Bursitis Causes Prevention and Treatment

Bursitis happens when the bursa is inflamed. The burse acts as a cushion between bones, tendons, joints and muscles - bursae are fluid-filled sacs (the plural of bursa is bursae). People with bursitis will feel pain at the site of inflammation. The medical word "bursa" comes from the Latin bursa, meaning a purse, which is what a bursa resembles. According to medical terms, bursitis is "inflammation of the bursa".

About the bursae
There are about 160 bursae in the human body. These little, fluid-filled sacs cushion pressure and lubricate points between our bones, tendons, and muscles near our joints. The bursae are lined with synovial cells. Synovial cells produce a lubricant that reduces friction. This cushioning and lubrication allows our joints to move easily. When a person has bursitis - inflammation of the bursa - movement or pressure is painful.

Overuse, injury and sometimes an infection from gout or rheumatoid arthritis may cause bursitis.
What parts of the body may become affected by bursitis?
Any bursa can become affected; however, the following are the most common places:

    Shoulder
    Elbow
    Ankle
    Knee
    Buttocks
    Hip
    Thigh

How prevalent is bursitis?
As many cases of bursitis are mild, lots of people with bursitis will sit it out or self treat and never see a doctor about it. It is therefore hard to know how common it is. GPs (general practitioners, primary care physicians) in the UK say that about 1 in every 200 patient visits are because of bursitis.
What are the symptoms of bursitis?
A person with bursitis can have one or more of the symptoms below:

    Pain - the pain increases with movement or pressure
    Tenderness is felt even without movement
    Swelling
    Loss of movement

If the bursitis is caused by an infection it is called Septic Bursitis. The patient with septic bursitis may have the following additional symptoms:

    Fever
    The affected area is red
    The affected area feels hot when touched

What causes bursitis?
Bursitis can be caused by an injury, an infection, or a pre-existing condition in which crystals can form in the bursa.

Injury

An injury can irritate the tissue inside the bursa and cause inflammation. Doctors say that bursitis caused by an injury usually takes time to develop. The joints, tendons, or muscles that are near the bursae may have been overused. Most commonly, injury is caused by repetitive movements.

Below are some examples of causes of bursitis:

    Tennis elbow - bursitis of the elbow is often termed tennis elbow. It is a common problem among tennis players and golfers. Repetitive bending of the elbow can eventually lead to injury and inflammation.

    Clergyman's knee - repeated kneeling can cause injury and eventual swelling to the bursae in the knee area.

    Shoulder - caused by repeated overhead lifting or reaching upwards.

    Ankle - injury to the ankle can be caused by walking too much and with the wrong shoes. Bursitis of the ankle is also common among ice skaters and athletes.

    Buttocks - the bursae in that area can become inflamed after sitting on a hard surface for a long time, such as on a bicycle.

    Hips - some long-distance runners, and also middle distance runners and sprinters if they train a lot can develop hip bursitis.

    Thigh - this can be caused by stretching.

    Bursitis can also be caused by a hard blow to the area.

Infection

Infection that causes bursitis tends to be in bursae that are nearer the surface of the skin, such as those near the elbow. A cut on the skin is an opportunity for the bacteria to get in. Most healthy people would not be affected by opportunistic bacteria trying to get in through the skin. However, people with weakened immune systems, such as those with diabetes, HIV/AIDS, Cancer (receiving chemotherapy or radiotherapy), as well as people taking steroids, and heavy consumers of alcohol.

Health conditions

People with certain health conditions are more prone to the formation of crystals inside the bursa. The crystals irritate the bursa and make it swell. The conditions that may cause this include gout, rheumatoid arthritis, and scleroderma.

How is bursitis diagnosed?

Carrying out a diagnosis for bursitis is fairly straightforward. The doctor will examine the affected area and ask the patient some questions about his/her recent activities. If the patient has a high temperature the physician may take a small sample of fluid from a bursa near the affected body part. The sample will be tested for bacteria, and perhaps also crystals.

If the patient does not get better after treatment the doctor may carry out further tests so that he/she can eliminate the possibility that the symptoms might not be due to something else. These may include:

    An x-ray, to make sure no bones are broken or fractured
    Blood tests, to check for rheumatoid arthritis
    A CT scan or MRI scan to see if there is a torn tendon

What is the treatment for bursitis?

    Self-treatment

    Most bursitis cases can be treated by the patient without having to see a doctor. A trip to a pharmacy, a conversation with the pharmacist, and some self-care techniques are usually enough. The NHS (National Health Service, UK) recommends PRICEM - a self-care management approach. PRICEM stands for:

    Protection
    Rest
    Ice
    Compression
    Elevation
    Medication

    Protect the affected area - Some people place padding to protect the affected bursae from any blow.

    Rest - Do not exercise or use the joints in the affected area unless you really have to. Let it rest. Bursitis is a condition that responds well to rest.

    Ice packs - Ice packs can help reduce pain and inflammation. Make sure you do not place the ice directly on the skin, use a pack or towel. A small pack of frozen vegetables are ideal.

    Raise the affected area - If you can, lift the affected area, raise it; less blood will gather there. This may help reduce the inflammation.

    Painkillers - Ibuprofen is an effective painkiller for treating pain, it also reduces inflammation.

    Steroids - For more severe symptoms the doctor may inject steroids into the affected area. Steroids block a body chemical called prostaglandin. Prostaglandin causes inflammation. Steroids may raise the patient's blood pressure if used for too long, as well as increasing his/her risk of getting an infection. UK doctors are advised not to give more than three steroid injections in one year.

    Antibiotics - If the fluid test confirms that there is a bacterial infection, the doctor will probably prescribe antibiotics. These will be administered orally (via mouth).

    Surgery - Very rarely, the bursa may have to be surgically drained.

Prevention

    Protect that part of the body that may be most vulnerable - If you have to kneel a lot, get some knee pads. Elbow braces can protect tennis and golf players. If you are an athlete or avid walker, invest in some good walking or running shoes.

    When doing repetitive tasks have breaks - Apart from taking regular breaks, try varying your movements so that you are using different parts of your body.

    Warm up before exercise - Before any type of vigorous exercise you should warm up for at least 5 to 10 minutes. The warm up could include walking at a good speed, slow jogging, or a cycling machine.

    Strong muscles add extra protection to the area - If you strengthen the muscles in the area where you had bursitis (after you are better), especially the area around the joint, you will have extra protection from injury. Make sure you do this well after your bursitis has gone completely.

Preventing Steroid-induced Osteoporosis

One of the side-effects of taking steroid tablets in the long term is an increased risk of developing osteoporosis (thinning of your bones). This is known as steroid-induced osteoporosis. Using a high-dose steroid inhaler in the long term may also be a risk. Various things can be done to reduce your risk of developing steroid-induced osteoporosis. These include lifestyle measures such as stopping smoking, reducing your alcohol intake and increasing your exercise levels. You should also make
sure that you have adequate amounts of calcium and vitamin D and sometimes supplement tablets may be needed. Medicines to prevent steroid-induced osteoporosis may also be prescribed for some people. Note: never stop or reduce your steroid treatment unless your doctor tells you to do so.

Why are steroid medicines taken?

Steroids may be taken to treat many different conditions. They work mainly by reducing inflammation and so are used to treat various conditions where inflammation occurs. For example: some autoimmune diseases; some types of muscle, skin, and joint diseases; asthma, etc. Steroids are also used to treat some cancers. The outlook (prognosis) for a number of diseases has improved, sometimes dramatically, since steroids became available.

Steroid medicines are sometimes called cortisone or corticosteroids. They can be taken in many ways. For example, as tablets by mouth, via inhalers to deliver steroid into your lungs, or by creams to rub on to your skin. Long-term steroid medication is needed to treat some conditions and keep symptoms under control. Unfortunately, this long-term treatment can have side-effects. There is often a balance between the risk of side-effects against the symptoms and damage that may result from some diseases if they are not treated with steroids. Note: long-term treatment with low-dose steroid inhalers or steroid skin creams does not carry the same risk of serious side-effects as long-term treatment with steroids.

What is steroid-induced osteoporosis?

One of the side-effects of taking a steroid medicine in the long term is that it can increase your risk of developing osteoporosis. The steroid lowers your bone density and increases your risk of developing a fragility fracture.

If osteoporosis is thought to be due in part to taking a steroid medicine, it is known as steroid-induced osteoporosis. In fact, the use of steroid medicines is one of the leading causes of osteoporosis. Between 3 and 5 in 10 people who take steroid medicines in the long term will develop a fragility fracture because of osteoporosis if nothing is done to prevent this.

In general, when we are talking about steroid medicines that can cause steroid-induced osteoporosis, we are talking about long-term treatment (for three months or more) with prednisolone tablets. As mentioned above, long-term treatment with steroid creams does not carry the same risks of steroid-induced osteoporosis. However, long-term use of high doses of inhaled steroids may also increase your risk of developing steroid-induced osteoporosis. For this reason, the dose of steroid in an inhaler is usually kept to a minimum so that it is just high enough to keep your asthma or other respiratory problem under control.

Note: if you are taking long-term high-dose steroid inhalers, your should discuss your risks of developing osteoporosis with your doctor. The rest of this leaflet focuses on long-term treatment with steroid tablets.

What can be done to prevent steroid-induced osteoporosis?

There are a number of things that can be done to reduce your risk of developing steroid-induced osteoporosis if you are taking steroid tablets for three months or more. These may be things that you can change yourself in terms of your lifestyle, as well as treatment with medicines or other measures that your doctor may suggest.
Stop smoking, limit alcohol intake and exercise more

Certain lifestyle factors (as described in the list above) can increase anyone's risk of developing osteoporosis. If you already have one risk factor for osteoporosis (being on long-term steroid tablets), then it is especially important to try to reduce your number of other risk factors.

Chemicals from tobacco can get into your bloodstream and can affect your bones, making bone loss worse. If you smoke, you should try to make every effort to stop. Also, you should try to cut down on your alcohol intake if you drink more than three to four units of alcohol daily. Separate leaflets called Tips to Help you Stop Smoking and Alcohol and Sensible Drinking give further details.

Exercise can help to prevent osteoporosis. The pulling and tugging on the bones by your muscles during exercise helps to stimulate bone-making cells and strengthens your bones. Regular weight-bearing exercise throughout life is best, but it is never too late to start. This means exercise where your feet and legs bear your body's weight, such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. However, the more vigorous the exercise, the better. For most benefit you should exercise regularly - aiming for at least 30 minutes of moderate exercise or physical activity at least five times per week. Excessive exercise such as marathon running may not be so good. (Note: because swimming is not weight-bearing exercise, this is not so good for preventing osteoporosis.)

Muscle strengthening exercises are also important. They help to give strength to the supporting muscles around bones. This helps to increase tone, improve balance, etc, which may help to prevent you from falling. Examples of muscle strengthening exercises include press-ups and weight lifting but you do not necessarily have to lift weights in a gym. There are some simple exercises that you can do at home.

Ensure an adequate calcium and vitamin D intake

Calcium and vitamin D are important for bone health. Your body needs adequate supplies of vitamin D in order to absorb (take up) the calcium that you eat or drink in your diet. If you are on steroid tablets for three months or more, your risk of steroid-induced osteoporosis can also be reduced by making sure your body has enough calcium and vitamin D.

The recommended daily intake for calcium in adults over the age of 50 is at least 1,000 mg per day. Everyone aged over 50 years should also aim for adequate amounts of vitamin D daily (800 IU). Protein is also important in your diet and one gram a day of protein per kilogram of your bodyweight is recommended. Briefly:

Calcium - you can get 1,000 mg of calcium most easily by:

    Drinking a pint of milk a day (this can include semi-skimmed or skimmed milk); PLUS
    Eating 50 g (2 oz) hard cheese such as Cheddar or Edam, or one pot of yoghurt (125 g), or 50 g of sardines.

Bread, calcium-fortified soya milk, some vegetables (curly kale, okra, spinach, and watercress) and some fruits (dried apricots, dried figs, and mixed peel) are also good sources of calcium. Butter, cream, and soft cheeses do not contain much calcium.

Vitamin D - there are only a few foods that are a good source of vitamin D. Approximately 115 g (4 oz) of cooked salmon or cooked mackerel provide 400 IU of vitamin D. The same amount of vitamin D can also be obtained from 170 g (6 oz) of tuna fish or 80 g (3 oz) of sardines (both canned in oil). Vitamin D is also made by your body after exposure to the sun. The ultraviolet rays in sunshine trigger your skin to make vitamin D.

Unless your doctor is sure that you have an adequate intake of calcium and have enough vitamin D, they may prescribe calcium and vitamin D supplements if you are taking long-term steroid tablets. If you are unsure about whether you should have calcium or vitamin D supplements, ask your practice nurse or GP.
Take the minimum dose of steroids possible for the shortest period of time

In general, the higher the dose of steroid tablets taken in the long term, the higher your risk of developing a fragility fracture. However, saying that, there is not really a safe dose of steroid tablets because even low doses can increase your fracture risk. Talk to your doctor about the dose of steroid tablets that you are taking. Could the amount of steroid be reduced? Is there another way that the steroid medication may be taken rather than as tablets by mouth? For example, steroids applied to the skin or inhaled into the lungs may be possible to treat some conditions. Taking the steroid medication in another way may help to reduce the effect of the steroids on your bones.

How long a course of steroid tablets do you need? You should also discuss this with your doctor. The course of treatment should be as short as possible. However, as mentioned already above, there is often a balance between the risk of side-effects from taking steroid tablets against the symptoms and damage that may result from some diseases if they are not treated with steroids.