Treatment of Semimembranosus-Tibial Bursitis
Begin with conservative management including rest, ice application, NSAIDs, and activity modification, reserving corticosteroid injection for cases that fail initial therapy. 1
Initial Conservative Management
The stepwise approach recommended by the American Academy of Family Physicians should guide treatment of this deep knee bursa:
- Start with rest and activity modification to reduce mechanical stress on the affected bursa 1
- Apply ice for 10-minute periods through a wet towel for pain relief 1
- Prescribe NSAIDs such as naproxen 500 mg twice daily for pain and inflammation control 2
- Avoid complete immobilization to prevent muscular atrophy and deconditioning 1
Pharmacologic Treatment
For acute bursitis and tendonitis, naproxen is FDA-approved with specific dosing:
- Initial dose: 500 mg naproxen, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed 2
- Maximum initial daily dose should not exceed 1250 mg; thereafter, do not exceed 1000 mg daily 2
- Consider lower doses in elderly patients or those with renal/hepatic impairment 2
- Naproxen sodium formulation provides more rapid absorption when prompt pain relief is desired 2
Advanced Interventions
If conservative measures fail after appropriate trial (typically several weeks):
- Consider corticosteroid injection for persistent symptoms, though this should be performed with caution in deep bursae near tendons 1, 3
- Ultrasound-guided injection may improve accuracy and outcomes 1
- Ensure septic bursitis is excluded before corticosteroid administration 4, 5
Critical Diagnostic Considerations
Before initiating treatment, rule out septic bursitis and other conditions:
- Assess for signs of infection: fever, severe erythema, warmth, or systemic symptoms requiring bursal aspiration with Gram stain and culture 4, 5
- Consider systemic rheumatic disease if multiple bursae are symptomatic 1
- Distinguish from arthritis, fracture, tendinitis, and nerve pathology 3
Surgical Referral
Reserve surgical intervention for truly refractory cases:
- Refer to orthopedic surgery if symptoms persist despite 3-6 months of appropriate conservative management 1, 3
- Surgical options may include bursectomy or addressing underlying mechanical factors 3, 6
Common Pitfalls
- Avoid corticosteroid injection without first excluding infection, as this can worsen septic bursitis 4, 5
- Do not routinely aspirate non-septic microtraumatic bursitis due to risk of iatrogenic infection 4
- Ensure adequate treatment duration, as recovery can take weeks to months even with appropriate therapy 7, 5