What is the treatment for knee bursitis?

Treatment of Knee Bursitis

The treatment of knee bursitis should begin with conservative measures including rest, ice, activity modification, and NSAIDs, followed by corticosteroid injections for refractory cases. 1, 2

Types of Knee Bursitis

Knee bursitis can affect several bursae around the knee joint:

• Prepatellar bursa (front of the kneecap)
• Pes anserine bursa (inner side of the knee)
• Infrapatellar bursa (below the kneecap)
• Medial collateral ligament bursa (inner knee)
• Baker's cyst (behind the knee)

Treatment Algorithm

First-Line Management

1. Non-pharmacological approaches:

   • Rest and activity modification to avoid movements that aggravate symptoms 1
   • Ice application for 15-20 minutes several times daily to reduce inflammation 2
   • Structured exercise program including quadriceps strengthening exercises 1
   • Appropriate footwear and bracing if needed 1

2. Pharmacological management:

   • Acetaminophen up to 4g daily in divided doses for mild to moderate pain 3, 1
   • Topical NSAIDs applied 3-4 times daily, particularly beneficial for patients over 75 years 1
   • Oral NSAIDs when acetaminophen or topical NSAIDs provide inadequate relief, using the lowest effective dose for the shortest duration 3, 1

Second-Line Management

• Intra-articular corticosteroid injections for persistent pain, especially with effusion, providing rapid relief of inflammatory symptoms 3, 1, 4
  • Particularly effective for prepatellar and olecranon bursitis 2
  • Caution: Steroid injection into retrocalcaneal bursa may adversely affect Achilles tendon properties 2

For Septic Bursitis

• Oral antibiotics should be administered 2
• May require aspiration of the bursa to remove infected fluid 5

For Refractory Cases

• Tramadol can be considered when NSAIDs and acetaminophen are ineffective or contraindicated (50mg every 4-6 hours as needed, not exceeding 400mg/day) 1
• Surgical intervention may be required for recalcitrant bursitis that doesn't respond to conservative treatment 2, 6
  • Procedures may include bursectomy or, in rare cases of trochanteric bursitis, iliotibial band release 6

Special Considerations

For Elderly Patients or Those with Increased GI Risk

• Use acetaminophen (not exceeding 4g per day), topical NSAIDs, or oral NSAIDs with gastroprotective agents 3
• Limit tramadol to 300mg/day for patients over 75 years 1

Monitoring

• Regular assessment of pain, function, and quality of life 1
• Monitor renal and hepatic function with prolonged NSAID use 1
• Consider referral to an orthopedic specialist if not responding to conservative treatment after 6-8 weeks 1

Diagnostic Pearls

• Musculoskeletal ultrasound can be used to confirm diagnosis and guide corticosteroid injections 7
• MRI may be used in complex cases to differentiate bursitis from other conditions 4, 7

Common Pitfalls to Avoid

• Failing to distinguish bursitis from arthritis, fracture, tendinitis, or nerve pathology 2
• Overuse of corticosteroid injections, which should be limited due to potential side effects
• Initiating opioids (including tramadol) without trying other treatments first, due to risk of addiction 1
• Neglecting to address underlying biomechanical issues that may contribute to bursitis