What is the treatment for knee bursitis?

Treatment of Knee Bursitis

The treatment of knee bursitis should follow a stepwise approach starting with conservative measures including rest, ice, compression, elevation (RICE), NSAIDs, and activity modification, with more invasive treatments such as aspiration and corticosteroid injection reserved for cases that don't respond to initial management. 1, 2

Types of Knee Bursitis

• The most commonly affected bursae in the knee include prepatellar, pes anserine, tibial collateral ligament, and infrapatellar bursae 1
• Other bursitic conditions include Baker's cysts and posttraumatic adventitious hemorrhagic bursitis 1

Initial Conservative Management

First-line Treatment

• Rest and activity modification to reduce pressure on the affected bursa 2, 3
• Ice application to reduce inflammation and pain 1, 3
• Compression with elastic bandage to limit swelling 3
• Elevation of the affected limb to reduce swelling 3
• NSAIDs for pain and inflammation control 4, 2
  • Naproxen 500mg initially, followed by 250mg every 6-8 hours as needed for acute bursitis 4
  • Total daily dose should not exceed 1000mg after the first day 4

Additional Conservative Measures

• Padding of the affected area to prevent further trauma 2
• Avoidance of activities that cause repetitive pressure on the bursa 2, 3
• Physical therapy modalities such as ultrasound and electrical stimulation may facilitate healing 3

Management Based on Type of Bursitis

Acute Traumatic/Hemorrhagic Bursitis

• Conservative treatment with RICE protocol and analgesics 2
• Aspiration may be considered to shorten the duration of symptoms 2

Chronic Microtraumatic Bursitis

• Address the underlying cause (e.g., modify kneeling activities for prepatellar bursitis) 2
• Bursal aspiration generally not recommended due to risk of iatrogenic infection 2

Septic Bursitis

• If infection is suspected, bursal aspiration should be performed for Gram stain, crystal analysis, glucose measurement, cell count, and culture 2
• Antibiotics effective against Staphylococcus aureus are the initial treatment 2
• Outpatient antibiotics for patients who are not acutely ill; hospitalization with IV antibiotics for those who are acutely ill 2
• Surgery may be necessary for cases not responsive to antibiotics or for recurrent cases 2

Inflammatory Bursitis (e.g., gout, rheumatoid arthritis)

• Treatment should address the underlying condition 2
• Intrabursal corticosteroid injections are often used, though high-quality evidence demonstrating benefit is limited 2

Advanced Interventions

Aspiration and Injection

• Aspiration of fluid from the bursa may provide relief in cases of significant swelling 1
• Corticosteroid injection may be beneficial for persistent bursitis 1, 5
• Caution: Steroid injection into retrocalcaneal bursa may adversely affect Achilles tendon properties 5

Surgical Management

• Surgical excision of the bursa may be required for chronic, recalcitrant cases that don't respond to conservative treatment 1, 5
• Surgery is typically reserved for refractory cases or recurrent septic bursitis 5, 2

Diagnostic Considerations

• Ultrasonography can help distinguish bursitis from cellulitis and detect dynamic changes in the patellar tendon and adjacent structures 2, 6
• MRI can confirm the diagnosis but ultrasound is quicker and highly sensitive 6
• For suspected septic bursitis, blood testing (WBC count, inflammatory markers) can help distinguish infectious from non-infectious causes 2

Rehabilitation

• Structured rehabilitation program to facilitate healing 3
• Activity modification and eccentric exercises play an important role in rehabilitation, particularly for cases with associated tendinopathy 6