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Bursitis

Introduction

Bursitis is inflammation (swelling) of a bursa. A bursa is a small fluid-filled sac which forms under the skin, usually over the joints and between tendons and bones.

A bursa can become inflamed through injury or repetitive movement. For example, runners and joggers have an increased risk of developing bursitis in their ankles. Less commonly, bursitis can occur as a result of an infection or as a complication of certain conditions, such as rheumatoid arthritis (see Bursitis - causes for more information).

Bursitis causes pain and swelling in the affected body part. The symptoms of bursitis usually improve within a few weeks. Resting the affected body part and taking painkillers, such as ibuprofen, can help to relieve symptoms and speed up recovery.

Bursae

There are around 160 bursae in the human body. They can be found in any area where friction occurs.

Bursae act as cushions between two surfaces that rub against each other, such as bones, muscles, joints and tendons, helping to reduce friction. Bursae reduce friction because they're lined with special cells called synovial cells, which produce a liquid that lubricates the moving parts of the body.

Where bursitis occurs

It's possible for any bursa to become inflamed, but the most common places where bursitis occurs are the:

  • shoulder
  • elbow
  • ankle
  • knee
  • hip
  • thigh

The risk of developing bursitis is increased if you regularly do an activity that involves a lot of repetitive movement. For example, darts players who repeatedly bend and straighten their elbow may get bursitis of the elbow. People who do a lot of kneeling, such as carpet fitters and gardeners, have a high risk of developing bursitis in their knee (known as 'housemaid's knee').

Taking precautions, such as wearing knee pads or warming up before exercise, may help to reduce your risk of getting bursitis. See Bursitis - prevention for more information.

When to see your GP

You should visit your GP if there's no improvement in your symptoms after two weeks.

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Symptoms

The symptoms of bursitis include:

  • pain – usually a dull ache in the affected body part that's made worse by movement or pressure
  • tenderness in the affected body part
  • swelling of the affected body part
  • loss of movement in the affected body part

Septic bursitis

Septic bursitis is bursitis that's caused by infection. Additional symptoms of septic bursitis include:

  • a high temperature (fever) of 38ºC (100.4ºF) or above
  • feeling shivery
  • the affected body part feeling warm to the touch
  • redness of the affected body part
  • having cellulitis (an infection of the deeper layers of the skin)
  • having some broken skin over the bursitis

When to seek medical advice

Always visit your GP if you have the symptoms of a fever because a fever is usually an indication that you have an infection. Otherwise, you should visit your GP if your symptoms don't improve after two weeks.

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Causes

Bursitis can develop in three main ways:

  • injury
  • infection
  • when you have a pre-existing health condition that causes inflammation of the bursa

Injury

If a bursa is injured, the tissue inside it can become irritated, resulting in inflammation (swelling).

In most cases, the injury develops over a prolonged period of time as a result of overuse of the joints, muscles and tendons that are near the bursae. Repetitive movement is a particular risk for this type of injury.

Some of the ways that specific parts of the body can become injured and cause bursitis are listed below.

  • The shoulder can become injured by overhead lifting or reaching.
  • The elbow can become injured by repeatedly bending and straightening it, or by falling on it. This may affect certain athletes, such as gymnasts or hockey players.
  • The knee can become injured by repeated movement or repeated kneeling (bursitis of the knee is known as 'housemaid's knee'). This may affect people with certain jobs, such as carpet layers, or certain sports players, such as footballers. 
  • The ankle can become injured by excessive walking (particularly if you're not wearing suitable walking shoes), or by activities such as ice skating or athletics.
  • The hips can become injured by running.

A bursa may also be injured if subjected to a sudden impact, such as banging your elbow on a piece of heavy furniture or by falling with heavy pressure on to your knees.

Infection

Bursae that are near the surface of your skin, such as those near your elbow, can become infected. Infection can occur if bacteria on the surface of your skin find their way into cuts and grazes and then move into a bursa. Bursitis caused by an infection is known as septic bursitis.

The immune system (the body’s natural defence against injury and illness) is usually very effective at preventing this sort of infection, so septic bursitis tends to only occur in people who have a weakened immune system. Factors that are known to weaken the immune system include:

Health conditions

A number of health conditions can sometimes cause inflammation of a bursa. 

These conditions include:

  • gout – a condition that's caused by a build-up of uric acid in the blood
  • rheumatoid arthritis – a condition where the immune system attacks the linings of the joints
  • scleroderma – a condition that causes hardening of the skin
  • ankylosing spondylitis – a type of long-term arthritis that affects parts of the spine
  • systemic lupus erythematosus – a poorly understood condition that affects many of the body’s tissues and organs
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Diagnosis

Your GP will usually be able to diagnose bursitis by carrying out a physical examination of the affected body part and asking you some questions. For example, your GP may ask if you have recently fallen on the joint, or if you have a job or hobby that involves repetitive use of the joint.

Fluid sample

If you have the symptoms of a fever – a temperature of 38ºC (100.4ºF) or above – your GP may remove a small sample of fluid from the affected bursa. This will be done using a needle in a procedure known as an aspiration. Afterwards, a dressing will be placed over the area and you'll need to avoid strenuous activity for around two days.

If there's blood in the fluid, it may suggest that you have injured your joint.

The fluid sample will be sent to a laboratory to check for the presence of bacteria, which will indicate that you have a bacterial infection (septic bursitis). The sample may also be checked for crystals, which can develop as a result of conditions such as gout.

Further testing

Further testing is usually only required if your symptoms don't respond to treatment. If this is the case, it will be necessary to rule out other conditions that may be responsible for your symptoms.

Further tests that you may have include:

  • an X-ray – to rule out fractures or broken bones
  • blood tests – to rule out conditions such as rheumatoid arthritis
  • a magnetic image resonance (MRI) scan – to rule out tissue damage, such as a torn tendon (tendons are the cords that join bones to muscles)

An MRI scan uses a strong magnetic field and radio waves to produce a detailed image of the inside of your body.

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Treatment

Self-care

In most cases, bursitis can be successfully treated using a combination of self-care techniques and over-the-counter (OTC) painkillers.

Healthcare professionals usually recommend a self-care management approach known as PRICEM which stands for:

  • Protection,
  • Rest,
  • Ice,
  • Compression,
  • Elevation, and
  • Medication.

Protection

You may wish to wear padding to protect any bursae that are close to the skin and could be damaged by an impact.

Rest

You should rest the affected body part until symptoms improve, and avoid any activity that causes additional pain.

Ice

The use of ice packs can be effective in reducing symptoms of inflammation and pain. Wrap an ice pack (a small pack of frozen vegetables is ideal) in a towel, and apply the towel to the affected area for 10 minutes, twice a day.

Compression

Using an elastic bandage, or dressing, to compress affected joints can help to relieve pain.

Elevation

If possible, elevating the affected body part above the level of your heart will stop blood gathering in the bursae, which should help to reduce inflammation.

Medication

The over-the-counter (OTC) painkiller ibuprofen has proved to be effective in treating pain and reducing inflammation.

Additional treatment

Steroids

If your symptoms of bursitis are particularly severe, or fail to respond to treatment, your GP may recommend the use of steroid medication.

Steroids work by blocking a chemical in the body, called prostaglandin, which causes inflammation.

Steroids are usually injected directly into the affected body part. However, due to the high number of side effects that are associated with long-term steroid use, such as high blood pressure (hypertension), and increased vulnerability to infection, it is likely that you will only be able to have a maximum of three steroid injections a year.

Antibiotics

If testing confirms that your bursitis is caused by infection, you will be given antibiotic tablets (oral antibiotics).

If you are prescribed antibiotics, it is very important that you finish the entire course even if your symptoms improve because this will prevent the infection returning.

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Prevention

There are some common sense precautions that can take to help prevent getting bursitis. These are briefly outlined below.

Protect exposed joints

If your job involves a lot of kneeling, you should buy a pair of knee pads.

If you run or walk regularly, make sure that you wear a good quality pair of running or walking shoes.

Regular breaks from repetitive tasks

Try to vary your patterns of physical activity by carrying out different tasks that don't all involve using the same part of the body.

Warm up before exercising

Make sure that you warm up for around 10 minutes by doing some light aerobic exercise, such as steady jogging or walking before you start to exercise more vigorously. 

Strengthen your muscles

If a joint has previously been affected by bursitis, strengthening the muscles around the joint will help to provide additional protection from further injury. However, you should only try to strengthen the muscles once your symptoms of bursitis have cleared up.

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