Back Pain Doctor
Bursitis
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Bursitis is inflammation of a bursa, one of the small fluid-filled sacs that cushion bones and the soft tissues around them. When a bursa is irritated by a knock, prolonged pressure, repetitive activity or a medical condition such as rheumatoid arthritis or gout, it fills with extra fluid, causing swelling and pain. Common sites include the tip of the elbow, the outer hip (usually as part of gluteal tendinopathy), the front of the kneecap, and the shoulder.
The most important first step is deciding whether the bursa is infected. A red, hot, increasingly painful bursa (especially with fever) may be a septic bursa, which is assessed promptly, drained and treated with antibiotics, and should not be injected with a corticosteroid. Fluid can be sampled to check for infection or gout, and ultrasound can help assess the bursa and guide any procedure.
Non-infected bursitis is usually managed with activity modification, padding or a splint, and simple analgesia or short-term anti-inflammatory medication. If it does not settle, the fluid can be drained and a corticosteroid injected. Because recurrent elbow or kneecap bursitis is often driven by pressure or kneeling, addressing the underlying activity and using protective padding is as important as treating the flare.
Common symptoms
- Swelling over a joint area, often the tip of the elbow or the kneecap
- Pain that worsens with pressure or bending the joint
- Warmth and redness over the area
- Fever or feeling unwell, which can suggest an infected bursa
Commonly seen in
Evidence for twelve treatment options in bursitis
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).
Pairing reviewed 2026-09-02.
Where it fits
Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Only if relevant
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Trigger-point injection reviews address confirmed myofascial pain and find heterogeneous, generally low-certainty results; they do not establish the technique as treatment for the underlying diagnosis. Condition reviewed: bursitis.
Evidence source: Debrosse et al., trigger-point injection systematic review (2022)
Pairing reviewed 2026-08-30.
Where it fits
For bursitis, this may be considered only when examination finds a separate tender muscle band reproducing part of the pain. It does not treat the primary pathology and is used to help movement or rehabilitation.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Good support
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).
Pairing reviewed 2026-08-30.
Where it fits
Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. No study at these bursae
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Searched 21 October 2026: shockwave, shock wave or ESWT with bursitis, bursa or bursopathy (42 records), a second pass naming the elbow, kneecap, heel, ischial, shoulder and trochanteric bursae (30), and a trial and review pass (7); 49 records read. None tests shockwave of either device for bursitis at the tip of the elbow or the front of the kneecap. The bursitis trials that exist are at other sites and used a focused device or do not name one: pes anserine bursitis at the inner knee (Khosrawi, Adv Biomed Res 2017) and bursitis under the shoulder blade (Acar, J Orthop Surg 2017, device not stated). The outer hip and the pes anserine have their own pages. The earlier line saying the trials here used focused devices was not accurate for this page.
Pairing reviewed 2026-10-21.
Where it fits
Not part of managing a swollen elbow or kneecap bursa, where infection and gout are excluded first and padding, drainage or an injection are the usual steps. Could be considered for a bursa that stays painful after those, with the lack of studies explained.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Studied at other bursae only
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Searched 21 October 2026: shockwave, shock wave or ESWT with bursitis, bursa or bursopathy (42 records), a second pass naming the elbow, kneecap, heel, ischial, shoulder and trochanteric bursae (30), and a trial and review pass (7); 49 records read. No study tests focused shockwave for bursitis at the tip of the elbow or the front of the kneecap. At other bursae the results are mixed: in 40 people with pes anserine bursitis at the inner knee, focused shockwave beat sham at three and eight weeks (Khosrawi, Adv Biomed Res 2017), but in 180 people it did worse than a cortisone injection at eight weeks (Gouda, Adv Orthop 2023); in 43 people with bursitis under the shoulder blade, three sessions did better than a cortisone injection at three and six months (Acar, J Orthop Surg 2017; device not stated). Those results belong to those bursae and are not evidence for the ones this page is mainly about.
Pairing reviewed 2026-10-21.
Where it fits
Not a first step. For a non-infected bursa that stays painful after padding, rest from pressure and, where appropriate, drainage or an injection, it can be discussed, with the caveat that the trials were done at other bursae.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. No better than placebo at the hip
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Trialled at three bursae, with mostly disappointing results. At the outer hip, the one double-blind placebo-controlled trial injected PRP into the trochanteric bursa and gluteal tendon in 79 people whose pain had not settled: both groups improved, there was no difference between PRP and placebo at any point to twelve months, and the authors do not support its routine use (Atchia, J Bone Joint Surg Am 2025). An earlier pilot in 18 people found no difference from cortisone, with only the cortisone group improving over 60 days (Ribeiro, Acta Ortop Bras 2016). At the inner knee, in 180 people with pes anserine bursitis a cortisone injection gave better pain and function scores than PRP at one and eight weeks, with no later follow-up (Gouda, Adv Orthop 2023). At the shoulder, in 60 people with impingement given one ultrasound-guided injection into the subacromial bursa, cortisone gave better pain relief at one week and PRP better shoulder movement over the longer term, with follow-up to a year (Hewavithana, Skeletal Radiol 2024). A search of 76 records found no clinical study of PRP injected for bursitis at the point of the elbow, the front of the knee, the heel, the front of the hip or the sitting bone.
Pairing reviewed 2026-10-10.
Where it fits
Not a first choice for an inflamed bursa. Most settle with load management and a rehabilitation program, and where an injection is needed to calm things enough to rehabilitate, cortisone has the better short-term evidence. Where the real problem is the tendon beside the bursa, as it often is at the outer hip, the tendon page is the relevant one. PRP is discussed only with these results stated.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Trials disagree; shoulder and knee only
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Tested only at the shoulder and the inner knee, with conflicting results. At the shoulder (subacromial-subdeltoid) bursa, three ultrasound-guided injections of 15% dextrose did no better than saline at three months (Chang, Arch Phys Med Rehabil 2021, 50 people); one injection of 20% dextrose added to a 12-week exercise program did better than saline plus exercise on shoulder pain and disability, though the 6.4-point SPADI difference at 13 weeks was below the 8 points the authors set as clinically important (Hsieh, Arch Phys Med Rehabil 2026, a pilot of 46 people with pain of under three months); and cortisone beat dextrose on pain at two and six weeks and on disability to twelve weeks in chronic subacromial bursitis (Lin, Am J Phys Med Rehabil 2023, 54 people). A pooled analysis of the shoulder trials found dextrose may have little to no benefit over saline, at very low certainty (Zerzan, PM R 2026). At the pes anserine bursa of the inner knee, 20% dextrose outlasted cortisone at eight weeks in a three-arm trial of 72 people with no placebo group (Babaei-Ghazani, Am J Phys Med Rehabil 2024). A PubMed search on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with bursitis, bursa or bursal, and with the trochanteric, olecranon, prepatellar, retrocalcaneal and pes anserine sites) found no trial or case series at the elbow, the front of the kneecap, the outer hip or the heel.
Pairing reviewed 2026-10-16.
Where it fits
Not a first-line option for a bursal problem, and never used for an infected bursa. Where it is considered, it is after load management, padding and a guided cortisone injection have been discussed, with the conflicting trial results stated, and it sits alongside the rehabilitation program.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used here
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Trialled at the shoulder, but not offered here. In a double-blind trial of 186 people with long-standing subacromial bursitis, three hyaluronic acid injections into the bursa lowered pain on activity at eight weeks a little more than saline (3.65 against 4.71 out of 10) without improving disability scores, and cortisone did better than both (Hsieh, Clin Rehabil 2021). A pilot of 22 people given cortisone plus hyaluronic acid into the bursa under the shoulder blade improved from 7.8 to 2.2 on pain at three months, with no comparison group and cortisone in every injection (Chang, Arch Phys Med Rehabil 2009). PubMed searches found no human study at the elbow or kneecap bursae, and at the outer hip a network meta-analysis found hyaluronic acid no better than no treatment (Gazendam, Clin J Sport Med 2021). An injection into a bursa is a different procedure from the joint injection in this row.
Pairing reviewed 2026-11-09.
Where it fits
Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a bursa sits outside the joint. Load modification and rehabilitation remain the centre of treatment.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
Perineural dextrose evidence is concentrated in diagnosed peripheral compression neuropathies, particularly the upper limb; no direct evidence was identified for this diagnosis itself. Condition reviewed: bursitis.
Evidence source: Perineural dextrose for upper-limb entrapment neuropathy review (2025)
Pairing reviewed 2026-08-30.
Where it fits
For bursitis, perineural treatment may be considered only if a separate superficial neuropathic pain pattern is found on examination. It is not treatment of the primary diagnosis.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Named only as a direction for future research. A narrative review of injection treatments for subacromial bursitis covers corticosteroid, hyaluronic acid, anti-inflammatories, hypertonic glucose and platelet-rich plasma, and lists integrating advanced ultrasound techniques including hydrodissection among the things future research should do, not among the treatments with evidence behind them now (Ding, Ann Med 2026). No trial of hydrodissection for bursitis was found.
Pairing reviewed 2026-09-08.
Where it fits
Only where a nerve is separately implicated. The bursa itself is treated by the options higher up this page.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How do I know if a bursa is infected?
How is non-infected bursitis treated?
When is surgery needed?
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