What is the treatment for suprapatellar bursitis resulting from a ground-level fall?

Treatment of Suprapatellar Bursitis from Ground-Level Fall

For suprapatellar bursitis following a ground-level fall, initiate conservative management with rest, ice application, NSAIDs, and activity modification, reserving aspiration and advanced interventions for cases that fail to improve after 6 weeks. 1, 2

Initial Assessment

First, determine if the bursitis is septic or non-septic, as this fundamentally changes management:

Clinical signs suggesting septic bursitis include:

• Fever >37.8°C 3
• Prebursal temperature difference >2.2°C 3
• Presence of skin lesions or breaks in skin integrity 3
• Purulent appearance of any visible fluid 3

If septic bursitis is suspected, perform bursal aspiration immediately and analyze fluid for: 2, 3

• Gram stain and culture
• White cell count (>3,000 cells/μl suggests infection) 3
• Polymorphonuclear cells (>50% suggests infection) 3
• Glucose measurement (fluid-to-serum ratio <50% suggests infection) 3

Conservative Management for Non-Septic Bursitis

Implement the following measures immediately: 1, 2

• Rest and activity modification: Avoid kneeling and direct pressure on the knee 1, 2
• Cryotherapy: Apply ice through a wet towel for 10-minute periods, repeated multiple times daily 1
• NSAIDs: Use for short-term pain relief (though they don't affect long-term outcomes) 1, 2
• Elevation: Keep the affected knee elevated when possible 2

Important caveat: Aspiration of non-septic traumatic bursitis is generally not recommended due to the risk of introducing infection (iatrogenic septic bursitis), though it may shorten symptom duration in acute hemorrhagic cases 2, 3

When to Consider Corticosteroid Injection

Corticosteroid injection may be considered if: 1, 2

• Conservative measures fail after initial treatment period
• Patient has high athletic or occupational demands requiring faster recovery 3
• Non-septic bursitis is confirmed (never inject if infection is suspected) 2

However, high-quality evidence demonstrating benefit is lacking, and this intervention carries infection risk 2

Management of Septic Bursitis

If septic bursitis is confirmed: 2, 3

• Initiate antibiotics effective against Staphylococcus aureus (the most common causative organism) 2
• Outpatient oral antibiotics may be appropriate for patients who are not acutely ill 2
• Hospitalization with IV antibiotics is required for acutely ill patients 2
• Perform bursal aspiration as both diagnostic and therapeutic measure 2, 3

Surgical Intervention

Reserve surgery for: 1, 2, 3

• Cases failing 6 weeks of appropriate conservative therapy 1
• Septic bursitis not responsive to antibiotics 2
• Recurrent or chronic cases 2, 3

Surgical options include incision, drainage, or bursectomy, with immediate bursectomy not supported by available evidence even in septic cases 3

Rehabilitation Phase

Once acute symptoms subside: 1

• Implement progressive knee-targeted exercise therapy 1
• Include eccentric strengthening exercises for associated knee structures 1
• Provide education regarding expected recovery timeframes 1

Critical pitfall to avoid: Do not immobilize the knee for extended periods, as this leads to muscular atrophy and deconditioning 1

Follow-up Timeline

• Reassess at 6 weeks: If no improvement with conservative measures, consider advanced interventions 1
• Monitor for infection: Even initially non-septic cases can become infected, particularly if aspirated 2, 3
• Watch for recurrence: Chronic or recurrent cases may ultimately require surgical management 2, 3