Treatment of Knee Bursitis: Ice vs Heat
For knee bursitis, ice is the recommended initial treatment, not heat. Ice application should be used during the acute phase to reduce pain and swelling, applied for 20-30 minutes at a time, several times daily, using ice and water wrapped in a damp cloth to avoid direct skin contact 1, 2.
Acute Phase Management (First 48-72 Hours)
Apply cold therapy as the primary modality for acute knee bursitis:
- Use ice and water surrounded by a damp cloth for optimal tissue cooling 1
- Limit application to 20-30 minutes per session, 3-4 times daily 1, 2
- Never place ice directly on skin to prevent cold injury 1, 2
- Ice reduces pain and swelling by decreasing tissue metabolism and blunting the inflammatory response 2
- Cold therapy slows the release of blood and proteins from surrounding vasculature, effectively managing acute inflammation 2
The American Heart Association specifically recommends cold application for acute sprains and strains, which shares similar pathophysiology with acute bursitis 1. Multiple studies confirm ice is effective for short-term pain relief in acute inflammatory conditions 2.
Conservative Treatment Beyond Ice
Combine ice therapy with these evidence-based interventions:
- Rest and activity modification: Avoid activities that cause pain and limit use of the affected knee 1, 3, 4
- Elevation: Keep the knee elevated when possible to reduce swelling 5
- NSAIDs: Oral or topical NSAIDs for pain relief and inflammation reduction, with topical formulations preferred in patients ≥75 years old 6, 4
- Compression: May be considered for comfort, but ensure it doesn't compromise circulation 1
When Heat Is NOT Recommended
Heat therapy is specifically indicated for chronic or persistent muscle pain, not acute bursitis 2. The American College of Physicians recommends heat for chronic conditions where degenerative changes predominate rather than acute inflammation 2. Using heat on acute knee bursitis could potentially worsen inflammation and swelling.
Additional Management Strategies
For chronic or recurrent bursitis:
- Quadriceps strengthening exercises to preserve normal knee mobility 6
- Weight reduction in overweight patients to reduce joint pressure 6
- Walking aids or insoles to decrease pressure on the affected bursa 6
- Intra-articular corticosteroid injections for acute exacerbations with effusion 6, 7
Critical Pitfall to Avoid
Rule out septic bursitis before proceeding with conservative treatment. If infection is suspected (increased warmth, systemic symptoms, acute illness), bursal aspiration with Gram stain and culture is mandatory, and antibiotics effective against Staphylococcus aureus should be initiated 3. Aspiration of non-infected microtraumatic bursitis is generally not recommended due to risk of iatrogenic infection 3.