Bursitis

Question 1

What is bursitis?

Answer 1

• Inflammation of a bursa

A bursa is a small, flat sac lined with synovium
The word bursa means purse
Both membranous surfaces of the bursa are normally in contact, separated by only a thin film of lubricating fluid
A bursa reduces friction, usually between tendons and bones
Since it is flat, a bursa is not palpable unless it is inflamed
A bursa can regrow in 6-24 months if surgically removed

Question 2

Causes of Bursitis

Answer 2

Overuse of structures surrounding the bursa, leading to excessive friction and inflammation of the bursal walls

Bursitis is usually secondary to other conditions such as tendinitis

• Contributing Factors:

Muscle imbalances, poor biomechanics, postural dysfunctions such as scoliosis or hyperkyphosis and a lack of flexibility

Less commonly acute trauma, infection and pathologies such as OA, gout and RA

Question 3

Shoulder Bursae

Answer 3

There are several bursa at the shoulder:

1. The subacromial (subdeltoid) bursa between the acromion and the supraspinatus tendon, with a portion of the bursa between the deltoid muscle and the humerus
2. The subcoracoid portion is not always present. It is palpated through the anterior deltoid muscle near the acromion
3. The subscapular bursa lies between the scapula and subscapularis muscle, but not easily palpable

Question 4

Olecranon Bursa

Answer 4

Lies between the olecranon and the subcutaneous fascia

It is quite swollen and obvious when inflamed

It is irritated by repetitive weight bearing or trauma such as dragging the elbow on the ground when wrestling

Question 5

Trochanteric Bursa

Answer 5

Two main bursae at the greater trochanter:

1. Ones lies between the gluteus maximus tendon and the trochanter
2. The other lies between the gluteus medius tendon and the trochanter

The bursae are palpated through the overlying gluteus maximus tendons

Pain is local to the lateral hip and the client will not be able to sleep on the involved side

Pain is worse on climbing stairs and getting out of a car (using those muscles, they put pressure to the bursa)

Causes include altered hip biomechanics, low back pain causing antalgic gait, OA

Question 6

Iliopectineal Bursa

Answer 6

Lies between the iliopsoas muscle and the iliofemoral ligament

To palpate, the supine client’s hip is flexed to 90 degrees

The bursa is located 1-2 cm inferior to the middle third of the inguinal ligament

Pain is at the anterior hip and may radiate down the anterior leg due to pressure on the femoral nerve

Antalgic posture is usually hip flexion and external rotation

This bursitis is caused by hip flexor tightness and repetitive activity (cylclist)

Question 7

Ischial Bursa

Answer 7

Lies between gluteus maximus and the ischial tuberosity

Palpated through gluteus maximus

With inflammation there is well-localized pain over the ischial tuberosity

May be referral down the posterior leg that mimics sciatic pain

When the client is driving, they may find that pressing down on the brake or gas pedal relieves the pain. This is due to increased tone in muscles that cross the knee which rotates the ischial tuberosity away from the car seat

Antalgic gait with the client leaning towards the affected side and shortening their stride

Question 8

Knee Bursa

Answer 8

Numerous bursa are around the knee:

1. The pes anserine bursa lies between the tendons of sartorius, semitendinosus & gracilis muscles & the medial tibia
2. The infrapatellar bursa lies between the patellar ligament and the tibia
3. Other bursae lie between the iliotibial band and the lateral collateral ligament and the tibia

All of these bursa are palpated through the overlying tendons

Pain is worse on use

The prepatellar bursa lies between the lower half of the patella, the patellar ligament and the skin

Question 9

Retrocalcaneal Bursa

Answer 9

Lies between the Achilles tendon and the calcaneus

The bursa is palpated on either side of the tendon

It is locally painful when inflamed

Overuse and a tight gastrocnemius-soleus complex are causes of inflammation

Question 10

Baker’s Cyst

Answer 10

A synovial cyst that usually appears at the lateral side of the popliteal space

It is thought to be an enlargement of the extracapsular bursa between the gastrocnemius and semimembranosus muscles, or a herniation thoát vị of the synovium through the posterior joint capsule wall

Can appear in children and adults

Question 11

Bunion

Answer 11

Occurs at the first metatarsophalangeal joint capsule

A bunion is formed by excessive bone growth (exostosis), a callus and an inflamed, thickened bursa developing over the joint

This is in response to joint hypermobility as poor biomechanics allow the first metatarsal bone to deviate medially

The phalanges deviate laterally, forming a hallux valgus

NSAIDS and corrective footwear are used to treat a bunion

Surgery to straighten the toe and reduce the exostosis is an option

Question 12

Medically

Answer 12

Acute bursitis is treated with rest and NSAIDs, ultrasound and ice

Superficial bursae such as the olecranon may be protected with a padded donut

A superficial bursae may also be aspirated, especially if it is infected, then infiltrated with a corticosteroid

Surgical excision is another option
(after acute) A program of stretching a gradual return to strengthening for the structures that cross the bursa are recommended

Question 13

Symptom Picture

Answer 13

• Acute: The bursa is compressed and irritated by surrounding structures

Inflammation, heat and swelling are present

Pain is deep and burning, at rest or on activity

ROM of the affected joint is restricted

Joints distal or proximal may have reduced range if crossed by a muscle or fascia that also crosses the affected bursa

• Chronic:

Pain or achiness is felt with activity or upon direct compression

Pain is more localized to the bursa

Chronic inflammation, fibrosis and adhesions are present

ROM of the affected joint is less restricted than in the acute stage

Question 14

Contraindications

Answer 14

With acute bursitis, the therapist should avoid compressing the bursa or applying techniques that place a drag on the surrounding tissues (so move toward not away technique)

On-site techniques are CI’d with acute bursitis

If infective bursitis is suspected, the client is referred for medical attention

Question 15

Observation and Palpation:

Answer 15

*Acute:

Swelling and redness are noted over bursae that are more superficial, but these symptoms may not be noted with deeper bursae

Antalgic posture or gait is present

Heat it palpated locally

The bursa is very painful on direct compression and feels fluctuant

Spasm, HT and TPs are present in muscles crossing the bursa

• Chronic:

A postural assessment may be performed to determine sources of muscle imbalance

Adhesions are palpated

Bogginess may be noted

HT and TPs are also present

Question 16

Testing:
Acute & Chronic

Answer 16

AF ROM of the affected joint is reduced in most directions due to pain, more so in the acute stage pain is experienced in a single position in the chronic stage

PR ROM in the acute stage reveals an empty end feel due to pain, with a markedly reduced range, similar to AF ROM. This is not pronounced in the chronic stage

AR isometric testing is painful for bursae that are completely surrounded by other structures. The pain stays constant while the bursa is compressed. This is called the bursa differentiation test

(Bursitis: consistent pain, tendinitis: sharp pain when moving)

Question 17

Massage: Acute

Answer 17

Hydrotherapy application is cold to the affected bursa, but it should not be heavy which would compress the bursa

Positioning is for comfort

Reduce edema in the affected limb

Reduce HT and TPs in the proximal and compensating muscles

Decrease compression of the bursa by working the attachments of the surrounding muscles using GTO and origin and insertion technique. No direct techniques should be applied directly on site of the bursa

Segmental strokes are used, working towards the bursa, not away from it

Decrease spasm in surrounding muscles with gently joint play

Stroking and gently muscle squeezing distal to the affected area

Pain-free PR and active assisted ROM is interspersed throughout the massage

Question 18

Massage: Chronic

Answer 18

Hydrotherapy application is deep moist heat before stretching the surrounding fascia. Contrast is used after treatment to increase local circulation

Positioning is for comfort

Decrease fascial restrictions crossing the bursa

Reduce HT and TPs in compensating structures and proximal muscles

Decrease compression of the bursa by working the attachments of the surrounding muscles using GTO and origin and insertion technique

Pain free PR ROM of the affected joints is interspersed with the massage

Frictions to adhered structures surrounding the bursa

Maintain ROM with stretching
Joint play to hypomobile joints

Distal areas are treated to increase circulation

Question 19

Self-care

Answer 19

• Acute:

Client is instructed to rest, ice and comfortably elevate the affected limb as much as possible

Pain-free AF and submaximal isometric exercises are started as soon as the client can tolerate them

• Chronic:

Rest from aggravating activities. Return to activity is gradual. If a flare-up of acute symptoms is experienced, ice is reapplied after activity

Self-massage to the muscle surrounding the bursa

Stretching is encouraged

Gradual progression from pain-free isometrics to isotonic exercises