Do I have bursitis or tendinitis?
By Dr. O'Connor

Iam often asked, “What is the difference between bursitis and tendonitis?” or “Will I need a joint replacement for my hip bursitis?” Another patient may lament, “My hip hurts too much to just have bursitis, it must be more serious than that!” This article will address these questions and shed some light on three commonly confused conditions: bursitis, tendonitis and arthritis.

Most people are aware that “itis” means “inflammation of.” We know that tonsillitis and appendicitis refer to inflammatory
conditions of the tonsils and the appendix. Inflammation is part of the body’s response to injury (trauma, infection, etc.). The affected area experiences increased blood flow, bringing
reparative healing factors from the bloodstream to the area of damage. This results in increased localized swelling and pain,
and often warmth and/or redness. Similarly bursitis, tendonitis, and arthritis refer to inflammatory conditions of a bursa, a tendon, or a joint. At this point, let’s define these three anatomic structures.

A bursa is a sac (pouch) that is located between the bone and its overlying tissue. The bursa allows the adjacent skin, tendons, or muscle to glide smoothly over the bone. The bursal sac normally contains very little fluid, but may become inflamed and
filled with fluid as a result of overuse or trauma to the skin, tendons, or muscle. Commonly, bursae (plural) are located in the shoulder, hip, elbow, knee, and near the attachment of the heel cord.

A tendon is a strong band of fibrous tissue that connects a muscle to a bone. When a muscle contracts the force is transmitted to the joint via the tendon. This causes movement
of the joint. Overuse (such as excess repetitive movement, aging, or localized trauma) can cause low level microscopic tearing of the tendon, which may produce the inflammation and irritation known as tendonitis. This can lead to restricted movement and loss of joint flexibility which can worsen the symptoms. The most common areas affected with tendonitis are the elbow, shoulder, knee, wrist and Achilles tendon.

Arthritis is a term used to describe inflammation of a joint. A joint is simply the location where two bones come together to allow movement. The joint capsule is a strong envelope of connective
tissue that attaches the bone ends and holds the bones
together. The capsule is lined with synovium, a membrane that
produces synovial fluid which lubricates and nourishes the joint. Various conditions such as aging, trauma, genetics, and disease (gout, rheumatoid arthritis) can lead to joint inflammation or arthritis, causing the characteristic pain and swelling which, when chronic, can lead to significant debilitation and deformity.

Now we can move on to discuss some of the most common
disorders that are seen in our practice. Hip (trochanteric)
bursitis is very common and is usually described as a dull
ache along the outside of the hip region. It is often aggravated
with hip rotation, when arising from the sitting position, or while lying directly on the hip. There usually is not a traumatic event. On physical exam, marked tenderness to touch is noted over the bony prominence of the outside of the hip. There may be
pain in the same region with range of motion of the hip. These findings can be differentiated from hip arthritis, which usually causes pain in the groin radiating to the anterior thigh. It is interesting to note that hip bursitis has nothing to do with the hip joint itself, but rather the soft tissues on the outside of the hip.
As with most inflammatory conditions, initial treatment consists of rest, stretching, and nonsteroidal antiinflammatory medications (NSAIDs). Often a corticosteroid injection or two is needed along with occasional physical therapy. The prognosis for cure is good.

Perhaps you have seen someone with a golf-ball size swelling on the back of the elbow. This is called olecranon bursitis, and is usually painless but can be annoying and unsightly. It is usually the result of direct trauma. The bursal swelling often resolves over a period of weeks without treatment but may require needle
aspiration or surgical excision. A similar problem can occur on the front of the knee and is an occupational hazard for those who kneel for a living (masons, maids, etc.).

There are also bursae around the back of the heel near the Achilles tendon insertion. Inflammation of these bursae may result from overuse or shoe irritation. Treatment includes combinations of rest, shoe modifications, orthotic inserts and occasionally surgery. Tennis elbow (lateral epicondylitis) is one of the most common forms of tendinitis and is not limited to tennis players. It is characterized by pain located at the bony
prominence of the outside of the elbow. Many of the tendons on the extensor aspect of the forearm attach to this prominence (lateral epicondyle). Chronic overuse (such as yard work, overhead painting, etc.) causes microscopic damage to these tendons, resulting in inflammation. The pain from the lateral epicondyle often radiates to the back of the forearm and occasionally into the hand. The symptoms are worse with moving the wrist backward, strong gripping, and upon awakening in the
morning. Full elbow extension may be difficult. Rest, stretching, NSAIDs, and corticosteroid injections often provide relief. Occasionally surgical release is indicated.

The shoulder is another joint commonly affected by both bursitis and tendinitis. The rotator cuff is a large flat tendon that stabilizes and moves the shoulder joint. It lies between two bony structures and is protected by a bursa, which helps the tendon glide smoothly between the bones. Repetitive shoulder motions (overhead use, throwing, etc.) can irritate the tendon and/or bursa, and cause inflammation and fluid accumulation. This can
inhibit the smooth gliding properties of the tendon, and further worsen the symptoms. Symptoms of this disorder include pain when reaching above shoulder level or behind the back, difficulty sleeping or lying directly on the shoulder, and pain over the front and outside aspect of the shoulder to the mid arm. Often these symptoms cause one to restrict use of the arm which can lead to
stiffness of the shoulder joint, which further affects proper tendon gliding. Initial treatment may include stretching, NSAIDs and often a corticosteroid injection. Physical therapy may also be necessary to stretch and strengthen the rotator cuff and surrounding structures. Patience is often necessary, as recovery may often take weeks or sometimes even months. Refractory cases may require surgical treatment.

I hope that this brief article has been helpful in clearing up some misconceptions about three common orthopedic conditions. I can hear someone asking, “That’s great, but – what’s the difference between a sprain – and a strain?”

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