Review Article Four Common Types of : Diagnosis and Management

Abstract Daniel L. Aaron, MD Bursitis is a common cause of musculoskeletal pain and often Amar Patel, MD prompts orthopaedic consultation. Bursitis must be distinguished from , fracture, tendinitis, and nerve pathology. Common Stephen Kayiaros, MD types of bursitis include prepatellar, olecranon, trochanteric, and Ryan Calfee, MD retrocalcaneal. Most patients respond to nonsurgical management, including ice, activity modification, and nonsteroidal anti- inflammatory drugs. In cases of septic bursitis, oral may be administered. Local corticosteroid injection may be used in the management of prepatellar and ; however, injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles . Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis.

From the Department of Orthopaedics, Alpert Medical School ain of the , , hip, and primary concern. Approximately at Brown University, Providence, RI Pheel is among the most common 80% of cases of septic prepatellar (Dr. Aaron and Dr. Kayiaros), the Department of Orthopaedics and musculoskeletal complaints. Septic bursitis are caused by Staphylo- 1 Rehabilitation, University of and aseptic bursitis are common coccus aureus. Other organisms, Rochester School of Medicine and causes of pain, and they must be dif- including other Staphylococcus spe- Dentistry, Rochester, NY (Dr. Patel), ferentiated from arthritis, tendinitis, cies, and , Mycobacte- and the Department of , Washington University fracture, tendon or ligament , rium, Brucella, and fungal species, School of Medicine, St. Louis, MO , and neoplasm. Bursitis have been implicated in the patho- (Dr. Calfee). arises from infectious and noninfec- genesis of .1,2 The Dr. Kayiaros or an immediate family tious etiologies, and distinguishing mechanism of infection is believed to member has stock or stock options between the two can be challenging. be direct inoculation, not hematoge- held in Pfizer. Dr. Calfee or an A thorough history and physical ex- nous seeding, likely because of the immediate family member has received research or institutional amination is required for diagnosis. poor blood supply to the bursa. support from Medartis and grant No. Adjunct tests are helpful in determin- Noninfectious etiologies of bursitis UL1RR024992 from the National ing the diagnosis. Most patients with include trauma; ; sarcoid; idio- Center for Research Resources and bursitis can be successfully treated pathic calcification; and calcinosis, the National Institutes of Health Roadmap for Medical Research. nonsurgically. For patients who do Raynaud phenomenon, esophageal Neither of the following authors nor not respond to nonsurgical treat- dysmotility, sclerodactyly, and tel- any immediate family member has ment, surgical options include open angiectasia (ie, CREST) syndrome. received anything of value from or , arthroscopic bursal ex- owns stock in a commercial company or institution related cision, and partial excision of in- volved bony processes. directly or indirectly to the subject of The subcutaneous this article: Dr. Aaron and Dr. Patel. and the superficial infrapatellar J Am Acad Orthop Surg 2011;19: bursa are the two main bursae about 359-367 Prepatellar Bursitis the knee joint. They are typically re- Copyright 2011 by the American Bursitis arises from many inflamma- ferred to collectively as the prepatel- Academy of Orthopaedic Surgeons. tory phenomena, but infection is the lar bursa, but they are usually ana-

June 2011, Vol 19, No 6 359 Four Common Types of Bursitis: Diagnosis and Management

Figure 1 lar bursa because entering the bursa anteriorly increases the risk of iatro- genic sinus tract formation. Diagnos- tic thresholds have been proposed for septic prepatellar bursitis, includ- ing a bursal aspirate nucleated count that is far lower than the cell count for (>1,000 per µL and 50,000 per µL, respectively).1 and culture of the aspi- rate should be obtained. Gram stain may be negative in some cases, and regular cultures may be negative for mycobacterial, fungal, and bacterial (ie, Brucella) .2-5 Inocula- tion of the bursal aspirate into liquid media is a more sensitive method of culture than plating on solid media.6

Management Management of septic prepatellar bursitis is controversial. Recommen- dations range from oral antibiotics alone to surgical excision of the bur- Illustration demonstrating the anatomy of the prepatellar bursa, which sal sac. The primary decision in de- consists of the subcutaneous prepatellar bursa and the superficial infrapatellar bursa. (Adapted with permission from McAfee JH, Smith DL: veloping a treatment algorithm is Olecranon and prepatellar bursitis: Diagnosis and treatment. West J Med whether to initiate nonsurgical or 1988;149:607-610.) surgical management. Most patients respond to nonsurgical treatment. Surgery is a definitive option that tomically distinct. The subcutaneous microtrauma (eg, prolonged kneel- is associated with complications. prepatellar bursa lies between the ing), as well as immunocompromised Management of aseptic prepatellar skin and the patella, and the superfi- status, , chronic obstruc- bursitis typically consists of rest, cial infrapatellar bursa lies between tive pulmonary disease, chronic renal compression, and nonsteroidal anti- the skin and the tibial tubercle. failure, history of local corticosteroid inflammatory drugs (NSAIDs). It These structures typically do not therapy, and previous bursal inflam- may include local corticosteroid in- communicate with the knee joint mation. There is a strong correlation jection.7 3 (Figure 1). between these risk factors and S au- Stell8 performed aspiration fol- 1 reus bursitis. Septic bursitis caused lowed by prescription of a 10-day Presentation and Physical by S aureus is most common in the course of oral antibiotics in seven pa- Examination summer months. tients with septic prepatellar bursitis. The clinical indications of septic pre- Mean time to recovery was 3 weeks patellar bursitis are swelling, pain, Diagnosis (range, 1 to 4 weeks). Two of seven , and warmth. Local tender- Diagnosis of septic prepatellar bursi- patients required admission for in- ness to palpation is a hallmark of tis is based on clinical presentation travenous antibiotics. this condition. Pain with joint range and risk factors. Distinguishing in- Knight et al9 managed two cases of motion is atypical except for dis- fectious from noninfectious etiolo- of septic prepatellar bursitis with in- comfort at extreme flexion, which gies can be challenging. Aspiration of travenous antibiotics and placement compresses the inflamed bursa.3 Pre- the bursa is often necessary. McAfee of a percutaneous tube to facilitate disposing factors include a history of and Smith3 recommend a lateral ap- suction-drainage and irrigation. trauma to the area, such as repetitive proach for aspiration of the prepatel- Symptoms resolved with 12 days of

360 Journal of the American Academy of Orthopaedic Surgeons Daniel L. Aaron, MD, et al irrigation and an average of 19 days elevation, and NSAIDs are accepted Presentation and Physical of coverage. No recur- first-line management for aseptic Examination rences or sinus tract formation were prepatellar bursitis, few data exist Olecranon bursitis typically presents reported. on their success rate. Intrabursal with unilateral swelling over the In a retrospective analysis, Cea- corticosteroid injections also are proximal olecranon. History of mi- Pereiro et al1 compared septic bursi- commonly used to manage aseptic nor or repetitive local trauma is com- tis caused by S aureus with septic prepatellar bursitis. Although symp- mon. Aseptic traumatic bursitis is bursitis caused by other organisms. tomatic relief may be faster with in- Surgery was required in only 4 of 47 jection than with more conservative characterized by a nontender fluctu- patients with bursitis caused by S au- approaches, injection has associated ant mass over the olecranon. How- reus and in 2 of 11 patients with bur- risks, including infection, skin atro- ever, depending on the degree of as- sitis caused by other organisms. phy, and . Historically, sociated , 20% to 45% Bursectomy is one surgical option prepatellar bursitis has been man- of these patients report tender- 17,18 for patients whose symptoms do not aged with intrabursal injection of au- ness. Septic olecranon bursitis is resolve with nonsurgical manage- tologous blood (ie, blood patch) or a often associated with greater tender- ment. Wang et al5 performed bursec- caustic chemical, such as sodium ness than the aseptic form, and septic tomy in a patient with septic prepa- morrhuate, and placement of a olecranon bursitis may have a visible tellar bursitis caused by Sporothrix short-term indwelling drainage cath- cellulitic component. Aseptic and schenckii. In their review of the liter- eter. These techniques have not septic olecranon bursitis may be in- ature, the authors found that five of proved to be successful, however.12 distinguishable on initial examina- seven patients with bursal sporo- tion, however. trichosis required bursectomy after Sterile bursitis is associated with failure of antimicrobial therapy. Olecranon Bursitis varying degrees of hyperemia of the Complications of bursectomy in- skin overlying the bursa as well as 19 clude wound healing problems, atro- Olecranon bursitis is the most com- extending into the forearm. 13 phic skin changes, accumulation of mon superficial bursitis. Fluid col- In persons undergoing hemodialysis, subcutaneous hematoma, and severe lection within and inflammation the arm used for vascular access has tenderness. around the bursa are caused by trau- a noted predilection for olecranon 20 Quayle and Robinson10 described a matic, inflammatory, and infectious bursitis. Severe olecranon bursitis modified technique in which only the processes. Olecranon bursitis is typi- may result in a sympathetic effusion 18 posterior wall is resected, leaving the cally noninfectious in origin; septic of the underlying elbow joint. Effu- anterior wall adherent to the subcu- bursitis accounts for approximately sion typically resolves with manage- 14 taneous tissue. They speculated that 20% of all cases. Although ment of the bursitis. this technique would protect the skin olecranon bursitis is readily recog- and reduce the risk of complications. nized on , the Diagnosis No major complications were associ- etiology may be difficult to deter- A fluid-filled olecranon bursa is gen- ated with the procedure. mine. erally recognized. However, olecra- Open surgical management of non bursitis occurs in conjunction aseptic prepatellar bursitis is subject Anatomy with several systemic conditions, to the same risk of complications as The olecranon bursa forms after age such as , gout, that of the infectious form. More re- 7 years.15 Pressure from the bony pseudogout, chondrocalcinosis, and cently, an endoscopic approach to olecranon and shearing forces ap- pigmented villonodular .21 bursectomy has been reported.11 plied to the overlying skin during ac- These underlying processes must be Wound complications are consider- tivity may contribute to bursa forma- recognized and managed to provide ably lower compared with open tion.15 This superficial bursa covers adequate treatment and prevent re- approaches. Ogilvie-Harris and Gil- the dorsal olecranon and extends currence. bart11 reported no significant compli- from the most distal triceps insertion In the patient with an acutely in- cations following endoscopic resec- to several centimeters along the flamed olecranon bursa, the clinician tion in 19 cases of aseptic prepatellar proximal subcutaneous border of the must distinguish between septic and bursitis. Two thirds of patients were ulna. The acutely distended bursa aseptic bursitis. In some cases, physi- asymptomatic postoperatively. may be 6 to 7 cm long and 2.5 cm cal examination alone is insufficient Although compressive wrapping, wide.16 to establish a diagnosis.17 In addition

June 2011, Vol 19, No 6 361 Four Common Types of Bursitis: Diagnosis and Management

Figure 2 guish septic from aseptic bursitis. A intravenously, but parenteral prepa- preponderance of polynuclear cells is rations require fewer days to sterilize indicative of septic bursitis, whereas the bursal fluid.18 Although positive predominance of mononuclear leu- cultures guide the selection of antibi- kocytes is indicative of aseptic bursi- otics, most cases of septic bursitis are tis.18,22 Bursal fluid glucose levels in- attributable to Staphylococcus and 21 dicate infection when values are other gram-positive organisms. <50% of serum levels.18 Several surgical procedures have Smith et al17 measured skin temper- been described for the management ature in 46 patients to distinguish of olecranon bursitis, including tra- ditional open bursectomy, ar- septic from aseptic olecranon bursi- throscopic bursal excision, and par- tis. Skin temperature of the affected tial excision of the olecranon.16,23,25 bursa ≥2.2°C (36°F) warmer than The skin incision should not be the contralateral olecranon bursa placed over the bony olecranon pro- predicted a septic process with 100% cess during open procedures because sensitivity and 94% specificity.17 even well-planned surgery may result Two of 35 aseptic cases demon- in sensitive scars, adherent skin, and strated this temperature differential. hypoesthesia.16 Stewart et al23 re- Mean surface temperature difference Illustration demonstrating the ported satisfactory outcomes at an location of the trochanteric bursa was 0.7°C (33.3°F) in aseptic cases average follow-up of 5.2 years in 15 between the gluteus medius (2) and 3.7°C (39°F) in septic cases. of 16 nonrheumatoid patients who and the iliotibial band (3) as well as the bursa located between tendon underwent surgical treatment for and at the gluteus minimus, Management aseptic bursitis. Postoperatively, pa- which is reflected downward (1). Management of olecranon bursitis is tients are often splinted in 90° of (Redrawn with permission from dictated by its etiology. Acute trau- flexion for 2 weeks to rest the soft Lequesne M: From “periarthritis” to hip “rotator cuff” tears: Trochanteric matic or idiopathic olecranon bursi- tissues and minimize hematoma for- tendinobursitis. Joint Bone Spine tis typically resolves with nonsurgi- mation. 2006;73[4]:344-348. http://www. cal management. Ice, compressive sciencedirect.com/science/journal/ 1297319X.) dressings, and avoidance of aggra- vating activity are sufficient in most Trochanteric Bursitis patients.23 When a patient does not improve as expected, aspiration Anatomy and to physical examination, bursal fluid should be performed to rule out in- Pathophysiology analysis and skin temperature mea- fection. Alternatively, in the patient The trochanteric bursa lies deep to surements may be used to establish in whom fluid collection is bother- the iliotibial band, just superficial to the diagnosis. Aspirated bursal fluid some at presentation, aspiration with the gluteus medius, at the lateral as- is quantitatively analyzed on Gram or without concurrent corticosteroid pect of the proximal thigh26 (Figure stain, culture, injection may be done.21 In a study 2). The glutei medius and minimus (WBC) count, and glucose level. of 47 patients with traumatic bursitis have additional bursae deep to their Positive Gram stain and culture de- who underwent aspiration, 90% re- respective in the peritro- finitively demonstrate a septic pro- covered in 6 months.24 Intrabursal chanteric area. The glutei medius cess. However, Gram stains are posi- corticosteroid injection is associated and minimus attach to the greater tive in only 50% to 60% of cases, with complications, including infec- trochanter superiorly and anteriorly, and it may take several days to ob- tion, skin atrophy, and chronic and they act to abduct and internally tain the results of culture.17,19 A WBC pain.24 rotate the hip. count <1,000/mm3 is consistent with Septic bursitis is managed with Tendinosis of the gluteus medius aseptic bursitis, and a WBC count drainage of collected fluid, mechani- and/or minimus tendons is increas- >10,000/mm3 is generally consistent cal rest, and systemic antibiotics. Se- ingly accepted as the primary pathol- with septic bursitis.18,22 With counts rial aspiration or open incision and ogy of trochanteric bursitis.27,28 In between these levels, the predomi- drainage may be performed. Antibi- fact, some authors have proposed the nant cell type may be used to distin- otics may be administered orally or term “greater trochanter pain syn-

362 Journal of the American Academy of Orthopaedic Surgeons Daniel L. Aaron, MD, et al

Figure 3

A, Axial T2-weighted magnetic resonance image demonstrating an inflamed trochanteric bursa (arrowhead) and tear of the gluteus medius tendon (curved arrow). Note the normal gluteus medius tendon (arrow) on the contralateral side. B, Coronal T2-weighted magnetic resonance image demonstrating tendinosis of the gluteus medius tendon (arrowhead). (Reproduced with permission from Kingzett-Taylor A, Tirman PF, Feller J, et al: Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. AJR Am J Roentgenol 1999;173[4]: 1123-1126.) drome” (GTPS) as a more accurate Another retrospective review of sign, pain with resisted abduction description of the condition.27 Glu- MRI studies reported that patients and internal rotation, and pain elic- teal tendon tearing is not well under- with trochanteric bursitis had abnor- ited with the Ober and flexion, stood; thus, well-defined clinical in- malities of the gluteus medius tendon abduction, and external rotation dications, physical examination without swelling of the trochanteric (FABER) tests. The Ober test is used tools, and management options are bursa.28 Bird et al29 reported that 20 to detect of the iliotibial needed. of 24 patients with definitive diagno- band. With the patient in the lateral In a review of 250 magnetic reso- sis of trochanteric bursitis had either position, the affected leg is abducted, nance images of the hip to evaluate abnormal signal at the insertional and the hip is extended with the of the buttock, lateral hip, and gluteus medius or a frank tear at the in extension. The leg is then allowed groin, Kingzett-Taylor et al27 identi- to adduct past neutral. A positive musculotendinous junction on MRI. fied 35 patients with evidence of ten- test is represented by inability to ad- dinopathy of the gluteus medius and Presentation and Physical duct past the midline. A positive minimus tendons (Figure 3). Twenty- FABER test is represented by pain in Examination two patients had gluteus medius the sacroiliac region. According to tears (8 complete, 14 partial). Thir- Patients with trochanteric bursitis the modified Krout and Anderson di- teen patients had tendinosis of the typically present with lateral hip agnostic criteria developed by Ege gluteus medius. The gluteus minimus pain, which may radiate to the but- Rasmussen and Fanø,30 the diagnosis was involved in 10 patients (5 each tock, groin, or low back. Symptoms of trochanteric bursitis requires lat- in the tear and tendinosis groups). may be exacerbated by ambulation, eral hip pain and tenderness over the Fourteen had evidence of fluid col- walking uphill, stair climbing, and greater trochanter as well as one of lection in the trochanteric bursa. Six rising from a seated position. the following criteria: pain at the ex- patients had osteoarthritis of the hip. Physical examination may reveal tremes of rotation, abduction, or ad- The authors concluded that tendin- normal range of motion at the hip duction; pain on forceful contraction opathy of the gluteus medius and joint. Positive findings include ten- of the hip abductors; and pseudora- minimus tendons is a substantial and derness over the lateral aspect of the diculopathy, with pain primarily ra- underrecognized cause of GTPS. greater trochanter, Trendelenburg diating down the lateral aspect of the

June 2011, Vol 19, No 6 363 Four Common Types of Bursitis: Diagnosis and Management thigh. Although these criteria are abductor tendons into the bone has has been given many names, includ- widely used in practice, their sensi- been described to manage tendinosis ing Haglund syndrome, Albert dis- tivity, specificity, and predictive value or partial or complete tear of the glu- ease, calcaneus altus, pump bump, have not been established.31 teus medius—the so-called rotator winter heel, and achillodynia.39 cuff tear of the hip.34,35 Degenerative Diagnosis and necrotic tissue is débrided, and Anatomy The diagnosis of trochanteric bursitis the tendon stump is secured to the The posterior calcaneal tuberosity is typically clinical, made after ex- trochanter with suture anchors. In a serves as the attachment point for 26 cluding lumbar pathology such as small series by Lequesne, six of the . This tuberosity, spinal stenosis, spondylosis, and ra- seven patients who underwent this which is located just proximal to the diculopathy; intrinsic hip pathology procedure were symptom-free after insertion of the Achilles tendon, is such as osteoarthritis, osteonecrosis, surgery. The remaining patient had covered with fibrocartilage40 (Figure and stress fracture; and local dis- partial improvement. 4). This area typically defines the an- 36 eases, such as soft-tissue infection Govaert et al described a tro- terior wall of the retrocalcaneal and bone and soft-tissue tumors.31 chanteric reduction osteotomy for bursa. The bony projection of Hag- MRI is a reliable modality in the di- the management of recalcitrant tro- lund deformity typically lies superior agnosis of trochanteric bursitis. Stan- chanteric bursitis. The authors ini- to this point. The retrocalcaneal dard hip radiographs are obtained to tially used the technique as a salvage bursa lies between the calcaneus an- evaluate for concomitant arthritic procedure for patients with failed ar- teriorly and the Achilles tendon. A disease of the hip joint and prior throscopic bursectomy and iliotibial synovial lining on the superior aspect trauma to the trochanter. band release. The osteotomy is per- separates the bursa from the Achilles Bird et al29 used MRI to assess 24 formed medial to the gluteus medius fat pad (ie, Kager fat pad).41 This fat patients with lateral hip pain and insertion proximally and extends be- pad is bordered by the flexor hallucis tenderness over the greater tro- yond the vastus ridge distally. De- longus anteriorly, the calcaneus infe- chanter. Three physical examination pending on the prominence of the riorly, and the Achilles tendon poste- techniques were performed as well, trochanter, a wafer of bone measur- riorly. The Achilles fat pad appears including assessment of the Trende- ing 5 to 10 mm thick is removed. as a sharply marginated, radiolucent lenburg sign, pain on resisted abduc- The trochanter is transferred medi- area on radiographs. tion, and pain on resisted internal ro- ally and distally and secured with The anterior wall of the retrocalca- tation. Only two patients had two 4.5-mm cortical lag screws. neal bursa is cartilaginous, and the evidence of bursal distension on Good results were reported at a posterior wall is tendinous. The magnetic resonance images, and no mean follow-up of 23.5 months. bursa is filled with highly viscous patient exhibited distention without Complications of trochanteric os- fluid rich in hyaluronate.42 concomitant pathology of the glu- teotomy have been well described in teus medius. Trendelenburg assess- the setting of total hip arthroplasty. Pathology and Physical ment exhibited the greatest sensitiv- Nonunion is the primary complica- Examination tion, occurring in 5% to 32% of ity, specificity, and intraobserver Because of the close anatomic rela- cases.37 Impaired abductor function reliability. tionship between the elements of the is another potential complication. posterior aspect of the calcaneus, pa- Transfer of the greater trochanter Management thology affecting one structure often distally, as is done in trochanteric ad- Initial management consists of physi- affects the surrounding structures as vancement, maintains the length and cal therapy and oral NSAIDs. If well. Pain anterior to the Achilles strength of the hip abductors.38 symptoms persist, local glucocorti- tendon and just superior to the calca- coid injection is performed.32,33 Most neus is the hallmark of retrocalca- patients respond to nonsurgical man- neal bursitis. Patients often have a agement. positive two-finger squeeze test, that Increased understanding of the un- Inflammation of the retrocalcaneal is, pain when pressure is applied derlying pathology of GTPS has led bursa can limit function and cause with two fingers placed medially and to the development of enhanced sur- pain. The Achilles tendon and its laterally anterior to the Achilles in- gical options for refractory trochan- bony insertion may be involved in se- sertion.43 Pain may be elicited with teric bursitis. Reattachment of the vere cases. This spectrum of disease dorsiflexion of the foot and on active

364 Journal of the American Academy of Orthopaedic Surgeons Daniel L. Aaron, MD, et al

Figure 4 cates that steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon.46 Careful con- sideration is warranted prior to ad- ministration of corticosteroid injec- tion. Surgical intervention is warranted for retrocalcaneal bursitis that does not resolve with nonsurgical man- agement. Accurate clinical diagnosis guides surgical management. For re- fractory cases associated with Hag- lund deformity, open procedures in- clude resection of the calcaneal prominence proximal to the Achilles insertion, débridement of Achilles , and complete excision of the retrocalcaneal bursa.47-49 Alter- Illustration demonstrating the anatomy of the hindfoot. The posterior natively, dorsal closing wedge osteot- calcaneal tuberosity is covered with fibrocartilage just proximal to the omy may be considered to rotate the insertion of the Achilles tendon. This tuberosity apposes the anterior wall of posterior calcaneus to a lesser promi- the retrocalcaneal bursa. (Reproduced with permission from Stephens MM: 50 Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am nence. Complications of open pro- 1994;25[1]:41-46.) cedures include skin breakdown, Achilles tendon avulsion, altered sen- sation, and painful scar forma- tion.39,51 resisted plantar flexion, as well.39 tomatic. Symptoms typically mani- Although the goal of these proce- Pain is primarily caused by overuse; fest as pain lateral to the Achilles in- dures is the removal of inflamed tis- however, pain resulting from septic sertion. sue, recovery time is based in part on retrocalcaneal bursitis has been re- Insertional Achilles tendinosis is the etiology of the symptoms. Wat- 44 45 ported. Retrocalcaneal bursitis is another common diagnosis that must son et al reported significantly lon- particularly common in runners, es- be differentiated from retrocalcaneal ger recovery times in patients whose pecially those who regularly train on bursitis. This tendinitis occurs with primary etiology of posterior heel inclines, because ankle dorsiflexion or without such bursal involvement. pain was preexisting calcific tendini- augments stress on the bursa. Per- Insertional Achilles tendinosis causes tis of the Achilles tendon (P < 0.05). Endoscopic techniques were devel- sons with hindfoot varus as well as pain directly at the insertion of the those with a rigid plantarflexed first oped to reduce recovery time and de- Achilles tendon.45 ray are also susceptible to retrocalca- crease morbidity compared with open procedures. Ortmann and neal bursitis. A diagnosis of bilateral Management retrocalcaneal bursitis is suggestive McBryde51 reported excellent results of inflammatory arthritis.43 Management of these causes of pos- in their series of 30 patients who un- The morphologic relationship be- terior heel pain begins with ice, ac- derwent endoscopic bony and soft- tween the shape of the posterior tu- tivity modification, NSAIDs, and or- tissue decompression for the man- berosity and retrocalcaneal bursitis is thoses. Shoe wear modification to agement of retrocalcaneal bursitis unclear. Although prominence of the prevent irritation of the posterior with Haglund deformity. Of the 28 posterosuperior lateral aspect of the heel by the shoe counter should be patients available for follow-up, av- tuberosity (ie, Haglund deformity) considered, as well. Maneuvers that erage American Orthopaedic Foot seems to be related to the occurrence stretch the local Achilles tendon may and Ankle Society score increased of bursitis, it is by no means causal. aid in attenuating the symptoms. Re- from 62 preoperatively to 97 postop- These deformities are seldom symp- cent evidence in a rabbit model indi- eratively.

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Case report and literature review. Clin 20. Cruz C, Shah SV: Dialysis elbow: Summary Rheumatol 2007;26(11):1941-1942. Olecranon bursitis from long-term hemodialysis. JAMA 1977;238(3):243. 5. Wang JP, Granlund KF, Bozzette SA, Prepatellar, olecranon, trochanteric, Botte MJ, Fierer J: Bursal sporotrichosis: 21. Morrey BF: Bursitis, in Morrey BF, and retrocalcaneal bursitis should be Case report and review. Clin Infect Dis Sanchez-Sotelo J, eds: The Elbow and its 2000;31(2):615-616. Disorders, ed 4. Philadelphia, PA, considered in the differential diagno- Saunders, 2009, pp 1164-1173. 6. Stell IM, Gransden WR: Simple tests for sis in the patient with musculoskele- 22. Canoso JJ: Idiopathic or traumatic septic bursitis: Comparative study. BMJ tal pain. Bursitis must be distin- olecranon bursitis: Clinical features and 1998;316(7148):1877. bursal fluid analysis. Arthritis Rheum guished from other causes of pain, 7. Langford CA, Gilliland BC: Periarticular 1977;20(6):1213-1216. including arthritis, tendinitis, frac- disorders of the extremities, in Fauci AS, 23. Stewart NJ, Manzanares JB, Morrey BF: ture, tendon or ligament injury, and Braunwald E, Kasper DL, et al, eds: Surgical treatment of aseptic olecranon nerve pathology. Infectious etiology Harrison’s Principles of Internal bursitis. J Shoulder Elbow Surg 1997; Medicine, 17e. http://www.accessmedic 6(1):49-54. must be promptly ruled out or man- ine.com/content.aspx?aID=2863288. 24. Weinstein PS, Canoso JJ, Wohlgethan JR: aged. Although nonsurgical manage- 8. Stell IM: Management of acute bursitis: Long-term follow-up of corticosteroid ment is a therapeutic mainstay, re- Outcome study of a structured approach. injection for traumatic olecranon bursi- J R Soc Med 1999;92(10):516-521. tis. Ann Rheum Dis 1984;43(1):44-46. fractory cases may require surgical intervention. The orthopaedic sur- 9. Knight JM, Thomas JC, Maurer RC: 25. 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