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Arthritis & Bursitis

Bursitis simply put is the inflammation of a bursa. In the normal state, the bursa provides a slippery surface that has almost no friction.

A problem arises when a bursa becomes inflamed. The bursa loses its gliding capabilities, and becomes more and more irritated when it is moved.

When the condition called bursitis occurs, the slippery bursa sac becomes swollen and inflamed. The added bulk of the swollen bursa causes more friction within already confined spaces. Also, the smooth gliding bursa becomes gritty and rough. Movement of an inflamed bursa are painful and irritating.

Bursitis usually results from a repetitive movement or due to prolonged and excessive pressure. Patients who rest on their elbows for long periods or those who bend their elbows frequently and repetitively (for example, a custodian using a vacuum for hours at a time) can develop elbow bursitis, also called olecranon bursitis. Similarly in other parts of the body, repetitive use or frequent pressure can irritate a bursa and cause inflammation.

Other causes of bursitis include traumatic injuries and systemic inflammatory conditions. Following trauma, such as a car accident or fall, a patient may develop bursitis. Usually a contusion causes swelling within the bursa. The bursa, which had functioned normally up to that point, no begins to develop irritation with what were normal movements and activities.

This can lead to bursitis. Systemic inflammatory conditions, such as rheumatoid arthritis, may also lead to bursitis. These type of conditions predispose patients to developing inflammation of a bursa.

Bursitis is almost always diagnosed on physical examination. Findings consistent with bursitis include tenderness directly over the bursa and pain with movement of the muscles and tendons that cross the bursa.

Studies such as x-rays and MRIs are not usually needed to make the diagnosis of bursitis. While they are not needed for diagnosis of bursitis, x-rays are often performed to ensure there is no other problem, such as a fracture, that could be causing the symptoms of pain and swelling. X-rays can show evidence of swelling of the bursa, especially in the case of olecranon bursitis. MRIs are also good tests to pick up swelling, and will show evidence of bursitis. However, these tests are not needed to confirm the diagnosis; MRIs are usually only performed if there is a suspicion of another problem.

There is a small risk that an inflamed bursa can become infected. This is mostly a concern when the inflamed bursa is close to the skin, such is the case with olecranon bursitis. In situations such as trochanteric bursitis or shoulder bursitis, where the inflammation is deeper within the body, infection is extremely rare. Signs of infection include an open wound around the area of bursitis, redness of the skin, fevers, chills, and sweats. If there is a suspicion of infection, your doctor will obtain some of the fluid from the swollen bursa for microscopic analysis. Patients with infected bursitis will need antibiotic treatment, and may require surgical drainage of the bursa.

Many patients seek medical attention for shoulder pain, and a common diagnosis given is 'shoulder bursitis,' or 'shoulder tendonitis.' The doctor will then often state that identifying which of these diagnosis is the true cause of pain is not important because the treatment is the same. This is true. Shoulder bursitis and rotator cuff tendonitis are all ways of saying there is inflammation of a particular area within the shoulder joint that is causing a common set of symptoms. The best terminology for these symptoms is 'impingement syndrome.' Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons.

The shoulder is interesting in that several bones, muscles, and ligaments contribute to this complex joint.

Impingement syndrome, or shoulder bursitis, occurs when there is inflammation between the top of the humerus (arm bone) and the acromion (tip of the shoulder). Between these bones lies the tendons of the rotator cuff, and the bursa that protects these tendons. Normally, these tendons slide effortlessly within this space. In some people this space becomes too narrow for normal motion, and the tendons and bursa become inflamed.

Inflammation leads to thickening of the tendons and bursa, and contributes to the loss of space in this location. Eventually, this space becomes too narrow to accommodate the tendons and the bursa, and every time these structures move between the bones they are pinched--this is the impingement.

Impingement syndrome is a descriptive term of pinching of the tendons and bursa of the rotator cuff between bones. In many individuals with this problem, the shape of their bones is such that they have less space than most others. Therefore, small thickenings of the tendons or bursa can cause symptoms.

Often there is an initial injury that sets off the process of inflammation. Thereafter, the problem can be self-exacerbating. Once there is an initial injury, the tendons and bursa become inflamed. This inflammation causes a thickening of these structures. The thickening then takes up more space, and therefore the tendons and bursa become are pinched upon even more. This causes more inflammation, and more thickening of the tendons and bursa, and so on.

Pain with overhead activities (arm above head height)

  • Pain while sleeping at night
  • Pain over the outside of the shoulder/upper arm

Impingement syndrome and a rotator cuff tear are different problems, and although they are related, the treatment is different. Impingement syndrome is a problem of inflammation around the rotator cuff tendons. A rotator cuff tear is an actual tear within the tendons. The best signs that differentiate these problems area the strength of the rotator cuff muscles. Your orthopedic doctor will be able to specifically isolate these muscles to better determine if a rotator cuff tear is present. A MRI can also show the tendons of the rotator cuff and help determine if a tear is present. The first step of shoulder bursitis treatment is to decrease the inflammation. This is best done by avoiding the problems that cause inflammation. The best rule of thumb to follow: 'If it causes pain, don't do it!' This includes simple activities such as reaching high objects or reaching behind yourself.

Inflammation can also be treated with anti-inflammatory medications such as Motrin, Advil, Marcy, Celebrex, Vioxx (taken off the market), or one of many others. These all fall within the category of 'non-steroidal anti-inflammatory medications.'(NSAIDs). Taken by mouth, these medications help with the inflammation of the tendons and bursa, and also help treat the pain.

For many patients, these measures will be sufficient shoulder bursitis treatment if done for a period of several weeks.

After the pain is gone, some simple exercises or physical therapy may help you return to normal activities without pain.

If the symptoms are not adequately treated, the next step is usually a cortisone injection, or steroid shot, into the area of inflammation. If the symptoms are significant, your doctor may opt to perform this cortisone injection on an initial visit. The cortisone injection places medication to treat the inflammation directly in the problem area. The most significant downside is that cortisone injections can weaken tendons, and repeated cortisone injections should be carefully considered. (NEVER MORE THAN 4 PER YEAR).

Surgery may be required, but the caveat is that surgery is RARELY needed to treat impingement syndrome. The surgical procedure to treat impingement syndrome is called a subacromial decompression. This can either be performed using an arthroscope or a small incision. During the surgery, the inflamed bursa is removed and some of the bone and any spurs are removed to create a larger space for the rotator cuff tendons. The surgery can be quite painful, and it is not without potential complications. You should discuss these possible complications with your doctor before proceeding to surgery.