What is the best treatment for pre-patellar bursitis resulting from a fall onto concrete?

Treatment of Pre-patellar Bursitis Following a Fall on Concrete

The best treatment for pre-patellar bursitis resulting from a fall on concrete is a stepwise approach beginning with relative rest, cryotherapy, and NSAIDs, followed by more invasive interventions only if conservative measures fail. 1

Initial Assessment and Conservative Management

• Relative rest and activity modification should be implemented immediately to prevent further damage and promote healing 1
• Cryotherapy (repeated applications of melting ice water through a wet towel for 10-minute periods) is effective for acute pain relief 1
• NSAIDs are recommended for short-term pain relief, though they don't affect long-term outcomes 1
• Compression and immobilization help reduce swelling and prevent further irritation of the bursa 2

Aspiration and Antibiotics

• Aspiration of the bursa should be considered if there is significant swelling causing pain or limiting function 3
• Analysis of bursal fluid is crucial to differentiate between septic and non-septic bursitis - a serous aspirate suggests non-septic bursitis while purulent fluid indicates infection 2
• For septic bursitis, intravenous antibiotics with splintage (with or without aspiration) are typically effective 3
• Oral antibiotics alone may be inadequate for treating infectious pre-patellar bursitis 3

Advanced Interventions

• Corticosteroid injection may provide more effective acute-phase pain relief than oral NSAIDs but doesn't alter long-term outcomes 1
• Surgical intervention should be reserved for cases that have failed 6 weeks of conservative therapy 4
• Endoscopic bursectomy under local anesthesia is an effective minimally invasive option for recalcitrant cases, with shorter recovery times (average return to work: 18 days) 5, 6
• Open bursectomy should be considered only as a last resort due to higher risk of complications including skin necrosis 7

Rehabilitation

• Eccentric strengthening exercises are effective for tendinopathy treatment and may help with associated knee issues 1
• Progressive knee-targeted exercise therapy should be implemented once acute symptoms have subsided 1
• Education should be provided regarding expected recovery timeframes and pain management strategies 1

Cautions and Considerations

• Avoid complete immobilization for extended periods to prevent muscular atrophy 4
• Monitor for signs of infection including increasing pain, redness, warmth, and systemic symptoms 3
• Patients with occupations requiring kneeling may have prolonged symptoms and may need workplace modifications 3
• Surgical complications can include skin problems and wound healing issues, particularly with open bursectomy 5, 7

Follow-up

• If no improvement is seen after 6 weeks of initial treatment, referral to an orthopedic specialist should be considered 4
• Patients should be monitored for recurrence, particularly those with occupations requiring kneeling 3, 6