Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Septic bursa or acute tendon rupture
Fever with a hot fluctuant olecranon or prepatellar swelling can represent septic bursitis, while a sudden pop, palpable gap and loss of tendon function suggests acute Achilles, patellar, quadriceps or other major rupture.
Action: Arrange same-day acute assessment, obtain bursal fluid and cultures when safe before antibiotics, treat systemic infection promptly, and immobilise a suspected rupture in a protective position with urgent orthopaedic referral.
Synopsis
Differentiate bursal, tendon and entheseal pain, recognise sepsis, rupture and inflammatory spondyloarthritis, use imaging or aspiration only for focused questions, and restore tissue capacity through progressive loading with safe selective medicines.
Bursitis produces local swelling and pressure tenderness over a bursa; tendinopathy produces load-related tendon pain; enthesitis localises at an insertion and may be mechanical or inflammatory.
A hot olecranon or prepatellar bursa with skin breach, fever or immune risk needs aspiration for Gram stain, culture, cell count and crystals when safe, plus prompt anti-staphylococcal treatment.
Do not aspirate or inject an uncomplicated mechanical bursa routinely; repeated needle entry can introduce infection and fluid reaccumulates unless pressure or loading changes.
Key red flags
Spreading erythema, fever, rigors, immunosuppression, a skin wound or systemic instability with superficial bursal swelling requires urgent septic-bursitis or sepsis management.
Investigation priorities
01
First-line anatomical examinationFirst stepFirst line
Distinguish bursa, tendon, enthesis, joint, nerve and bone and identify infection or rupture before rehabilitation.
Management branches
First-line localisationName structure and mechanism
A focal periarticular pain syndrome presents without systemic instability or obvious complete rupture.
Map bursa, tendon course and insertion, test passive joint movement and resisted action, and examine skin, neurology and adjacent bone.
Establish whether onset follows pressure or load, is infectious or crystal-like, or clusters with systemic inflammatory features.
Preferred tendon rehabilitationReload rather than rest indefinitely
Clinical tendinopathy is present without complete rupture, infection or bone stress injury needing protection.
Key medicines
Topical diclofenac gelApply the product-directed amount over focal pain, commonly 2–4 g of 1.16% gel three or four times daily for one to two weeks initially, without exceeding the product maximum.
Naproxen with gastroprotectionUse 250–500 mg orally twice daily with food for the shortest course; add omeprazole 20 mg orally once daily when gastrointestinal risk indicates protection.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE CKS BursitisUK recognition, aspiration, infection treatment and injection precautions.