What is the initial treatment for an acute flare-up of bursitis (inflammation of the bursa) in the knee?

Acute Treatment for Knee Bursitis Flare-Up

The initial treatment for an acute knee bursitis flare-up should include rest, ice application, activity modification, and NSAIDs, with intra-articular corticosteroid injections reserved for cases with persistent symptoms or effusion. 1

First-Line Management

Non-Pharmacological Interventions

• Rest and Activity Modification:

  • Avoid overuse of the affected knee for 24 hours following treatment 2
  • Avoid movements that aggravate symptoms 1
  • Complete immobilization is discouraged 2

• Ice Application:

  • Apply ice for 15-20 minutes every 2-4 hours during acute phase
  • Continue for 48-72 hours to reduce inflammation and pain 1

• Compression:

  • Use an elastic bandage to provide gentle compression
  • Ensure it's not too tight to avoid restricting circulation

• Elevation:

  • Keep the affected knee elevated when possible to reduce swelling

Pharmacological Management

• NSAIDs (First-line medication):

  • Naproxen 500mg initially, followed by 500mg every 12 hours or 250mg every 6-8 hours as needed 3
  • Initial total daily dose should not exceed 1250mg, thereafter not exceeding 1000mg daily 3
  • Use the lowest effective dose for the shortest duration 2
  • Monitor for GI, cardiovascular, and renal side effects, especially in elderly patients 2, 1

• Acetaminophen (Alternative for those who cannot take NSAIDs):

  • Up to 4g daily in divided doses 1
  • Caution to avoid other products containing acetaminophen to prevent overdose 1

• Topical NSAIDs:

  • Apply 3-4 times daily 1
  • Preferred for patients over 75 years due to better safety profile 1

Second-Line Management (If No Improvement After 1-2 Weeks)

• Intra-articular Corticosteroid Injection:
  • Indicated for persistent knee pain, especially with effusion 1
  • Provides rapid relief of inflammatory symptoms 1
  • Effective short-term pain relief (1-16 weeks) 1
  • Should be performed using aseptic technique 2
  • Consider ultrasound guidance to improve accuracy if available 2

Special Considerations

For Septic Bursitis

• If infection is suspected (fever, intense erythema, severe pain):
  • Bursal aspiration should be performed 4
  • Fluid should be examined using Gram stain, crystal analysis, and culture 4
  • Antibiotics effective against Staphylococcus aureus are generally the initial treatment 4

For Chronic or Recurrent Bursitis

• Structured exercise program including quadriceps strengthening exercises 1
• Weight loss for overweight patients (each pound lost reduces four pounds of pressure on the knee joint) 1
• Consider appropriate footwear and bracing 1
• Address underlying causes (e.g., repetitive kneeling, occupational factors) 4

Monitoring and Follow-up

• Reassess pain, function, and quality of life regularly 1
• If no improvement after 6-8 weeks of conservative treatment, consider referral to an orthopedic specialist 1
• Regular monitoring of renal and hepatic function is necessary with prolonged NSAID use 1

Common Pitfalls and Caveats

1. Avoiding Diagnostic Errors:

   • Don't assume all knee pain with swelling is bursitis; rule out arthritis, fracture, tendinitis, and nerve pathology 5
   • Distinguish between septic and non-septic bursitis, as management differs significantly 4

2. Medication Cautions:

   • NSAIDs should be used with caution in patients with cardiovascular disease, renal impairment, or history of GI bleeding 2
   • For patients on anticoagulants, NSAIDs are not recommended due to high risk of pharmacological interaction 1

3. Injection Considerations:

   • Intrabursal corticosteroid injections for microtraumatic bursitis lack high-quality evidence demonstrating benefit 4
   • There's risk of iatrogenic septic bursitis with aspiration of non-septic bursitis 4

4. Recovery Expectations:

   • Inform patients that recovery from bursitis, especially septic cases, can take weeks to months 6
   • Recurrent episodes may require more aggressive intervention 5

By following this structured approach to treating knee bursitis flare-ups, most patients will experience significant symptom improvement within 1-2 weeks. The key is early intervention with appropriate rest, ice, compression, elevation, and anti-inflammatory medication.