Treatment of Superficial Infrapatellar Bursitis
Superficial infrapatellar bursitis should be managed conservatively with rest, activity modification, ice application, NSAIDs for pain relief, and protective padding, with aspiration generally avoided due to risk of iatrogenic infection. 1
Initial Conservative Management
The cornerstone of treatment involves non-invasive measures that address both symptoms and underlying mechanical causes:
- Rest and activity modification are essential first-line interventions to prevent further bursal irritation and allow healing 1, 2
- Cryotherapy should be applied using melting ice water through a wet towel for repeated 10-minute periods to reduce acute inflammation and pain 3
- NSAIDs provide effective short-term pain relief, though they do not alter long-term outcomes 3, 1
- Protective padding during activities that stress the knee helps prevent recurrent trauma 4, 1
Key Management Principle: Avoid Aspiration
A critical distinction in managing superficial infrapatellar bursitis is that bursal aspiration is generally NOT recommended for chronic microtraumatic bursitis due to the significant risk of introducing iatrogenic septic bursitis. 1 This differs from management of acute traumatic/hemorrhagic bursitis where aspiration may shorten symptom duration. 1
When to Consider Advanced Interventions
- Corticosteroid injections may be considered for persistent cases, though high-quality evidence demonstrating benefit is lacking 4, 1
- If corticosteroid injection is performed, strict aseptic technique is mandatory to minimize infection risk 4
- Surgical excision should be reserved only for cases that have failed 6 weeks of conservative therapy 3, 2
Rehabilitation Approach
Once acute symptoms subside, progressive rehabilitation is important:
- Eccentric strengthening exercises targeting the knee extensors help address associated tendinopathy and prevent recurrence 3
- Progressive knee-targeted exercise therapy should be implemented as symptoms improve 3
- Avoid prolonged immobilization to prevent muscular atrophy 3
Critical Diagnostic Caveat
If infection is suspected based on clinical presentation (warmth, erythema, systemic symptoms), bursal aspiration MUST be performed with fluid sent for Gram stain, culture, cell count, glucose, and crystal analysis. 1 Septic bursitis requires antibiotics effective against Staphylococcus aureus as initial treatment. 1 Ultrasonography can help distinguish bursitis from cellulitis when the diagnosis is unclear. 1
Addressing Underlying Causes
The most common cause of superficial infrapatellar bursitis is chronic microtrauma from repetitive kneeling or direct pressure. 1 Identifying and modifying the inciting activity is essential to prevent recurrence—simply treating symptoms without addressing mechanical factors leads to chronic, recalcitrant disease. 1