Bursitis of the Hip, Elbow and Knee: Symptoms and Treatment

A review published in American Family Physician distinguishes several types of superficial bursitis, which most often affects the olecranon and prepatellar bursae. The commonest is the microtraumatic form, resulting from repeated pressure (for example resting the elbow on a desk, kneeling for long periods). Other causes are acute injury or haemorrhage, inflammatory diseases (gout, rheumatoid arthritis) and infection. Diagnosis is usually clinical, with attention to signs of infection; ultrasound can help tell bursitis from cellulitis, and blood tests and MRI can help distinguish infectious from non-infectious causes.

The distinction has practical meaning. The microtraumatic form is treated conservatively and by removing the cause (pressure, repeated load). The form linked to gout or RA requires treatment of the underlying disease; we write about gout in the article on gout and about inflammatory joint diseases in the text on morning stiffness. The septic form is, in turn, an urgent matter, because bacteria (most often staphylococci) can cause a rapidly progressing soft-tissue infection.

The hip is an exception to this scheme. Pain on the outer side of the hip is greater trochanteric pain syndrome (GTPS), covering trochanteric bursitis, pathology of the gluteal tendons and the 'snapping hip' phenomenon. As reviews summarise, the diagnosis is above all clinical; imaging mainly serves to exclude other causes, and most patients respond well to conservative treatment (physiotherapy, NSAIDs, sometimes injections), with surgery reserved for chronic, resistant cases.

What does this mean for a person with pain on the outer side of the hip? First, pain at this site often comes from the gluteal tendons attaching to the greater trochanter, not from 'bursitis', as many patients are still told. Second, a structured programme of load-management education and strengthening exercises produced better and more lasting effects than a single injection. The injection acts faster, but its advantage fades over time: after a year there was no difference in pain, and in global assessment it did worse than exercise.

It is also worth being careful about the scope of this trial: participants had tendinopathy confirmed on MRI and pain lasting at least 3 months, not everyone with hip pain. The trial also does not settle whether different injection variants give different results. Even so, given the low risk of exercise and the durability of the effect, it is a reasonable starting point for most people with chronic pain on the outer side of the hip.

The olecranon bursa lies just under the skin over the point of the elbow, and the prepatellar bursa over the kneecap, so both are easy to damage with pressure, a fall or a skin graze. The typical symptom is a visible, soft, usually not very painful 'lump' or swelling over the joint, with the movement of the joint itself preserved. That last feature matters: an inflamed bursa without joint involvement usually allows normal bending and straightening of the elbow or knee, unlike arthritis of the joint, where movement is painful and limited.

The practical conclusion: uncomplicated, mechanical bursitis of the elbow is usually treated conservatively, by offloading, avoiding pressure, cooling and painkillers, and surgery is avoided, while a steroid injection carries risks (including skin atrophy) with no demonstrated benefit. The American Family Physician review adds that in chronic microtraumatic bursitis, high-quality evidence for the benefit of steroid injections does not exist, and aspiration of such a bursa is generally not recommended because of the risk of iatrogenic infection. Both of these works rest mainly on observations, however, so discussion with a doctor is not superfluous.

This discrepancy, one source saying that aspiration does not increase the risk of infection while another advises caution, is an example of real uncertainty in this field. Medical practice depends on whether the bursa is tense and pressing (in which case fluid is sometimes drawn off) and on whether the doctor suspects infection (in which case the fluid is tested). The decision is best left to the examining doctor rather than guided by puncturing it yourself, which must not be done at home.

This study shows two things at once. On the one hand, most septic bursitis has a good outcome after appropriate treatment, affecting to a large extent middle-aged men, often in manual work, and rarely leading to serious complications. On the other, it shows that the result depends on correct and sufficiently long antibiotic treatment: failures were more frequent with therapy shorter than 14 days. That is an argument against 'finishing off' with leftover antibiotics and for having a doctor treat the infection.

The 2023 French recommendations on septic bursitis of the prepatellar and olecranon bursae, drawn up by a team of rheumatologists, infectious disease specialists, orthopaedic surgeons and general practitioners, point out that management is heterogeneous (outpatient or hospital) and until now has had no unified guidance. They thus show how important medical assessment is at any suspicion of infection. In practice the doctor takes into account fever, the extent of redness, coexisting diseases and general condition, and, when infection is suspected, sends fluid from the bursa for testing.

The opposite myth can be equally dangerous: that a swollen bursa is 'nothing, it will pass by itself', even when it is warm, painful and the skin around it is red. Such symptoms may mean infection, in which delay promotes deterioration. A sensible boundary therefore runs not between 'treat' and 'do not treat', but between an uncomplicated form, in which patience and offloading are enough, and a form with signs of infection, which needs urgent assessment.

Bursitis seems a simple diagnosis, but in practice it hides two different scenarios: a harmless irritation that passes after offloading, and the rarer but more serious infection. For the hip the message from the studies is different again: lateral pain often comes from the tendons, not the bursa, and in that case regular strengthening exercises give a more lasting effect than an injection. A sensible plan is to start with the least invasive methods and to know well the signs at which delay is a mistake.