What is the treatment for knee bursitis?

Treatment of Knee Bursitis

The treatment of knee bursitis should focus on conservative measures including rest, ice, compression, elevation (RICE), NSAIDs, and activity modification, with aspiration and corticosteroid injections reserved for cases that don't respond to initial treatment. 1, 2

Types of Knee Bursitis

• Knee bursitis commonly affects several bursae including prepatellar, pes anserine, tibial collateral ligament, infrapatellar (superficial and deep), and Baker's cysts 1, 2
• Causes include chronic microtrauma (most common), acute trauma/hemorrhage, inflammatory disorders (gout, rheumatoid arthritis), and infection (septic bursitis) 2

Initial Conservative Management

• RICE therapy (Rest, Ice, Compression, Elevation) is the first-line treatment for acute traumatic/hemorrhagic bursitis 2, 3
• Activity modification to prevent continued irritation of the affected bursa is essential 4, 3
• NSAIDs (oral or topical) are recommended for pain relief and reducing inflammation 5, 4
• For patients ≥75 years old, topical NSAIDs are preferred due to their better safety profile 5
• Acetaminophen (up to 4,000 mg/day) can be used as an alternative first-line medication for pain relief 5

Aspiration and Injection Therapy

• Bursal aspiration may be considered to shorten the duration of symptoms in acute traumatic/hemorrhagic bursitis 2
• Aspiration is generally not recommended for chronic microtraumatic bursitis due to the risk of iatrogenic septic bursitis 2
• If infection is suspected, bursal fluid should be aspirated and examined using Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 2
• Intrabursal corticosteroid injections may be beneficial for prepatellar and olecranon bursitis that don't respond to conservative treatment 4
• Ultrasound guidance can improve accuracy of corticosteroid injections into the bursa 6

Management of Septic Bursitis

• Antibiotics effective against Staphylococcus aureus are the initial treatment for septic bursitis 2
• Outpatient antibiotics may be considered for patients who are not acutely ill 2
• Patients who are acutely ill should be hospitalized and treated with intravenous antibiotics 2
• Surgical intervention may be required for bursitis not responsive to antibiotics or for recurrent cases 2

Rehabilitation

• A structured rehabilitation program is important to facilitate healing 3
• Exercises focused on strengthening the quadriceps and preserving normal knee mobility are strongly recommended 7
• Eccentric exercises play an important role in rehabilitation, particularly when bursitis is associated with tendinopathy 6
• Appliances such as walking sticks or insoles may be helpful in reducing pressure on the affected area 7

When to Consider Surgical Intervention

• Surgical excision of the bursa may be necessary for chronic bursitis that doesn't respond to conservative treatment 1, 4
• Recalcitrant bursitis, such as refractory trochanteric bursitis, may require surgical intervention 4

Common Pitfalls and Caveats

• Knee bursitis often mimics other pathologies, making correct diagnosis necessary to initiate appropriate treatment 1
• Ultrasonography can help distinguish bursitis from cellulitis and other conditions 2
• Intrabursal corticosteroid injections, while commonly used, lack high-quality evidence demonstrating benefit 2
• Weight reduction should be considered for overweight patients to reduce pressure on knee joints 5