Elbow bursitis. Bobyr Clinic

What is this?

This is an inflammation of the periarticular bursae (from the Latin bursa - bag). Near some joints there are small cavities called bags that allow tissue to glide over the bones. Strictly speaking, the bursae are not directly related to the joints, are not connected to them, but are simply located nearby. From the inside, they are lined with a synovial membrane, which normally secretes a small amount of fluid, which is enough to lubricate and slide the tissues. When such a bursa becomes inflamed, the joint itself is not involved in the process.

Modern approaches to the treatment of bursitis (recommendations for an outpatient surgeon)

For citation. Akhtyamova N.E. Modern approaches to the treatment of bursitis (recommendations for an outpatient surgeon) // RMZh. 2021. No. 3. pp. 193–196.

Pathological processes in extra-articular soft tissues (skeletal muscles, tendons and their synovial sheaths, fascia, aponeuroses, synovial bursae) constitute a large group of pain syndromes of the musculoskeletal system and are united under the name “diseases of soft periarticular tissues” [1–4].
Diseases of soft periarticular tissues are very common, and currently there is a tendency towards a further increase in the incidence of this nosology. According to literature data, in a survey of 6000 people, lesions of periarticular soft tissues are detected in 8% of individuals. At least 25–30% of patients seeking outpatient medical care from surgeons, traumatologists, neurologists, and rheumatologists are patients with lesions of soft periarticular tissues [3, 4]. Pathological changes in the periarticular soft tissues can be a manifestation of both local and systemic disease. Most often, damage to extra-articular tissues is local in nature in the form of bursitis, tendinitis, tenosynovitis, tendovaginitis, enthesitis, fasciitis - due to local overloads, microtraumas and overstrain, especially against the background of congenital or acquired skeletal anomalies, such as scoliosis and kyphosis of the spine, hypermobility syndrome, axial bone deformations, etc. [3, 4]. On the other hand, extra-articular lesions can be one of the manifestations of systemic diseases, including inflammatory (rheumatoid arthritis, seronegative spondyloarthritis), endocrine (diabetes mellitus, hypothyroidism), metabolic (gout, hyperlipidemia, etc.) [1]. The structure of diseases of extra-articular soft tissues is represented by more than 50 independent nosological forms, among which lesions of the tendon-ligamentous apparatus, called diseases of periarticular soft tissues, prevail: periarthritis, enthesopathies, tendonitis, tendovaginitis, ligamentitis, bursitis, etc. [1]. Despite the high prevalence and variety of forms of damage, there is still no unity in terminology, methods of examining patients and criteria for diagnosing soft tissue diseases. Various options for systematizing lesions of extra-articular soft tissues were proposed: diseases were grouped according to anatomical, etiopathogenetic principles, clinical manifestations, etc. Classification and systematization of nosologies is necessary in order to improve diagnosis. The most reasonable systematization of lesions of periarticular soft tissues according to the anatomical and functional principle seems to be most reasonable. According to this principle, all lesions of periarticular soft tissues can be combined into 4 groups [2]. I. Muscle diseases
1.1.
Inflammatory muscle diseases – myositis 1.2. Non-inflammatory muscle diseases – myopathies 1.2.1. Reactive 1.2.2. Metabolic 1.2.3. Endocrine 1.2.4. Vascular 1.2.5. Toxic II.
Lesions of fibrous and synovial formations 2.1.
Tendinitis 2.2. Tenosynovitis and tenosynovitis 2.3. Bursitis 2.4. Ligamentitis – tunnel syndromes 2.5. Fasciitis and aponeurositis 2.6. Combined forms of damage - periarthritis 2.7. Combined forms of damage III.
Diseases of subcutaneous fat tissue 3.1.
Erythema nodosum 3.2. Painful lipomatosis - Dercum's syndrome 3.3. Panniculitis IV.
Primary fibromyalgia Despite the high prevalence of the disease, the variety of nosological forms and the high level of disability caused by the pathology of extra-articular soft tissues, to date this problem has received undeservedly little attention. One of the most common nosological forms of damage to periarticular soft tissues is bursitis. The proportion of this pathology in the general structure of diseases of the musculoskeletal system is very high, therefore this pathology attracts the close attention of specialists. Ideas about it have changed and been supplemented as a result of recent research. Often, bursitis was rightly considered a typical pathology of representatives of certain professions, which determine the localization of the process: the elbow joints are more often affected by tanners, engravers, polishers, and embossers; knee - for tilers, parquet workers, miners; shoulder - for blacksmiths, loaders; bursitis of the anterior surface of the scapula - in diggers and sawyers; calcaneal bursitis – among sellers and ballerinas [5–7]. However, occupational bursitis is only part of the problem of pathological processes faced by doctors in both outpatient and inpatient practice. According to modern concepts, the key factor in the development of bursitis is mechanical damage to the periarticular bursa, less often - infection, metabolic disorders, intoxication, allergic reactions, autoimmune processes. Mechanical damage may be associated with excessive load or a decrease in tolerance to the previous load with age-related changes [8]. Mechanical load on the synovial bursa leads to an increase in the production of synovial fluid, thereby providing the necessary shock absorption of the structural elements. The structure of the synovial bursa is favorable for the development of inflammation. It is a narrow slit-like cavity lined with synovial membrane, delimited from surrounding tissues by a capsule and filled with synovial fluid. Such features ensure the attachment of an infectious component and the formation of inflammatory infiltrates. Synovial macrophages play a key role in the formation of the immune response and can be activated by a variety of proinflammatory factors, so constant antigenic stimulation of the synovium can contribute to the development of chronic bursitis [5, 8, 9]. In clinical practice, there are classifications of bursitis of different causes [5]: • taking into account the location (elbow, knee, shoulder joint, etc.) and the name of the affected bursa; • depending on the clinical course: acute, subacute, chronic bursitis; • aseptic (non-infected) and infected bursitis; • taking into account the pathogen: specific (for syphilis, tuberculosis, brucellosis, gonorrhea) and nonspecific bursitis; • according to the nature of the exudate: serous (plasma mixed with a small amount of blood cells), purulent (microorganisms, destroyed cells, disintegrated leukocytes), hemorrhagic (liquid with a large number of red blood cells) and fibrinous (high fibrin content) bursitis. The clinical manifestations of bursitis are determined by the peculiarities of the structure and function of the joint around which the synovial bursae are located. The leading symptom of bursitis is a round, fluctuating swelling that appears at the site of the lesion, painful on palpation, with symptoms of local hyperthermia. In addition, clinically, bursitis is characterized by the presence of pain, which significantly reduces the quality of life of patients. In most cases, the duration of the disease is limited to one to two weeks and does not pose a serious danger to human health. However, with the addition of microbial flora and the further development of the inflammatory process, serous inflammation quickly turns into a purulent form. The spread of the purulent process to surrounding tissues can occur as a phlegmonous inflammation with necrosis of the bursa wall and the formation of subcutaneous and intermuscular phlegmon. In advanced cases, long-term non-healing fistulas form. The breakthrough of pus into the joint cavity leads to the development of purulent arthritis. The most common bursitis is the elbow bursae and the bursae of the shoulder, hip and knee joints, as well as the Achilles tendon area. Elbow bursitis in most cases is a consequence of chronic injury during sports or professional activities. In this case, the subcutaneous synovial bursa of the olecranon process is mainly affected, and less commonly, the radiobrachial synovial bursa of the lateral epicondyle [7, 8]. In the area of the shoulder joint, the most commonly affected bursae are those that do not communicate with the joint cavity - the subcutaneous acromial, subdeltoid and subacromial. Complaints boil down to pain during abduction and rotation of the upper limb. Bursitis of the subdeltoid bursa is especially painful [7, 10]. Bursitis in the hip joint is characterized by severity. The deep-lying iliopectineal bursa, located between the muscles and the joint capsule, as well as the superficial or deep synovial bursae in the area of the greater trochanter of the femur are more often affected by inflammation. Bursitis of these localizations is accompanied by pain in the hip joint, aggravated by walking, especially at the beginning of movement, and local pain on palpation in the greater trochanter. Active movements, especially external rotation and abduction, are acutely painful. Iliopsoas bursitis is associated with inflammation of the bursa located between the iliopsoas muscle and the anterior surface of the hip joint. The bursa is large and in some cases communicates with the joint cavity. When a significant amount of exudate accumulates in it, it can be detected in the groin in the form of a tumor-like formation. Bursitis is accompanied by pain in the hip joint. Compression of the femoral nerve by a stretched bursa can lead to pain and paresthesia in the thigh [8, 11]. The appearance of limited swelling in the area of the knee joint is observed when the synovial bursae are affected. Thus, in the popliteal region, a limited elastic formation may be detected, associated with inflammation of the semimembranosocnemius bursa (Baker's cyst). In some patients it reaches a large size and can spread to the lower leg. Limited swelling in the area of the patella is characteristic of prepatellar bursitis. The development of infrapatellar bursitis leads to the formation of a cyst-like formation that protrudes on either side of the patellar tendon. Foot anserine bursitis is an inflammation of the synovial bursae located in the area where the semitendinosus, sartorius, and gracilis tendons attach to the tibia. It is usually not accompanied by significant swelling, but causes pain during exercise and local tenderness upon palpation in the affected area [6, 8, 11, 12]. A consequence of heavy physical activity can be bursitis in the Achilles tendon area. Bursitis of this localization is accompanied by pain near the site of attachment of the Achilles tendon to the heel bone. Objectively, swelling, hyperemia of the skin, and local pain on palpation are determined in this area [11]. Particular attention should be paid to the timely treatment of bursitis, since the lack of effectiveness of treatment measures leads to long periods of disability, and in 35–50% of patients, according to literature data, to the frequent development of recurrent and chronic forms [1, 4, 5, 8, 9] . The consequence of this may be the occurrence of persistent functional disorders, which significantly limit physical activity, including ability to work, and have a negative impact on the quality of life of patients. A prerequisite for effective treatment of bursitis is the elimination of stress on the affected area. The nature of the load limitation depends on the severity of the disease and the location of the affected area. Traditionally, treatment of bursitis begins with the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) (Fig. 1). NSAIDs are included in the program of pathogenetic therapy of bursitis as one of the main components.

The mechanism of anti-inflammatory action of non-steroidal drugs is the same for all drugs in this group, based on inhibition of the synthesis of inflammatory mediators - prostaglandins due to inhibition of the activity of the enzyme cyclooxygenase (COX) [2, 8, 9]. Given the variety of existing drugs, choosing one of them can be difficult and requires attention to each individual case. The selection of NSAIDs is carried out empirically, taking into account the severity of the analgesic and anti-inflammatory effect, duration of action, and individual tolerance of the drug. If there is no effect within 5–7 days, the drug should be replaced with a non-steroidal agent of another chemical group (Table 1) [2].

Despite the variety of drugs, there is no ideal non-steroidal anti-inflammatory drug. Nevertheless, the results of the studies, as well as an assessment of the dynamics of the use of NSAIDs, make it possible to identify certain leaders. One of these drugs from the NSAID group is nimesulide (Nise®). Unlike most NSAIDs, nimesulide selectively inhibits the proinflammatory isoform of COX-2 and does not affect the physiological COX-1 [13]. It is the first selective COX-2 inhibitor synthesized [14]. Another advantage when prescribing nimesulide is its non-acidic origin (in the nimesulide molecule the carboxyl group is replaced by sulfonanilide), which provides additional protection of the gastrointestinal mucosa [14, 15]. The analgesic activity of nimesulide is close to that of indomethacin, diclofenac, and piroxicam. Nimesulide also has a number of pharmacological effects that are independent of COX-2 blockade. In particular, it suppresses the hyperproduction of the main pro-inflammatory cytokines (interleukin-6, TNF-), the phosphodiesterase-4 enzyme and thereby reduces the activity of macrophages and neutrophils, which play a fundamental role in the pathogenesis of the acute inflammatory reaction [14, 15]. According to the statement of the British professor K. Rainsford, “nimesulide is an NSAID that has analgesic, anti-inflammatory and antipyretic effects due to unique chemical and pharmacokinetic properties and has a multifactorial mechanism of action that goes beyond its selective inhibitory activity against the COX-2 enzyme” [16] . To enhance the therapeutic effect and quickly relieve inflammation and pain, it is important to use an integrated approach to treatment. It has been proven that the combined use of Nise tablets and Nise gel enhances the therapeutic effect and promotes rapid relief of pain and inflammation [17]. The base of the Nise gel is represented by isopropyl alcohol, which allows the active substance to quickly penetrate deep into the tissue, directly to the source of inflammation. And after 15 minutes, the medicine is almost completely absorbed from the surface of the skin and concentrated at the site of inflammation. The drug Nise® (nimesulide) is available in two forms - in the form of 100 mg tablets for oral use and in the form of a 1% gel for external local use [18]. Thus, the variety of forms of damage to extra-articular soft tissues, their high prevalence and social significance determine the relevance of the problem of diagnosis and treatment of bursitis. Timely and complete treatment helps to avoid the development of protracted and recurrent forms of the disease. Among the variety of NSAIDs that are the drugs of choice in the treatment of bursitis, nimesulide claims to be one of the first places in terms of treatment effectiveness. The combined use of oral and local forms of NSAIDs improves treatment results for persistent and severe disease.

What could be the reason?

Most often, damage or heavy load is necessary for the disease to develop. Less commonly, the disease is part of a symptom complex of another, more serious pathology. Therefore the main reasons are:

Trauma (bruise, awkward movement)
Physical overload
Friction (for example, constant support on the elbow (with inflammation of the olecranon bursa) or moving on all fours with damage to the patella
Some rheumatological diseases (gout, ankylosing spondylitis)

Sometimes the cause cannot be determined.

Causes of elbow bursitis

Factors that provoke the occurrence of bursitis of the elbow joint can be divided into 2 groups:

Infectious bursitis occurs:

As a complication of bacterial and viral processes
As a result of the introduction of microbes with the flow of lymph or blood from foci of purulent inflammation, for example, from abscesses

Non-infectious bursitis occurs as a result of:

Minor but frequently recurring elbow injuries
Posterior elbow injury
Arthrosis of the joint is the most common cause of chronic bursitis as a result of constant irritation of the joint by osteophyte bone spines.
Excessive stress on the elbow joint, for example in heavyweight athletes
Metabolic disorders, such as gout
Hormonal changes
Rheumatoid arthritis, psoriasis

Symptoms

Symptoms are caused by inflammation - the walls of the periarticular bursa thicken, discharge accumulates in it, sometimes a significant amount, up to 15 - 20 ml. The liquid is usually clear and yellowish in color. In case of injury, it may be stained with blood due to hemorrhage. When an infection occurs, pus accumulates in the cavity.

Complaints and other manifestations of pathology depend on the location of the lesion. The most common are pain, redness of the skin, and swelling.

There are serous and purulent bursitis. In the first case, the inflammation is aseptic (without the participation of microbes) in nature. In this case, the general condition suffers little, body temperature does not rise, local inflammatory phenomena are not pronounced. If the process is purulent, you can almost always find an entry point for infection (trauma, abrasions, microcracks). There is always hyperemia (redness of the skin), swelling, and an increase in body temperature, sometimes to high levels. When diagnosing, it can be difficult to distinguish these two varieties; if there are difficulties, a diagnostic puncture is required.

In this article we will consider serous bursitis as the most common one.

Why might this disease occur?

This disease can be caused by:

professional activity: people who do heavy physical work often suffer from bursitis: painters, loaders, lumberjacks, and builders;
sports training: with repeated movements combined with increased regular and monotonous load, the likelihood of developing an inflammatory process in the bursa is much higher, so athletes (tennis players, badminton players) are susceptible to the disease;
tissue damage: bursitis can occur as a result of injury, cut or even an injection;
injuries: a blow to the shoulder or a fall often causes hemorrhage into the periarticular bursa followed by inflammation;
disease of the musculoskeletal system: sometimes gout or chronic arthritis can become the basis for the development of the disease;
infectious process in the body: a bacterial or viral infection that enters the bursa through the blood vessels can cause bursitis;
autoimmune disease: in this case, the aseptic process in the periarticular bursa is a reflection of a similar condition of the joints;
genetic factor: in some cases the disease is inherited.

With age, the likelihood of developing shoulder bursitis increases, because this joint has the greatest range of motion of all others.

Poor posture is another cause of inflammation. When the body bends strongly forward, the space under the acromion narrows. If this area is narrowed long enough, the pressure on the subacromial bursa, as well as the tendons near it, increases, which leads to the development of inflammation.

Bursitis of the knee joint

In the projection of the patella (kneecap), swelling, moderate pain, and less commonly, redness appear. There are several bursae - prepatellar, infrapatellar, etc. Depending on which of them is inflamed, the symptoms may differ in location and severity. With prepatellar bursitis, there is swelling immediately above the patella (photo below), there is practically no swelling, pain, or redness of the skin. In the case of infrapatellar inflammation, on the contrary, pain predominates.

Diagnostics

In simple cases, the diagnosis is made on the basis of symptoms; a simple examination by a doctor is sufficient. The easiest way to diagnose the disease is in the area of the elbow and patella. With the shoulder and hip, the situation is more complicated; here, as a rule, additional research methods are needed - ultrasound, X-ray, MRI. Most often, one or less often two of these methods are sufficient to make a correct diagnosis. If it is impossible to differentiate between serous and purulent bursitis, a diagnostic puncture is performed - the cavity is pierced with a needle and syringe. With serous inflammation, a clear yellowish or reddish liquid is obtained, with purulent inflammation, pus is obtained.

Laboratory tests are of little value. If no obvious causative factor is identified (trauma, etc.), then rheumatological tests are prescribed to exclude systemic diseases.

Bursitis of the feet and heels

Inflammation in this area occurs due to:

constant increased loads (in weightlifters, overweight patients);
congenital foot abnormalities (valgus deformity of the big toe, flat feet);
traumatic injuries to the foot (deep wounds/cuts in the area of the synovial bursae);
arthritis of the foot;
chronic inflammatory processes (abscesses, boils).

Bunions can occur in women who wear high-heeled shoes. However, an absolutely flat sole also acts as a provoking factor in the development of inflammation of the synovial bursa. Bursitis of the feet and heels can be a consequence of constantly wearing poorly fitting shoes. The unnatural position of the foot causes deformation of the synovial bursa, which is why the inflammatory process develops. Achilles bursitis (calcaneal) is an inflammation of the synovial bursa located between the Achilles tendon and the heel bone. One of the causes of the disease is traumatization of the synovial bursa by the hard back of the shoe.

Treatment

In most cases it is conservative. Restriction of physical activity is recommended, sometimes immobilization bandages are applied for this purpose. A quick and good result is obtained by puncture of the bursa with evacuation of the contents and administration of a powerful anti-inflammatory drug (see video below). In complex therapy, non-steroidal anti-inflammatory drugs (Voltaren, Nimesil, etc.), physiotherapy, and kinesiotaping are used. If fluid accumulates again, repeat punctures are performed.

If the disease persists and repeated punctures are ineffective, surgical treatment is indicated - excision of the affected bursa. The intervention is performed under anesthesia in orthopedic hospitals.

With the development of purulent bursitis, surgery is also necessary - the abscess is opened from a small incision under local anesthesia and sanitized with antiseptics. Antibiotics are indicated. Hospitalization is not required; the procedure is performed on an outpatient basis.

Advantages of Dr. Elshansky I.V.

Our clinic, located in the center of Moscow, traditionally deals with bursitis of various types and locations.

Main competitive advantages:

Doctor with extensive (over 25 years) experience, Ph.D.
The ability to perform all necessary manipulations immediately, on the day of treatment, incl. ultrasound guided punctures
If necessary, an ultrasound scan is performed immediately during the appointment and is included in the cost.
We do not prescribe unnecessary tests and examinations, and if there is still a need for them, we do not require them to be done exclusively in our clinic
Qualified, polite staff
No queues - we plan the time and accept appointments strictly by appointment
Convenient transport accessibility - 5 minutes walk from Turgenevskaya metro station, Chisty Prudy, Sretensky Boulevard