What is the treatment for prepatella bursitis?

Treatment of Prepatellar Bursitis

The treatment of prepatellar bursitis should follow a stepwise approach, beginning with conservative measures including rest, ice, compression, elevation (RICE), and NSAIDs, followed by aspiration and/or antibiotics if infection is suspected, with surgical intervention reserved for refractory cases.

Initial Assessment and Classification

First, determine whether the bursitis is septic or non-septic:

Clinical Features Suggesting Septic Bursitis:

• Fever >37.8°C
• Significant erythema and warmth
• Skin lesions or breaks in the skin
• Purulent aspirate
• White cell count >3,000 cells/μl in aspirate
• Positive Gram stain or culture 1

Treatment Algorithm

1. Non-Septic Prepatellar Bursitis (Initial Management)

• Rest and activity modification: Limit standing and walking during acute episodes
• Ice: Apply for 15-20 minutes several times daily
• Compression: Use elastic bandage to reduce swelling
• Elevation: Keep the affected knee elevated when possible
• NSAIDs: Naproxen 500mg twice daily for pain and inflammation 2
• Protective padding: Use knee pads to prevent recurrence

2. Persistent Non-Septic Bursitis (After 2-3 weeks of conservative treatment)

• Aspiration: To relieve pressure and pain
• Corticosteroid injection: Consider if inadequate improvement after conservative measures
• Continued protection: Use padding to prevent recurrence
• Footwear modifications: Shoes with adequate depth and width 3

3. Septic Prepatellar Bursitis

• Aspiration: For diagnosis and therapeutic drainage
• Antibiotics: Empiric therapy covering Staphylococcus aureus
  • Amoxicillin-clavulanate 875/125 mg twice daily 4
  • For penicillin-allergic patients: Doxycycline 100 mg twice daily or trimethoprim-sulfamethoxazole 4
• Serial aspirations: May be necessary to remove purulent fluid
• Close monitoring: For clinical improvement

4. Refractory or Recurrent Cases

• Surgical intervention: Bursectomy for cases that don't respond to conservative measures 1, 5
• Referral to specialist: If no improvement after 6 weeks of treatment 3

Special Considerations

For Acute Traumatic Bursitis

• Early aspiration may be beneficial to relieve pressure and pain 5
• Apply compression immediately after aspiration

For Chronic Bursitis

• Focus on preventive measures like protective padding and activity modification
• Consider orthotic devices if anatomical factors contribute to recurrence 3

Pitfalls and Caveats

1. Avoid corticosteroid injection in suspected septic bursitis as this may worsen infection
2. Don't delay antibiotic therapy if septic bursitis is suspected
3. Distinguish bursitis from other conditions like arthritis, tendinitis, or fracture
4. Avoid early surgical intervention for septic bursitis; most cases respond to conservative treatment and antibiotics 1
5. Don't miss underlying conditions that may predispose to bursitis (e.g., rheumatoid arthritis, gout)

The evidence supports a primarily conservative approach to prepatellar bursitis, with surgical intervention reserved only for severe, refractory, or chronic/recurrent cases. The European practice of immediate bursectomy for septic bursitis is not supported by current evidence 1.