Dr Iain Duncan
Dr Wes Cormick

What are the generally accepted indications for a bursal injection?

The main indication for bursal injection is bursitis from any cause not responding to conservative measures (anti-inflammatories, activity modification and physical therapy).

Common sites of inflammation include trochanteric bursitis, subacromial bursitis, pes anserine bursitis, prepatellar bursitis and olecranon bursitis. Occasionally, bursal injections are undertaken to treat symptomatic tendinopathy in adjacent structures (gluteal and rotator cuff tendinopathy being the commonest).

Gout is an occasional cause of bursitis, and although an injection is an effective therapy, the underlying disorder needs to be assessed and treated.

Imaging guidance (mostly ultrasound, but occasionally fluoroscopic screening) can improve the accuracy of the needle placement for bursal injection. It is useful in patients where a palpation-guided injection might be difficult or when a palpation-guided injection has not achieved significant symptom relief.

What are the prerequisites for having a bursal injection done?

Any patients who are on coumarin anticoagulants need to have an up-to-date INR before the injection. Other anticoagulants, such as clopidogrel, dabigatran, prasugrel, dipyridamole or asasantin, are not usually stopped for these more superficial procedures.

Diabetics should be warned about the possibility of a temporary elevation in blood glucose levels related to the effects of the corticosteroid.

What are the absolute contraindications for a bursal injection?

Infection in or around a bursa.

What are the relative contraindications for a bursal injection?

Uncontrolled diabetes and high levels of anticoagulation.

What are the adverse effects of a bursal injection?

This is a very safe procedure with few significant risks. Very few patients complain of side-effects, but occasionally problems are experienced.

Immediate: Local bruising and bleeding. A temporary aggravation of symptoms (1–3 days). Allergic reactions are uncommon, but can occur.

Delayed: Rupture of an adjacent tendon that has pre-existing tendinopathy or partial tear can occur – usually within the first days or weeks. There is also a very slight risk of infection, estimated at between 1 in 20,000 and 1 in 75,000 injections carried out.

Corticosteroid injection has variable local and systemic effects. These are less likely with a well-placed injection and the relatively small corticosteroid dose as a single injection. The local effects are tissue atrophy and a flare of the symptoms. Systemic effects are the usual side-effects of any corticosteroid.

Is there any specific post- procedural care required after a bursal injection?

The affected limb or part should generally be rested completely for 6 hours, and then restricted use of the part for between 1 and 3 days. Occasionally, a cold pack should be applied if there is any swelling.

The corticosteroid does not start working for at least 24 hours, and sometimes for up to 3 days. During this time, the normal symptoms might continue or occasionally worsen. Reassurance is sometimes required during this period. A major flare of symptoms generally indicates a local reaction to a part of the injected material, or simply to the needling. If the bursitis is associated with calcification, then a flare might occur up to a week later due to the breakdown of calcium. If the reaction is distressing, then anti-inflammatories, rest (use of a splint) and the application of cold packs is recommended. If persistent, then the injection site should be reviewed for infection, though this is less likely than a local reaction or tear of a tendon.

Are there alternative imaging tests, interventions or surgical procedures to a bursal injection?

Bursitis can be due to many causes. Attention should be paid to any underlying pathology (rheumatoid arthritis, gout, trauma, tendinopathy and overuse are all common). Investigations to elucidate the cause should be undertaken. Plain X-rays, ultrasound, MRI and blood tests might be considered. Surgical referral should be considered for resistant cases; however, surgical treatment is generally for recalcitrant cases.

Further information about bursal injection:

If infective bursitis is suspected, then surgical referral and treatment with antibiotics might be indicated, and injection or needling avoided.

Useful websites about bursal injection:

Medscape reference
Shoulder – emedicine.medscape.com/article/1592584-overview#a03
Hip – emedicine.medscape.com/article/87788-overview

Last saved on 29 September 2016.

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