer than surgery, with lower rates of complications, persistent drainage and infection. Bursectomy is reserved for the few cases that fail well-delivered conservative care.
The evidence
Key references
- Mellor R, et al. 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 (the LEAP trial). BMJ 2018;361:k1662. doi:10.1136/bmj.k1662
- Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg 2014;134:1517–1536. doi:10.1007/s00402-014-2088-3
- Lormeau C, et al. Management of septic bursitis. Joint Bone Spine 2019;86:583–588. doi:10.1016/j.jbspin.2018.10.006
Common questions
Bursitis FAQs
Not necessarily, and this is one of the most important things to understand about bursitis. There is no absolute consensus on normal bursa sizes, and an enlarged bursa can be a completely painless and normal process to protect against friction. Swimmers, for example, have large bursae in their shoulders to protect them from repetitive movement. Seeing an enlarged bursa on a scan does not mean the cause of the pain has been found.
It can mean one of several things: a normal response to abnormal friction (from an injury, a bone spur or weakness causing extra friction), a response to direct trauma (typically at the knee and elbow bursae), or a pathological process such as infection or gout. Working out which one applies to you is what determines the treatment.
When the bursa is infected. Septic bursitis usually involves a superficial bursa at the elbow or knee, and typically shows marked redness, heat, severe tenderness and rapid swelling, often with fever or feeling generally unwell, sometimes after a cut, scrape or graze over the area. This needs prompt medical assessment, because it is diagnosed by aspirating the bursa and treated with antibiotics rather than with rest and anti-inflammatories.
Sometimes, but far less often than people expect. For deep bursitis such as at the shoulder or hip, the bursa is usually reacting to something else, so exercise-based treatment aimed at the underlying problem outperforms injection in the longer term. For superficial bursitis at the elbow, the evidence shows corticosteroid injection increases complications such as skin atrophy without improving the outcome. When an injection is genuinely indicated, we deliver it under ultrasound guidance.
Very rarely. In olecranon (elbow) bursitis, the evidence is clear that non-surgical management is significantly more effective and safer than surgery, which carries higher rates of complications, persistent drainage and infection. Surgery is reserved for the small number of cases that fail properly delivered conservative care.
Told you have bursitis, but nothing has really changed?
Our Sport and Exercise Physicians in Leichhardt can work out whether the bursa is the problem or the symptom, exclude infection and other causes, and treat what is actually driving it.
This page provides general information only and is not a substitute for personalised medical advice. Please consult a qualified health practitioner for assessment of your individual circumstances.