What the Bursa!?
It seems of late that the bursa is the scapegoat of the medical world. Because of their location, irritability and inherent function, bursae take the fall for a large number of pathologies that tend to go unnoticed, undiagnosed and untreated. Meanwhile, the bursa shoulders the blame (pardon the pun) whilst enduring cortisone injection after cortisone injection, and in some cases removal altogether!
Contrary to what your ultrasound would have you believe, the bursa is not, in fact, the root of all evil *gasp*. There are actually more than 150 bursa in the human body, and all are located in positions of high stress. So, why is it that only a handful of bursae are implicated in painful conditions whilst the others seem to cause no trouble at all? Physios are forever seeing people diagnosed with “hip bursitis” or “shoulder bursitis” – why not so in other areas? Sadly, the bursae are misunderstood, and are implicated in many conditions that become chronic because the underlying problem is not being addressed.
A bursa is a small sac filled with synovial fluid. It’s purpose in life is to reduce friction and lubricate movement between body tissues; especially around joints, tendons and bony protuberances. There are actually four different types of bursa:
1. Synovial bursae are the most common and are found between tendons, muscles and bone. These are the bursa that are found in your hip and shoulder and are often reported as being inflamed on ultrasounds
2. Subcutaneous bursae are found under the skin and lubricate movement between the skin and deep connective tissues
3. Sub-muscular bursae are found between muscles and lubricate their movements
4. Adventitious bursae (or accidental bursae) form after birth as a result of repeated friction or stress, and are different in everybody depending on what you do!
(Also, Bursa is a city in Turkey.)
The bursa is designed to lubricate movement in areas of high friction, and so is designed to withstand friction. Why, then, would a bursa tolerate such friction for decades, and then one day out of the blue become inflamed and leave you unable to lie on your side or lift your arm? The answer is simple – it doesn’t! Bursae are built for friction, but like all tissues in our body they can only tolerate so much. When friction increases, the bursa can start to become irritated, and eventually become inflamed - known as a bursitis.
Bursitis
Bursitis is like a big red flashing light – it is a warning signal designed to catch your attention (by using unnecessarily large amounts of pain) to let you know that something is wrong! Where we can go wrong, however, is assuming that the bursitis is the actual problem.
9 times out of 10, bursitis is usually the secondary condition to an underlying problem that has caused the increase in friction/load in the first place.
This can be due to many reasons, for example, lifting heavier weights in the gym, imbalances in muscle strength, alterations to the mechanics of a joint, and restriction to movement due to a stiff joint or muscle tightness. Usually these things build up slowly over time, under the radar, and it is not until your bursa starts to scream and shout that you notice anything is wrong.
If this is the case, then treating the bursitis alone with ant-inflammatories, rest and cortisone injections is treating the symptom, not the cause. All of the above work great for settling pain, but will do nothing to address the underlying deficits. A period of relative rest plus or minus the use of anti-inflammatories is recommended to settle someone in a lot of pain. However, it’s important to understand that this is purely buying you your “window of opportunity”. Once your pain settles, you should go about fixing the underlying problems to ensure that your bursitis doesn’t just flare right back up!
So, before you go running for your next cortisone injection to defeat that wicked bursitis, give a thought to your poor little misunderstood bursa and the real reason you can’t lift that arm. And remember, rest is not rehab!