Bursitis, tendinopathy and overuse injuries

• Bursitis is inflammation of a bursa, the small fluid-filled sac that reduces friction between bone and soft tissue; tendinopathy is painful deterioration or inflammation of a tendon from overuse. Both are common, usually self-limiting musculoskeletal problems.
• The classic picture is focal pain and swelling made worse by movement or pressure, with preserved passive joint range of motion when the lesion is isolated; pain anywhere from the shoulder to the heel can be explained this way.
• Septic bursitis must be excluded whenever a superficial bursa is red, warm, tender or swollen, because those bursae (olecranon, prepatellar) can be infected.
• First-line care is almost never immediate surgery: rest or activity modification, ice, an exercise and stretching programme, NSAIDs where safe, and only then aspiration or injection.
• Corticosteroid injections help selected deep bursae and some tendon insertion sites, but they are unsafe in the Achilles tendon and can weaken tendons if repeated or misplaced.

By the end of this page you should be able to:

1. Define a bursa and a tendon, and tell bursitis, tendinopathy, tendinitis and tendinosis apart.
2. Localise the common bursitides (subacromial, olecranon, trochanteric, prepatellar, pes anserine) and tendinopathies (lateral epicondylitis, plantar fasciitis, Achilles) from the history and examination.
3. Choose and interpret the investigations that exclude infection, crystal disease and tendon rupture.
4. Plan first-line treatment with rest, exercise, NSAIDs and injection, and state the contraindications to corticosteroid injection.
5. Recognise the red flags of septic bursitis and know how to manage it.
6. Advise about prognosis, prevention and care in older adults and pregnant patients.

A bursa is a fluid-filled sac lined by synovial membrane that sits where tendons, muscles or skin glide over bone, reducing friction and cushioning the joint. Bursitis is inflammation of that sac. A tendon is the cord that joins muscle to bone; tendinopathy (often called tendinitis) is a painful tendon condition due to overuse, microtrauma or degeneration. Tendinitis implies acute inflammation, tendinosis implies chronic degeneration, and in practice the umbrella term tendinopathy is used for both.

Bursitis can be classified by location (superficial or deep), by duration (acute or chronic), and by cause. Acute bursitis produces pain when the bursa is stretched or compressed, may cause swelling, and usually limits movement a little, although passive joint movement can stay normal if the bursa alone is inflamed. Chronic bursitis can last months, recur, thicken the bursal wall, and limit movement (these and the other points below are based on the MSD Manual and AAOS sources listed at the end). Septic bursitis is infection of the sac, most often with staphylococci.

The common bursitides are: subacromial (shoulder, usually secondary to rotator cuff tendinopathy), olecranon (posterior elbow), trochanteric (lateral hip, now more often considered gluteus medius tendinopathy than isolated bursitis), prepatellar (anterior knee, "housemaid's knee") and pes anserine (medial knee just below the joint). Common tendinopathies are lateral epicondylitis ("tennis elbow"), plantar fasciitis, and Achilles tendinopathy, which may be non-insertional (mid-portion) or insertional (at the heel bone).

Bursitis and tendinopathy are everyday problems in primary care and sports medicine. Plantar fasciitis is among the commonest causes of heel pain: the AAOS patient resource used here notes that about 2 million patients are treated for it each year.^[6] Tennis elbow is most often seen between the ages of 30 and 50 years.^[5] Hip bursitis (greater trochanteric pain syndrome) is more common in women and in middle-aged or older adults.^[3] Several forms of bursitis show a female predominance, particularly pes anserine and trochanteric, and are more common in people who are obese, whereas olecranon bursitis affects men more often because of manual occupations.^[9]

Pes anserine and trochanteric syndromes are more common with obesity and osteoarthritis of the knee or hip. Risk rises with repetitive loading, sudden increases in training, and age-related tendon change from middle life onwards.

Bursitis is usually idiopathic or traumatic. Recognised causes include injury (acute or repetitive), chronic overuse or pressure, osteoarthritis, crystal-induced arthropathy (gout, pseudogout), inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, spondyloarthritis) and infection.^[9] Superficial bursae such as the olecranon and prepatellar are the ones most easily infected because of their exposed position.^[9]

Risk factors by site:

• Subacromial. Repetitive overhead work or sport (swimming, tennis, baseball pitching, weightlifting), an acromial bone spur and advancing age; subacromial bursitis usually results from rotator cuff tendinopathy.^[8][11]
• Olecranon. Prolonged leaning on hard surfaces, a hard blow to the elbow tip, gout or rheumatoid arthritis, and skin breakdown allowing infection.^[2]
• Trochanteric. Repetitive running, stair climbing or cycling, direct trauma, tight iliotibial band, leg-length inequality, lumbar spine disease, rheumatoid arthritis, prior hip surgery and bone spurs.^[3]
• Prepatellar. Constant kneeling (plumbers, roofers, carpet layers, gardeners), contact-sport impacts and gout or rheumatoid arthritis; infection follows any break in the skin.^[1]
• Pes anserine. Runners, swimmers and cyclists, sports with cutting movements, tight hamstrings, obesity, flat feet or knock-knees and knee osteoarthritis.^[4]
• Tennis elbow. Repetitive forearm extensor loading in manual workers (painters, plumbers, carpenters, butchers) and racquet-sport players; most patients are 30 to 50 years old.^[5]
• Plantar fasciitis. New or increased activity, repetitive high-impact loading, prolonged standing on hard surfaces, flat feet or high arches, tight calves, obesity and age 40 to 60 years.^[6]
• Achilles tendinopathy. Sudden increase in training load, change of footwear, tight calf muscles and Haglund deformity; non-insertional disease is commoner in younger runners.^[7]

Fluoroquinolone antibiotics have been linked with tendinopathy and tendon rupture and should be kept in mind when an overuse problem starts after a prescription.^[10]

Repeated mechanical load exceeds the tendon or bursa's capacity to recover. In tendons, repetitive microtrauma produces degenerative change (tendinosis) with or without superimposed inflammation (tendinitis); in bursae the synovial lining is irritated and produces excess fluid, so the sac swells and stretches, causing pain. In the shoulder, a tight or inflamed rotator cuff tendon occupies the subacromial space, so the acromion impinges on the tendon and bursa when the arm is lifted, producing the painful arc and bursitis.^[8][11]

The supraspinatus tendon is particularly vulnerable because of a relatively avascular zone near its insertion; inflammation and oedema then narrow the subacromial space further.^[11] In trochanteric pain, the problem is now thought to be gluteus medius/minimus tendinopathy rather than an inflamed bursa alone. In plantar fasciitis, repetitive tension at the calcaneal insertion leads to degenerative change and, only in longstanding cases, a heel spur, which is a consequence not a cause of the pain.^[6]

Septic bursitis follows skin breakdown (or a nearby cellulitis): bacteria enter the sac, fluid turns purulent, and the sac becomes painful, red, warm and swollen. The olecranon and prepatellar bursae are the common sites because of their superficial position.^[2][9]

• Bursitis. "A lump or swelling that appeared after I knelt/leaned/elbowed", pain with touch or movement, maybe a report of a fall. Over the shoulder the patient struggles to reach overhead or behind the back; over the hip, pain at night lying on the affected side.
• Tendinopathy. Pain that came on with a change in training or workload, often first thing in the morning or after rest ("first step pain" in plantar fasciitis), easing after a few minutes of walking but returning after prolonged activity.
• Red flags for infection. Rapidly increasing pain, redness, warmth, fever, chills, skin break or recent insect bite.

General features: localised swelling and tenderness, warmth in acute (especially septic or crystal) disease, normal or near-normal passive movement when only the bursa is involved, pain with active movement and resisted loading.^[9]

Site-specific signs:

• Subacromial. Painful arc between 60 and 120 degrees of abduction/flexion, pain on overhead reaching, tenderness below the acromion. Impingement tests (forced forward flexion/Neer, 90 degrees abduction with internal rotation/Hawkins) may reproduce pain.^[11]
• Olecranon. Swelling over the posterior elbow tip, sometimes larger than the pain; preserved flexion-extension if isolated. Redness and warmth point to infection.^[2][9]
• Trochanteric. Point tenderness over the greater trochanter, pain lying on the hip, with prolonged walking or stair climbing.^[3]
• Prepatellar. Rapid swelling in front of the kneecap, tenderness and warmth; fever and chills if infected.^[1]
• Pes anserine. Tenderness 2 to 3 inches below the medial knee joint line, worse with exercise or stairs, puffiness.^[4]
• Tennis elbow. Tenderness just distal to the lateral epicondyle, pain on resisted wrist extension or middle-finger extension (Maudsley test), reduced grip strength, full passive range preserved.^[5]
• Plantar fasciitis. Point tenderness over the medial calcaneal tuberosity, limited ankle dorsiflexion with the knee straight, positive Windlass test (heel pain on forced dorsiflexion of the toes).^[6]
• Achilles tendinopathy. Morning pain and stiffness, swelling and tenderness along the tendon or at the insertion, reduced dorsiflexion.^[7]

Clinical diagnosis comes first; investigations are used to exclude mimics and to confirm when deep bursae are involved.

Ambulatory ultrasound and MRI are also considered when symptoms persist and other causes are suspected. In plantar fasciitis, imaging is reserved for atypical or refractory cases.^[6]

Current named guidance: the NICE Clinical Knowledge Summaries (CKS) topics on olecranon bursitis, pre-patellar bursitis, greater trochanteric pain syndrome, plantar fasciitis, Achilles tendinopathy and tennis elbow (the latest online topic revisions), and the AAOS OrthoInfo patient and clinician education on bursitis and tendinopathy (AAOS). Guidance names used below are NICE CKS and AAOS. Every patient should also be checked against local formularies for drug safety and dosing.

• Reduce or stop the provoking activity but keep gentle movement; for tendons, avoid prolonged complete rest and return to load when pain allows.^[6][7]
• Ice the area for 20 minutes (less if the skin goes numb), 3 to 4 times a day for at least the acute phase.^[1][6][7]
• Elevation and rest for superficial bursitis; splint to keep the elbow straight in olecranon bursitis.^[2]
• Stretch and strengthen: calf/plantar fascia stretches for plantar fasciitis (10 second holds, 20 repetitions each side), calf stretches (30 second holds, 10 repetitions) and eccentric heel drops for non-insertional Achilles tendinopathy.^[6][7]
• Physical therapy for IT-band and hip strengthening in trochanteric pain; rotator cuff strengthening for subacromial disease.^[3][11]
• Weight loss, footwear advice and orthoses for plantar fasciitis; kneepads for prepatellar disease.^[1][6]

• NSAIDs (ibuprofen, naproxen, piroxicam, celecoxib and others) reduce pain and inflammation in non-septic bursitis and tendinopathy, and are the mainstay of drug treatment; use cautiously and for short periods, and avoid long-term unsupervised use.^{[3][6][7][10] [9]}
• Topical NSAIDs, such as over-the-counter diclofenac gel, are an option in pes anserine bursitis.^[4]
• Acetaminophen/paracetamol is an alternative when NSAIDs are not tolerated.^[1]
• Do not use NSAIDs for more than 1 month without consulting the primary care clinician.^[6][7]

Injection is helpful in selected cases but should be used with strict limits.

• Deep bursae (subacromial, trochanteric, pes anserine): depot glucocorticoid 0.5 to 1 mL (for example triamcinolone acetonide 40 mg/mL) plus about 1 mL local anaesthetic (for example 2% lidocaine) after infection and crystal disease are excluded; the injection gives short-term pain relief (less than 6 weeks) in shoulder bursitis.^{[9] [10]}
• Prepatellar and olecranon bursae: injection is less commonly used for these superficial bursae; many are treated by aspiration with or without injection of steroid.^[9]
• Tennis elbow: steroid injections may help short term but should be used very sparingly, because excessive use can weaken the lateral epicondyle.^[5]
• Plantar fascia: injection reduces pain but can weaken the fascia and lead to rupture, so many clinicians limit or avoid it; PRP does not carry the same rupture risk.^[6]
• Achilles tendon: corticosteroid injection is not recommended, because it can weaken the tendon and cause rupture.^[7][10]
• Never inject into the tendon itself: resistance on injection signals intratendinous placement, which weakens the tendon and raises rupture risk.^[10]
• In tendinopathy generally, steroid is not effective for long-term pain relief and some evidence suggests it may increase tendon rupture.^[10]
• Repeat steroid injections are discouraged (in hip bursitis the injection may be repeated once a few months later if needed, but repeated use can damage surrounding tissues).^[3]
• Post-injection flare: local pain can worsen for 24 hours or less and resolve within 48 hours; cold compresses and analgesia are usually enough.^[9][10]
• Injection volume in tendons ranges 0.3 to 1 mL depending on site; an injection of equal or double volume of local anaesthetic confirms the diagnosis if pain is immediately relieved.^[10]

Suspected septic bursitis (especially olecranon and prepatellar) is managed as an infection:

• Aspirate the bursa, send fluid for cell count, Gram stain and culture, and crystals; start empiric antibiotics active against Staphylococcus aureus after aspiration.^[1][2][9]
• Superficial overlying cellulitis is a relative contraindication to puncture through the cellulitis, but if septic bursitis is strongly suspected aspiration should still be performed.^[9]
• Surgical drainage or bursectomy is used if infection does not respond to antibiotics and aspiration.^[1][2][9]
• Urgent admission is needed for a suspected septic joint or septic bursitis with severe infection or systemic toxicity.^[9]

• Surgery for bursitis is reserved for infected bursae that fail to respond and for chronic non-infected bursae that remain disabling after months of conservative care.^[1][2][9]
• Olecranon bursitis that has not responded after 3 to 6 weeks may be considered for aspiration and injection.^[2]
• Tennis elbow surgery is considered only after 6 to 12 months of failed non-surgical care; about 80 to 95% of patients succeed without surgery.^[5]
• Achilles surgery (debridement, with transfer of another tendon if more than 50% of the tendon must be removed) is considered only after 6 months of failed care; return to pre-surgical activity level occurs in up to 75% of patients and satisfaction in up to 90%, with 20 to 30% experiencing continued pain and up to 12 months of rehabilitation.^[7]
• Plantar fasciitis surgery (partial fascia release or gastrocnemius recession) is generally reserved for those without improvement after 12 months of aggressive conservative care.^[6]
• Hip bursitis surgery (bursectomy, open or endoscopic) is used only after all non-surgical options have failed.^[3]

• Infection progression / septic bursitis if a superficial bursa is not treated.^[1][2][9]
• Tendon rupture, especially after intratendinous or repeated steroid injection, with fluoroquinolone use, or in asymptomatic tendinopathy.^[7][10]
• Chronic pain and disability from prolonged inflammation and muscle wasting with chronic bursitis.^[9]
• Calcific change and thickening in longstanding Achilles or rotator cuff disease.^[7]
• Surgical risks (infection, wound problems, possible prolonged rehabilitation, loss of strength after tennis elbow surgery).^[5][7]
• Post-surgical persistent pain (20 to 30% after Achilles surgery).^[7]

Most cases recover with conservative care. Plantar fasciitis has an excellent prognosis: more than 90% of patients improve within 10 months of simple conservative care.^[6] Tennis elbow settles without surgery in 80 to 95% of patients.^[5] Achilles tendinopathy often takes longer; even with early treatment, pain can last longer than 3 months.^[7] Steroid-related tendon weakening and the possibility of rupture are the avoidable complications that otherwise worsen outcome.

• Modify activities early; do not push through pain, and increase load and mileage gradually.^[5][6][7]
• Warm up and cool down, and maintain calf, hamstring and hip flexibility and strength.^[5][6][7]
• Use appropriate equipment (racquet size and tension, footwear), surfaces and kneepads.^[1][5][6]
• Lose excess weight where obesity is a risk factor, and avoid prolonged kneeling or leaning.^[1][3][4][6]
• Take regular breaks from repetitive work and cross-train to avoid overuse of one tissue.^[3][5][6]
• No population screening test exists; prevention is risk-factor modification and early self-management.

• Older adults. Degenerative rotator cuff tendinitis and trochanteric pain are common in adults over 40 years who are not athletes.^[3][11] NSAID and injection risks (renal, gastrointestinal, cardiovascular) are higher; discuss all drugs with the clinician, and emphasise supervised exercise.
• Children and adolescents. Overuse in young athletes is an increasing problem; overuse in a child needs assessment of training load and technique, and not simply adult protocols. (No paediatric dosing evidence is used here.)
• Pregnancy. No special pregnancy-specific protocol is given in the sources used; imaging and drug choices, including NSAIDs and injection, should follow obstetric guidance and local formulary. Keep exercise-based management first.
• Immunosuppressed patients. Signs of septic bursitis can be subtle; aspirate early when there is any warmth, erythema or tenderness.^[9]

• The diagnosis is clinical in most cases; a good history and targeted examination will localise the problem without imaging.^[9]
• Ultrasound (even portable equipment) helps confirm deep bursitis and tendon tears; X-ray rules out fracture and spur if available.^[9][11]
• Use oral NSAIDs where safe, simple stretching and strengthening, activity modification, ice and, where available, one carefully sited steroid injection into a deep bursa. Avoid steroid injection into the Achilles and avoid unnecessary repeated injections.^{[3][7][9][10]}
• Aspiration for septic bursitis can be done with basic sterile technique; empiric anti-staphylococcal antibiotics are started after the sample is taken.^[9]
• Surgical or endoscopic bursectomy needs referral to an orthopaedic centre.

See the differential diagnosis table above for pointers on infection, crystal disease, nerve entrapment, referred pain and tendon rupture.

• Bursitis is inflammation of a synovium-lined sac; tendinopathy is overuse-related pain and degeneration of a tendon. Both are common and usually self-limiting.
• Bursae of the shoulder (subacromial), elbow (olecranon), hip (trochanteric) and knee (prepatellar, pes anserine) are commonly affected; tendinopathy commonly involves the lateral epicondyle, plantar fascia and Achilles tendon.
• Superficial bursae (olecranon, prepatellar) are the ones that become septic; exclude infection, crystal disease and haemorrhage before injecting.
• First-line care is activity modification with maintained movement, ice, stretching and strengthening, and NSAIDs where safe; topical NSAIDs are an option for pes anserine bursitis.
• Corticosteroid injections help for selected deep bursae (subacromial, trochanteric, pes anserine; dose 0.5 to 1 mL of depot steroid such as triamcinolone acetonide 40 mg/mL) with short-term relief under 6 weeks, but are to be used very sparingly for tennis elbow and plantar fasciitis and are not recommended for the Achilles tendon. ^[9]
• Never inject into the tendon; intratendinous placement risks rupture.
• Plantar fasciitis: more than 90% improve within 10 months with simple measures.^[6]
• Tennis elbow: 80 to 95% recover without surgery; surgery is reserved for failure after 6 to 12 months.^[5]
• Achilles tendinopathy often lasts longer than 3 months; repeated steroid injections are associated with tendon damage; surgery is reserved for 6 months of failed care.^[7]
• Rehabilitate after surgery; recurrence prevention depends on load management, flexibility and strength.

• Musculoskeletal examination and red flags for bone and joint pain.
• Rotator cuff disease and shoulder pain.
• Gout and other crystal arthropathies.
• Spondyloarthritis and inflammatory back pain.
• Osteoarthritis of the knee and hip.
• Soft tissue infections and sepsis recognition.