What is the treatment for bursitis of the knee?

Treatment of Knee Bursitis

The treatment of knee bursitis should begin with conservative measures including rest, ice, compression, elevation (RICE), NSAIDs, and activity modification, with corticosteroid injections reserved for cases that don't respond to initial therapy. 1

Types of Knee Bursitis

Knee bursitis can affect several bursae around the knee:

• Prepatellar bursa (front of kneecap)
• Infrapatellar bursa (below kneecap)
• Pes anserine bursa (inside of knee)
• Tibial collateral ligament bursa (medial side)
• Baker's cyst (popliteal bursa at back of knee)

Diagnostic Considerations

When evaluating knee bursitis, look for:

• Localized swelling over the affected bursa
• Pain with direct pressure
• Limited range of motion
• Signs of infection (redness, warmth, fever)
• Possible fluctuance or fluid collection

Treatment Algorithm

First-Line Treatment

1. Conservative Management 2, 3

   • Rest and activity modification
   • Ice application (10-minute periods through a wet towel) 4
   • Compression with elastic bandage
   • Elevation of the affected limb
   • Open-backed shoes or accommodative footwear for posterior knee bursitis 4

2. Pharmacological Treatment

   • Paracetamol (acetaminophen) as first-line oral analgesic up to 4g daily divided every 8 hours 1
   • Topical NSAIDs (such as diclofenac) 3-4 times daily to the affected knee 1
   • Oral NSAIDs such as naproxen 500mg twice daily if more significant pain relief is needed 5
     • Caution in elderly patients or those with renal/hepatic impairment
     • Avoid in patients on anticoagulation therapy

Second-Line Treatment

1. Aspiration and Injection 6, 2

   • Indicated for:
     • Persistent pain despite conservative treatment
     • Significant effusion limiting function
     • Acute inflammatory bursitis with effusion
   • Technique:
     • Aspiration of bursal fluid (also allows for diagnostic testing if infection suspected)
     • Injection of corticosteroid (avoiding injection into tendons)
   • Note: Intrabursal corticosteroid injections are specifically indicated for bursitis with effusion 1

2. Physical Therapy 1

   • Quadriceps strengthening exercises
   • Range of motion exercises
   • Stretching of tight structures (hamstrings, iliotibial band)
   • Gait training if needed

For Specific Types of Bursitis

1. Prepatellar Bursitis

   • Avoid kneeling
   • Consider knee pads for occupations requiring kneeling 2
   • Aspiration may be needed for significant effusion

2. Pes Anserine Bursitis

   • Address biomechanical issues (orthotics if needed)
   • Stretching of hamstrings
   • Weight loss if overweight 1

3. Posterior Knee Bursitis (Baker's Cyst)

   • Open-backed shoes to reduce pressure 4
   • Address underlying knee joint pathology if present

Special Considerations

Septic Bursitis

If infection is suspected (fever, significant erythema, warmth):

• Aspiration of fluid for Gram stain, culture, cell count
• Empiric antibiotics effective against Staphylococcus aureus 2
• Hospitalization and IV antibiotics for acutely ill patients
• Surgical drainage may be necessary for refractory cases

Chronic Bursitis

For cases not responding to conservative treatment after 6-8 weeks:

• Reassess diagnosis
• Consider referral to orthopedic specialist 4
• Surgical intervention (bursectomy) may be considered for recalcitrant cases 3

Patient Education

• Educate about activity modification to reduce pressure on affected bursa
• Advise weight loss if overweight (each pound lost reduces four pounds of pressure on the knee joint) 1
• Instruct on proper home exercise program
• Discuss prevention strategies (proper footwear, knee pads for occupational kneeling)

Monitoring and Follow-up

• Follow up in 2-4 weeks to assess response to treatment
• If using NSAIDs long-term, monitor renal and hepatic function 1
• Consider alternative diagnosis if no improvement after 6-8 weeks of treatment

By following this structured approach to treating knee bursitis, most patients will experience significant improvement in pain and function without requiring surgical intervention.