Musculoskeletal · PANCE / PANRE

Bursitis (Olecranon, Prepatellar, Trochanteric)

Inflammation of a synovial bursa from repetitive pressure, trauma, crystal disease, or infection.

Also known as: olecranon bursitis, student's elbow, prepatellar bursitis, housemaid's knee, trochanteric bursitis, greater trochanteric pain syndrome, GTPS

Overview

Inflammation of a synovial-lined bursa, the fluid-filled sac that reduces friction between skin, tendon, and bone. The three most commonly encountered locations on PA boards are the olecranon bursa (posterior elbow), prepatellar bursa (anterior knee), and trochanteric bursa (lateral hip — now more accurately called greater trochanteric pain syndrome since the underlying pathology is often gluteal tendinopathy).

Epidemiology

Olecranon and prepatellar bursitis predominate in working-age adults with occupational kneeling or leaning. Trochanteric pain syndrome is most common in women aged 40-60 and in patients with obesity, low back pain, or knee osteoarthritis.

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Risk factors

Repetitive pressure or friction (plumbers, carpet layers, gardeners, students leaning on elbows)
Direct trauma or abrasion overlying a superficial bursa
Crystal arthropathy (gout, pseudogout) — particularly olecranon bursa
Rheumatoid arthritis or other inflammatory arthritis
Immunosuppression and diabetes (increased risk for septic bursitis)
Hip abductor weakness and iliotibial band tightness (trochanteric pain syndrome)

Pathophysiology

Repeated microtrauma or compression provokes synovial hyperplasia and effusion. Aseptic bursitis is sterile inflammation; septic bursitis results from skin flora (most often Staphylococcus aureus, including MRSA) entering through a break in the skin overlying a superficial bursa. Crystal-induced bursitis follows urate or calcium pyrophosphate deposition with neutrophilic inflammation. In greater trochanteric pain syndrome, gluteus medius and minimus tendinopathy with secondary trochanteric bursa irritation accounts for most cases.

Clinical presentation

Symptoms

Localized swelling and discomfort over a bony prominence
Pain with direct pressure (kneeling, leaning) and at end-range motion
Trochanteric pain syndrome: lateral hip pain worse with lying on the affected side, climbing stairs, and prolonged standing
Fever, expanding erythema, or rapidly worsening pain suggests septic bursitis

Signs / physical exam

Discrete fluctuant, often boggy swelling overlying the bursa with preserved underlying joint range of motion
Warmth and erythema (more pronounced in septic or crystal-induced cases)
Trochanteric pain syndrome: point tenderness over the greater trochanter, pain with resisted hip abduction, positive single-leg stance test

Classic findings

Olecranon bursitis classically produces a goose-egg over the posterior elbow with full elbow flexion and extension — the hallmark feature that distinguishes it from septic arthritis.

Differential diagnosis

Septic arthritis — Pain with passive joint range of motion (bursitis spares the joint), fever, true intra-articular effusion; aspirate the joint if uncertain
Cellulitis — Diffuse erythema and warmth without a discrete fluid collection; no fluctuance to aspirate
Gout / pseudogout — Monoarticular crystal arthropathy; aspirate fluid for monosodium urate or calcium pyrophosphate crystals under polarized microscopy
Rheumatoid nodule — Firm, fixed, painless subcutaneous nodule over extensor surfaces in seropositive RA
Iliotibial band syndrome — Lateral knee pain with running; tenderness over lateral femoral epicondyle rather than greater trochanter
Hip osteoarthritis — Groin pain with internal rotation and flexion; trochanteric pain syndrome localizes laterally and reproduces with direct palpation
Lumbar radiculopathy (L4-L5) — Pain radiating down the lateral thigh and leg with positive straight leg raise; trochanteric tenderness usually absent

Diagnostic workup

Diagnostic criteria

Aspirate fluctuant superficial bursae when infection is suspected: send fluid for Gram stain, culture, cell count with differential, and crystal analysis. Bursal fluid WBC >2,000-5,000/mm3 with neutrophil predominance and positive Gram stain or culture confirms septic bursitis.

Labs

CBC with differential, ESR, and CRP if septic bursitis is suspected
Serum urate is not diagnostic but supports gout if elevated; obtain in atypical or recurrent olecranon bursitis

Imaging

Clinical diagnosis in most cases; imaging not routinely required
Plain radiographs if trauma, foreign body, or chronic refractory symptoms (look for fracture, calcific deposits, olecranon spur)
Ultrasound differentiates bursal fluid from intra-articular effusion and guides aspiration
MRI for refractory greater trochanteric pain syndrome to evaluate gluteal tendons and rule out tear

Diagnostic algorithm

Location	Common Trigger	Distinguishing Feature	Initial Step
Olecranon	Repeated leaning, gout, trauma	Posterior elbow goose-egg, full ROM	Aspirate if effusion or signs of infection
Prepatellar	Kneeling occupations, trauma	Superficial swelling anterior to patella	Aspirate if fluctuant or warm
Trochanteric	Hip abductor weakness, ITB tightness	Lateral hip tenderness, pain lying on side	Exercise therapy and NSAIDs

Three common bursitis locations on PA board examinations and the initial management approach.

Treatment

First-line

Activity modification, padding, and avoidance of direct pressure
Ice and NSAIDs — ibuprofen, naproxen, or diclofenac for 7-14 days
Compressive wrap for superficial bursae
Bursal aspiration for symptomatic effusion and to obtain diagnostic fluid
Physical therapy with hip abductor strengthening and iliotibial band stretching for greater trochanteric pain syndrome

Second-line / adjunct

Intrabursal corticosteroid injection (triamcinolone or methylprednisolone) after sterile aspiration — avoid if infection is possible because steroid worsens septic bursitis
Colchicine or oral steroids for crystal-induced bursitis
Empiric antibiotics for confirmed or strongly suspected septic bursitis: cephalexin or dicloxacillin for mild cases; trimethoprim-sulfamethoxazole, doxycycline, or clindamycin if MRSA suspected; IV vancomycin for severe or systemic infection
Surgical bursectomy reserved for recurrent, chronic, or refractory aseptic bursitis or for drainage of complicated septic bursitis

Complications

Recurrence — particularly with continued mechanical irritation
Septic bursitis with abscess formation or contiguous osteomyelitis
Skin breakdown and sinus tract formation over chronically inflamed bursae
Steroid-induced atrophy of overlying skin and subcutaneous tissue after intrabursal injection

PANCE pearls

Preserved passive joint range of motion is the cardinal feature that separates bursitis from septic arthritis.
Never inject corticosteroid into a bursa until septic bursitis has been excluded by aspiration and Gram stain.
Trochanteric pain syndrome is predominantly tendinopathy; exercise therapy outperforms steroid injection at one year (LEAP trial).
Recurrent gouty olecranon bursitis can mimic chronic infection — examine for tophi and check urate.

References

AAOS — American Academy of Orthopaedic Surgeons clinical guidance on olecranon and prepatellar bursitis
ACR 2020 — American College of Rheumatology Guideline for the Management of Gout (FitzGerald et al., Arthritis Care Res 2020)
LEAP Trial — Mellor R et al., Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy (BMJ 2018)

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