Bursitis

Each bursa is a slim pouch of fluid that eases the movement of skin, tendon and bone across one another. When a bursa is irritated it produces more fluid and puffs up. Most often the cause is pressure, rubbing or overuse, again and again: kneeling for long periods, propping yourself on your elbows, or work and sport that knock or load the elbow or the knee time after time. One knock or fall can be enough as well.

Sometimes there is an underlying cause. Bursitis can go along with tendinopathy or rotator cuff problems, which is how it often arises at the shoulder and the hip, and gout or rheumatoid arthritis may be driving it. Now and then a bursa lying just under the skin, at the elbow or the front of the knee, becomes infected, where a graze or a cut can let bacteria in. Elbow and kneecap bursitis are commoner in men: at the elbow when young or middle-aged, at the knee between about 40 and 60. Tenderness over the outer hip is often the tendons as much as the bursa, the condition our hip pain guide calls greater trochanteric pain syndrome (GTPS).

The trouble is felt right over the bursa:

• A dull ache and tenderness over one spot near a joint, at the shoulder, the elbow, the hip or the knee
• Swelling, which can be soft and easy to see over the tip of the elbow or in front of the kneecap
• Warmth, and sometimes redness, which can show less clearly on brown or black skin
• Pain that is worse when the area is pressed or the joint is moved

A bursa that turns hot, red or very painful, or that has broken skin over it or comes with a fever, is the picture of an infected one; the lists under when to seek help give its route.

Bursitis is often clear from the story and an examination, but the cause is worth confirming, because a tendon problem or a joint problem can look the same.

Where the picture is unclear, an ultrasound scan can help confirm that the bursa is swollen and full of fluid. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the area can usually be scanned on the day, as the ultrasound clinic page describes. Where infection or gout is a question, fluid drawn off with a fine needle is sent for testing.

Treatment usually starts at home: rest from the pressure or activity that set it off, a cold pack and simple painkillers. Where it does not settle, an ultrasound-guided injection can calm the inflammation, the scan placing it accurately and letting any fluid be drained at the same time; a steroid is not injected where there may be infection, and the injection brings a higher risk of infection and thinned skin than care at home. An infected bursa is treated with antibiotics, usually for at least a week, and drained where that can be done. Surgery to drain or remove a bursa is rare, kept for bursitis that is severe or keeps coming back. You and Dr Borukhson settle the plan together.

A few simple steps help most bursitis settle and make it less likely to return:

• Rest it at first: do not move the joint more than you need to, and avoid the kneeling, leaning or activity that put pressure on it
• Cushion the spot: padding over the knee or the elbow, and a change in the way you sit, kneel or work
• Cool it and ease the pain: an ice pack in a tea towel for around ten minutes, repeated every few hours, and paracetamol or another simple painkiller; a pharmacist can advise
• Build back gently: once the pain eases, return step by step to your normal activity, as far as is comfortable
• Clean any cut or graze over a joint straight after it happens, since a cut can let bacteria reach a bursa

Most cases improve within a week or two. A few hang on, or come back for as long as the pressure goes on, so removing the cause counts as much as treating the flare-up.

Bursitis is rarely a danger in itself. The lists below route the handful of pictures that call for more: an infected bursa, which can spread into the skin or become sepsis, a joint you cannot put weight on or move, an injury, and, for a sore elbow or shoulder, pain that is really the heart's.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Arm pain that comes on suddenly with pressure, heaviness or squeezing across the chest, which can mean a heart attack
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A bursa that has turned hot, red or very painful, or has broken skin over it, since an infected bursa needs treating quickly; with a fever or feeling unwell, short of the signs that follow, at A&E or through NHS 111; with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, it is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• After an injury, swelling or bruising around the joint that is large or still getting worse, since a break or a torn ligament has to be ruled out; NHS 111 can say where to go, and an urgent treatment centre can sometimes X-ray it; a joint or limb left at an odd angle or out of shape after the injury, a knee that swells up very quickly or gave a pop or a snap, or a shoulder that is painful, bruised or swollen after it slipped out of place, is a 999 or A&E emergency
• Arm pain that is brought on by exercise, stress, emotion or the cold, rather than by a particular movement of the arm, and stops within a few minutes of rest, which can mean angina, a sign of a heart problem; NHS 111 will tell you where to be seen

See a GP if the swelling and pain have not improved, or are getting worse, after one to two weeks of looking after it yourself, if you have sharp or shooting pains in the joint, or if it keeps coming back; and if a sore bursa comes on top of gout or another inflammatory condition, so that its cause can be found and treated. After an injury, a joint or limb left at an odd angle or out of shape, a knee that swells up very quickly or gave a pop or a snap, or a shoulder that is painful, bruised or swollen after it slipped out of place, is a 999 or A&E emergency. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

With the right care most bursitis settles; an assessment makes sure of the diagnosis, looks for what is keeping it going, and excludes the other reasons for a sore swelling by a joint. If yours is not settling, keeps returning, or you are unsure what it is, a specialist review with ultrasound can make sense of it and guide the right treatment.

How do you know it is bursitis?

Usually from how it began and an examination of the area that hurts. Other problems near a joint can feel just the same, so the cause is worth confirming, and where the picture is unclear an ultrasound scan can help confirm a swollen bursa. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the area can usually be scanned at the first appointment; if infection or gout is possible, a little fluid can be taken with a fine needle and tested.

Does bursitis clear up without treatment?

Usually, with care: resting the joint from the pressure or activity that set it off, a cold pack and simple painkillers. Most improve within a week or two; see a GP if it has not, or is getting worse, after one to two weeks of looking after it yourself, or if you have sharp or shooting pains in the joint. A bursa that has turned very painful is a same-day matter, in the list under when to seek help. Some cases are stubborn, or return while the pressure continues, and benefit from treatment.

Do I need surgery?

Rarely. Where bursitis does not settle, a steroid injection guided by ultrasound can calm it, as long as there is no infection, though it carries a higher risk of infecting the bursa or thinning the skin than care at home does; drawing the fluid off with the same guidance can ease a tense swelling. An infected bursa is treated with antibiotics. An operation to drain or remove a bursa is kept for the few that are severe or keep coming back despite everything else.

How can I tell if a bursa is infected?

A bursa that has turned hot, red or very painful, or has broken skin over it, may be infected. With a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, confusion, or another sign that the second list under when to seek help names for a hot, red bursa, or with one of the sepsis signs in the first list, it is a 999 or A&E emergency. Call 999 and do not drive yourself to A&E. With a fever or feeling unwell, short of those signs, it is for A&E or NHS 111 the same day; without them, it still needs your GP or NHS 111 the same day. The section on when to seek help has the full lists.

Is bursitis serious?

Usually not: it causes pain and swelling in one place, it is treatable, and most people do well. Seeing a specialist makes sense if it is not getting better, if it is unclear what it is, or if other causes near the joint have to be excluded, and an assessment, with an ultrasound scan if it would help, can establish what is happening and point to the right treatment.