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.
Try two board-style Bursitis questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1MusculoskeletalMedium
A 52-year-old carpet layer presents with a 3-day history of a swollen, painful posterior elbow. He reports the area has become increasingly warm and red over the past day, and he has a low-grade fever. On examination there is a fluctuant, erythematous, tender swelling over the olecranon with overlying skin abrasions. Elbow flexion and extension are preserved and painless. Which of the following is the most appropriate next diagnostic test?
AAspiration of the bursal fluid
BMRI of the elbow with IV contrast
CMeasurement of serum uric acid
DPlain radiograph of the elbow
Reveal answer & full explanation
Correct answer: A — Aspiration of the bursal fluid
AAspiration of the bursal fluid✓
BMRI of the elbow with IV contrast
CMeasurement of serum uric acid
DPlain radiograph of the elbow
Why Aspiration of the bursal fluid is correct
The combination of warmth, expanding erythema, fever, and overlying skin breakage over a superficial olecranon bursa raises concern for septic bursitis, most often from Staphylococcus aureus (including MRSA) entering through the skin.
Aspirating the fluctuant bursa and sending fluid for Gram stain, culture, cell count with differential, and crystal analysis is the definitive next step: bursal fluid WBC >2,000-5,000/mm3 with neutrophil predominance plus a positive Gram stain or culture confirms infection and guides antibiotic therapy.
Preserved, painless joint range of motion confirms the process is bursal rather than intra-articular, so the bursa (not the joint) is the structure to sample.
Why the others are wrong
Plain radiograph of the elbow is useful for trauma, foreign body, calcific deposits, or an olecranon spur, but it cannot distinguish septic from aseptic bursitis and does not change acute management when infection is suspected.
Measurement of serum uric acid supports gout if elevated but is neither sensitive nor specific, can be normal during an acute flare, and does not exclude the infection that must be ruled out first.
MRI of the elbow with IV contrast is reserved for refractory or complicated cases such as suspected osteomyelitis or abscess; it is costly, delays care, and is not the first study when bedside aspiration can rapidly confirm the diagnosis.
Question 2MusculoskeletalMedium
A 44-year-old male carpet layer presents with a 1-week history of painless swelling over the tip of his right elbow that he first noticed after a long week of kneeling and leaning on his elbows. He reports no fever, chills, or recent skin breaks. On examination there is a soft, fluctuant, "goose-egg" swelling over the olecranon without overlying erythema or warmth. Elbow flexion and extension are full and pain-free, and there is no tenderness with passive range of motion. Vital signs are normal. Which of the following is the most appropriate initial management?
AActivity modification and NSAIDs
BSurgical bursectomy of the bursa
CIntrabursal triamcinolone injection
DImmobilization in a long-arm splint
Reveal answer & full explanation
Correct answer: A — Activity modification and NSAIDs
AActivity modification and NSAIDs✓
BSurgical bursectomy of the bursa
CIntrabursal triamcinolone injection
DImmobilization in a long-arm splint
Why Activity modification and NSAIDs is correct
This is uncomplicated aseptic olecranon bursitis: a soft fluctuant goose-egg swelling with full, pain-free elbow range of motion and no fever, erythema, or warmth to suggest infection.
First-line care is conservative: avoid the inciting pressure, pad the elbow, apply ice and a short course of NSAIDs (ibuprofen, naproxen, or diclofenac for 7-14 days), and use a compressive wrap. Most aseptic cases resolve without further intervention.
Why the others are wrong
Intrabursal triamcinolone injection is a second-line option, but corticosteroid should not be injected until septic bursitis is excluded by aspiration and Gram stain, and it risks skin and subcutaneous atrophy.
Immobilization in a long-arm splint — splinting is not part of bursitis care and risks elbow stiffness and contracture; motion is already full and pain-free, and the problem is external pressure over the bursa, which is addressed with elbow padding, compression, and avoiding kneeling on the elbow.
Surgical bursectomy of the bursa is reserved for recurrent, chronic, or refractory aseptic bursitis or complicated septic cases, not a first presentation with new swelling.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Bursitis (Olecranon, Prepatellar, Trochanteric) outline — plus all 514 diagnoses, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
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)
Practice Musculoskeletal questions on FirstPassPA
Turn this outline into retention. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.