Knee Bursitis

Bursitis of the knee is inflammation of small collections of fluid in and around the knee joint known as bursae. These are normal anatomical findings and their purpose is to help facilitate fluid and smooth movement of tendons, muscles and fascia between one another and the knee joint. When these small pockets of fluid become inflamed, they will typically get larger and become tender. They may also cause pain with ambulation, weight bearing or even certain specific movements depending on the bursa affected.

There are a great many different causes of knee bursitis that can range from the less serious such as idiopathic causes, underlying osteoarthritis, repetitive straining of the muscle or joint around which the bursa is located and simple muscle fatigue to the more serious such as infection, rhabdomyolysis, local trauma and potentially even undiagnosed malignancy. Fortunately, the most serious causes are exceptionally rare and the vast majority of bursitis cases are caused by less serious diagnoses.

Bursitis tends to present typically as pain in and around the knee. The pain is usually a burning sensation in nature, although it can be felt sharply in certain areas. The best way to differentiate bursitis pain from generalized muscle or joint pain such as from osteoarthritis is try and localize the pain to a specific area around the joint.

Pain that localizes to a specific area is much more likely to appear as a result of bursitis, especially if the area that is localized is known to have a bursa directly underneath the point of maximal tenderness (e.g. the pes anserine bursa, the prepatellar bursa). Osteoarthritis pain is much more generalized and far more difficult to localize with the patients typically describing this as more of a global sensation around the whole joint itself rather than pinpointing it to a specific spot.

Activity and weight bearing will typically worsen the pain experienced from bursitis, especially activity of the muscles that directly interact with or are directly adjacent to the culpable bursa. For example, a prepatellar bursitis will worsen with extension and flexion of the knee joint and activation of the quadriceps/hamstring mechanism whereas pes anserine bursitis will be specific to flexion of the knee, in particular the hamstrings, and be localized to the anteromedial aspect of the joint.

First line treatment for any kind of bursitis should be cessation of the offending activity for a short period of time. If the bursitis does not self-resolve when returning to said activity, then over-the-counter nonsteroidal antiinflammatory drugs should be trialed if the patient is able to tolerate them. These will fight against the inflammation that is present in the bursa and will reduce it, thereby reducing the patient’s pain.

If this is not effective or only effective for a short period of time, the next line of treatment would be to trial a corticosteroid injection directly into the bursa itself. This is typically not necessary in the majority of patients and is reserved only for those who have symptoms refractory to activity modification and oral or topical antiinflammatory drugs.

For patients with persistent bursitis that is refractory to all of the aforementioned, there is a surgical option to undergo a bursectomy, although this is rarely performed and is typically not necessary due to the very small number of patients who do not respond to any of the aforementioned interventions.

Most patients should notice that the bursitis settles down within several weeks, whether this is due to the activity modification or whether this is due to the commencement of a course of antiinflammatory medication. If neither of these are effective after 3 or 4 weeks then consideration of an injection should be given.

If the patient does wish to proceed with injection as an intervention then typically these injections will take several days to become effective and should provide significant pain relief that will hopefully be semi-permanent in nature (i.e. may very well relieve the pain in its entirety, although there is a small risk that the bursitis will return with repeated activity in the future).

There are multiple bursas around the knee. The most important of them are the prepatellar bursa, infrapatellar bursa and pes anserine bursa. These are most commonly involved in the inflammation and the swelling. They can be caused due to daily activities like kneeling or may be caused due to pathology in the knee leading to bad biomechanics around the knee.

They can be treated usually with RICE that is rest, ice, compression and elevation along with anti-inflammatory medications. They can also be treated with cortisone shot if not improved. The patient should see a physician if the pain is not relieved with over-the-counter medications.

Gout can affect multiple joints of the body and knee and ankle are among the common ones that can be involved. Gout is usually treated with medications which is provided by the primary care physician. If the knee is severely involved and is not relieved with medications, then the patient should seek treatment with a sports physician.

Pes bursitis or pes anserine bursitis or goose foot bursitis of the knee is an inflammation of the bursa around the three tendons on the inner side of the knee. This happens usually due to bad biomechanics of the knee particularly in osteoarthritis of the knee. It can be treated with medications along with rest, ice, compression and elevation.

If the pain is not relieved with over-the-counter medications and conservative measures, then the patient should seek physician attention. They can get cortisone injection also in the knee. Occasionally pes bursitis may be caused due to pathology inside the knee which may need attention and management.

Knee bursitis can usually be cured with conservative means including medication and cortisone injection. Mostly patients with bursitis get good relief with these measures.

Bursitis of the knee usually presents with localized pain along with swelling which may or may not be worsen with activity. It may affect the gait of the patient.

Knee brace can be used in patients with bursitis as it gives compression and thereby decreases the swelling and the pain due to bursitis. It can prevent recurrence of bursitits.

In acute onset cases ice is better for the first two to three days to relieve pain. If the bursitis is longstanding, then heat usually gives better results than ice. In some cases, patients may have preferential benefit with ice and heat and should try using that.

Bursitis of the knee is usually treated with anti-inflammatory medications along with compression with sleeve. The patient can also use physical modality like ice or heat to relieve pain. If the pain is not improved with these measures, then prescription medication as well as cortisone injection with or without aspiration can help in decreasing the pain and swelling.

Patellar bursitis is the inflammation of the bursa in the front of the knee cap. It is usually found in people who are involved in kneeling activities like housemaids, technicians, plumbers. It presents with pain and swelling in the front of the knee cap. It is usually treated with compression and anti-inflammatory along with ice or heat. If the patient is not relieved, then the fluid from the bursa can be aspirated and the cortisone injection can be given which may help in early healing of the bursitis. The patients are also asked to avoid activities lie kneeling that may cause recurrence of the bursa.

Bursitis is not a form of arthritis but may be caused as a secondary presentation of arthritis. Most of the times when arthritis is controlled, bursitis usually resolves itself.

Septic bursitis means inflammation of the bursa caused due to micro-organisms like bacteria. It presents with pain, swelling, redness, and may also have fever and chills. These patients should seek urgent attention for management. The patient may need antibiotic according to the sensitivity. The patient may need surgical treatment to clean up the bursa and eradicate the infection.

Bursa is usually present between the skin and the bone to allow easy gliding of the skin over the bone due to the fluid filled in the bursa. This fluid is in minimal quantity and allows proper gliding of the skin or the bone. It is present in all places where the bone is directly underneath the skin.

The bursal sac can be removed surgically in patients who have recurrent bursitis or have septic arthritis and are not improved with medication. This procedure is called bursectomy and has a good success rate.

The risks for removing a bursa are usually the same as of any minor surgery. Occasionally the patient may have recurrence of the bursa and may need prolonged treatment for the management.

A bony bump just below the knee usually is a tibial tuberosity where the patellar tendon from the knee cap inserts. It acts as a point of stress because all the forces from quadriceps are passed through the patellar tendon on to the leg. It may be enlarged in patients of Osgood-Schlatter disease in which there is hypertrophy of the tibial tuberosity which is usually found in teenagers.

Housewives knee or Housemaid’s knee is usually the inflammation of the prepatellar bursa. These patients are involved in kneeling activities due to their profession or work and have caused inflammation and irritation of the prepatellar bursa causing it to be inflamed.

Baker’s cyst is outpouching of the synovial lining of the knee joint. Occasionally when the patient has fluid in the knee, the fluid may track outside into this outpouching causing it to collect the fluid and swell up that can be felt as a soft swelling of the back of the knee. It is usually treated by the management of the pathology that causes the formation of the fluid as well as aspiration of the fluid from the knee joint. Rarely the Baker’s cyst just needs a surgery to remove it.

Infrapatellar bursitis is inflammation of the bursa that is present below the knee joint. This bursitis is also called clergyman bursitis and is usually found in clergies due to the way that they stand on their knees.

Knee bursitis if under control or being managed actively by physician can allow the patient to gentle workouts. The patient can involve in exercises which are not worsening the pain and swelling of the knee. If any specific exercise worsens the pain, then it should be avoided.

Cortisone shots do help in decreasing the pain and swelling of the pes anserine bursitis of the knee. Most of the time the bursitis is secondary to pathology inside the knee which may also need to be taken care so as to prevent the recurrence of the bursitis.