What is the treatment for knee bursitis?

Treatment for Knee Bursitis

The treatment for knee bursitis should begin with conservative measures including rest, activity modification, ice application, and NSAIDs, followed by intra-articular corticosteroid injections for cases with persistent symptoms or effusion. 1, 2

Initial Conservative Management

Non-Pharmacological Interventions

• Rest and Activity Modification

  • Avoid movements that aggravate the bursitis
  • Use open-backed shoes or accommodative footwear for posterior knee bursitis 1
  • Consider appropriate bracing with soft braces if mobility is significantly affected 1

• Physical Interventions

  • Apply ice to the affected area for 15-20 minutes several times daily to reduce inflammation 1, 3
  • Elevation of the affected limb to reduce swelling 3
  • Compression may help control swelling 4
  • Structured exercise program focusing on quadriceps strengthening and range of motion exercises once acute symptoms subside 1

Pharmacological Management

• First-line medications

  • Acetaminophen (up to 4g daily in divided doses) for mild to moderate pain 2, 1
  • Topical NSAIDs applied 3-4 times daily, particularly preferred for patients over 75 years due to favorable safety profile 1

• Second-line medications

  • Oral NSAIDs (such as naproxen) if acetaminophen or topical NSAIDs provide inadequate relief
    • Naproxen dosing: 500mg initially, followed by 250mg every 6-8 hours as required 5
    • Maximum initial daily dose should not exceed 1250mg, with subsequent daily doses not exceeding 1000mg 5
    • Use the lowest effective dose for the shortest duration 1
    • Monitor for GI, cardiovascular, and renal side effects 1

Management for Persistent Symptoms

Intra-articular Corticosteroid Injections

• Indicated for persistent knee pain, especially with effusion 2, 1
• Provides rapid relief of inflammatory symptoms 1
• Effective for short-term pain relief (1-16 weeks) 2
• Clinically important and statistically significant effects on pain at 1-2 weeks post-injection 2

Special Considerations

• For patients with increased GI risk (age ≥60 years, comorbid conditions, history of peptic ulcer disease or GI bleeding, concurrent use of corticosteroids or anticoagulants):

  • Use acetaminophen (not exceeding 4g per day)
  • Consider topical NSAIDs
  • If oral NSAIDs are necessary, use with gastroprotective agents or COX-2 inhibitors 2

• For elderly patients:

  • Use the lowest effective dose of NSAIDs
  • Consider dose adjustment based on renal function 5
  • Topical NSAIDs are preferred for patients over 75 years 1

Management of Specific Types of Knee Bursitis

Septic Bursitis

• If infection is suspected (fever, significant erythema, warmth):
  • Perform bursal aspiration for fluid analysis (Gram stain, culture, cell count) 3
  • Initiate antibiotics effective against Staphylococcus aureus 3
  • Outpatient antibiotics for mild cases; hospitalization with IV antibiotics for acutely ill patients 3

Chronic or Recalcitrant Bursitis

• Consider surgical intervention (bursectomy) for cases that fail to respond to conservative treatment 6
• Surgical excision may be necessary for chronic bursitis that doesn't respond to other treatments 7

Monitoring and Follow-up

• Regular assessment of pain, function, and quality of life
• 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

Pitfalls and Caveats

• Avoid aspiration of non-infectious bursitis due to risk of iatrogenic infection 3
• Distinguish bursitis from other conditions like arthritis, tendinitis, or fracture before initiating treatment 6
• While intrabursal corticosteroid injections are commonly used, high-quality evidence demonstrating benefit for all types of bursitis is limited 3
• NSAIDs should be used cautiously in patients with renal impairment, cardiovascular disease, or history of GI bleeding 1, 5