What is the best approach to manage monoarticular prepatellar bursitis in a young woman with no past medical history?

Management of Monoarticular Prepatellar Bursitis in a Young Woman

For monoarticular prepatellar bursitis in a young woman with no past medical history, the recommended first-line approach is conservative management with rest, ice application, compression, and NSAIDs, with aspiration and/or corticosteroid injection reserved for cases that don't respond to initial treatment. 1

Initial Assessment

When evaluating prepatellar bursitis, focus on:

• Determining if the bursitis is septic vs. non-septic
• Identifying any underlying cause (trauma, occupation, inflammatory condition)
• Assessing severity and impact on function

Key Diagnostic Features

• Localized swelling over the anterior knee
• Tenderness directly over the patella
• Pain with direct pressure or kneeling
• Preserved knee range of motion (distinguishing from intra-articular pathology)
• Absence of systemic symptoms (if non-septic)

Treatment Algorithm

Step 1: Conservative Management (First-Line)

• Rest and activity modification: Avoid kneeling and direct pressure on the affected knee
• Ice application: Apply ice through a wet towel for 10-minute periods to reduce inflammation 2
• Compression: Use an elastic bandage to reduce swelling
• NSAIDs: Short-term use for pain relief and anti-inflammatory effect 2, 1
• Elevation: Keep the affected limb elevated when possible

Step 2: For Cases Not Responding to Conservative Treatment (After 1-2 Weeks)

If symptoms persist despite conservative measures:

Option A: Aspiration

• Consider aspiration if significant fluid collection is present
• Aspiration may shorten the duration of symptoms in acute cases 3
• Caution: Routine aspiration for non-septic bursitis is generally not recommended due to risk of iatrogenic infection 3

Option B: Corticosteroid Injection

• A short-acting corticosteroid injection into the bursa may be considered for persistent cases 1
• Important technique points:
  • Use sterile technique
  • Avoid injecting into the Achilles tendon or other tendinous structures
  • Single injection is preferred over multiple injections

Step 3: For Refractory Cases (After 4-6 Weeks of Failed Conservative Treatment)

• Referral to orthopedic specialist if no improvement occurs 2
• Surgical intervention (bursectomy) may be considered in chronic, recalcitrant cases 4
• Note: Surgery should be reserved for cases that fail 3-6 months of conservative treatment 2

Special Considerations

If Septic Bursitis is Suspected

Septic bursitis requires a different management approach:

• Immediate aspiration for Gram stain, culture, cell count, and crystal analysis 1
• Antibiotics effective against Staphylococcus aureus (most common pathogen) 3
• Consider hospitalization and IV antibiotics if patient appears acutely ill 3

Prevention of Recurrence

• Address underlying causes (e.g., occupational kneeling)
• Consider protective knee pads for those with occupational risk factors
• Proper footwear and activity modification

Monitoring and Follow-up

• Evaluate response to treatment every 1-2 weeks
• If no improvement after 4-6 weeks of conservative treatment, consider referral to specialist 2
• Monitor for complications such as skin necrosis (rare but serious complication of surgical management) 5

Cautions and Pitfalls

• Avoid multiple corticosteroid injections as they may lead to skin atrophy or tendon weakening
• Be vigilant for signs of infection (increased pain, erythema, warmth, systemic symptoms)
• Open bursectomy carries risk of surgical site complications including skin necrosis 5
• Distinguish bursitis from other causes of anterior knee pain (arthritis, tendinitis, fracture)

This approach prioritizes conservative management while providing clear guidance on when to escalate treatment, aligning with current evidence-based recommendations for managing prepatellar bursitis.