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Bursitis and periarticular inflammation 147
injection but performance of such injections in the acute care setting is
uncommon, in part owing to technical difficulties. 12,13 No more than two
injections (per bursa) should be administered during a single episode of
bursitis.
Many corticosteroids have demonstrated effectiveness for injection of
subacromial inflammation. Triamcinolone (20 mg) provides persistent pain
relief that is additive to that achieved by outpatient physical therapy. 14
Cochrane review of literature addressing pain relief in patients with lateral
epicondylitis (“tennis elbow”) concluded that corticosteroid injection provides
better short-term analgesia than oral NSAIDs. 3
The most relevant RCT investigating intrabursal injections for olecranon
bursitis demonstrated improved clinical response from combination therapy
with intrabursal methylprednisolone (20 mg) and oral naproxen (500 mg PO
bid for 10 days), compared with monotherapy with PO naproxen or placebo. 15
For trochanteric bursitis, studies investigating intrabursal injection of
corticosteroids have found efficacy similar to that reported for other bursal
injection sites. 16–18 For example, one investigation found benefit in two thirds
to three quarters of patients after injection of betamethasone (6, 12, or 24
mg) mixed with 4 mL of 1% lidocaine; the higher response rates are seen with
the higher doses of corticosteroid. 16
Radiographic guidance (i.e. fluoroscopy) significantly improves the success
rates of injection therapy for trochanteric injection. 19 Fluoroscopy may
also be necessary to guide corticosteroid injection for bursitis in unusual
locations (e.g. interspinous). 20
Adjuvant therapy with sodium hyaluronidate (20 mg injected into the
bursa) may be useful in the long-term management of bursitis, but in the
acute care setting is unnecessary. 21
A wide variety of medical conditions, each with disease-specific therapy,
can predispose patients to bursitis and related inflammatory conditions. One
long-recognized and commonly encountered medication-related etiology of
subacromial inflammation is the use of protease inhibitors (e.g. indinavir,
lamivudine). 22 Given the obvious risks in altering these medication regimens,
the ED provider should reduce dosages only after consultation with patients’
physicians.