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146 Bursitis and periarticular inflammation
The treatment of patellofemoral pain syndrome has been overviewed in a
2004 Cochrane review. 4 Notable from the report are findings that while there
is no difference in pain relief achieved with diflunisal or naproxen, aspirin is
no better than placebo for pain relief in this indication. 4
For patients with shoulder bursitis, oral corticosteroids (prednisolone,
30 mg PO QD) provide early improvement over placebo, but treatment
benefit is lost after the first few weeks of therapy. 5
There are no RCTs that demonstrate a therapeutic difference between
nonselective NSAIDs and COX-2 selective NSAIDs. 6–9 Patients treated for a
week with either celecoxib (400 mg PO followed by 200 mg PO BID) or
naproxen (500 mg PO BID) experienced similar pain relief benefit over
placebo. 6 After a more prolonged treatment period (14 days), patients receiving
celecoxib, but not those taking naproxen, maintained pain score reductions
exceeding those seen in patients taking placebo. 6 Two studies assessing
short-term treatment of bursitis and tendinitis showed therapeutic equivalence
for the COX-2 selective NSAID nimesulide (100 mg PO BID), diclofenac
(75 mg PO BID), and naproxen (500 mg PO BID). 8,9 Issues regarding COX-2
selective NSAIDs and cardiovascular toxicity, which may be relevant even to
the ED provider prescribing a short course of therapy, are discussed in detail
in the Arthritis chapter (p. 94).
Evidence addressing use of topical agents for bursitis is sparse. Diclofenac
epolamine (2-hydroxyethyl-pyrrolidine, DHEP), an enhanced-permeation
lecithin-enriched diclofenac salt gel, shows potential for clinical utility. An
RCT assessing a 10 day (TID) course of 1.3% gel for shoulder or elbow
inflammatory pain found a persistent and significant pain score improvement,
although rescue medication need was not reduced compared with
placebo. 10
Once septic bursitis has been excluded, intrabursal corticosteroid injections
are recommended for acute management. Injection therapy is particularly
useful for bursitis of the elbow, knee, and shoulder; subacromial
injection results are improved with ultrasound guidance. 11 Hip and ankle
injections may be useful, but the former are technically difficult and the latter
risk steroid-associated Achilles tendon rupture. Other areas of inflammation,
such as the wrist or anserine bursae, may be amenable to corticosteroid