What is the recommended treatment for mild knee bursitis/synovitis?

Treatment of Mild Knee Bursitis/Synovitis

For mild knee bursitis/synovitis, begin with NSAIDs (topical preferred in patients ≥75 years, oral otherwise) combined with quadriceps strengthening exercises, ice, and activity modification; reserve corticosteroid injections for acute exacerbations with effusion. 1

Initial Conservative Management

First-Line Pharmacological Options

• NSAIDs are the cornerstone of initial treatment for reducing inflammation and pain in knee bursitis 1, 2

  • Topical NSAIDs are strongly preferred for patients ≥75 years old due to superior safety profile 1, 3
  • Oral NSAIDs (e.g., naproxen 500 mg twice daily) are appropriate for younger patients without contraindications 4, 2
  • For patients with GI risk factors requiring oral NSAIDs, use COX-2 selective inhibitors or nonselective NSAIDs with proton-pump inhibitors 3

• Acetaminophen (up to 4,000 mg/day) serves as an alternative first-line option for patients who cannot tolerate NSAIDs 1, 3

  • Counsel patients to avoid other acetaminophen-containing products to prevent exceeding maximum daily dose 3
  • A full dosage trial must be completed before deeming it ineffective 3

Non-Pharmacological Interventions (Equally Important)

• Quadriceps strengthening exercises are strongly recommended to maintain knee mobility and prevent recurrence 1, 5

  • These should be initiated early, not delayed until pharmacological treatment fails 5

• Ice, elevation, and relative rest form the foundation of acute management 6, 2

  • Ice should be applied to reduce inflammation in the acute phase 2, 7
  • Relative rest means activity modification, not complete immobilization 6

• Compression and protective padding help reduce pressure on affected bursae 6

• Weight reduction is strongly recommended for overweight patients to decrease mechanical stress on the knee 1, 5

• Assistive devices (walking sticks, insoles, knee padding) may reduce pressure on the affected area 1

Treatment for Inadequate Response After 2-4 Weeks

• Intra-articular corticosteroid injections are indicated for acute exacerbations, particularly when accompanied by effusion 1, 3, 8

  • Injections should be limited to every 3-4 months to avoid adverse effects 8
  • Direct injection into tendons or ligaments must be avoided 8

• Intensify rehabilitation program with professional supervision if conservative measures prove insufficient 5

• Bursal aspiration may be considered for acute traumatic/hemorrhagic bursitis to shorten symptom duration 9

  • However, aspiration of chronic microtraumatic bursitis is generally not recommended due to risk of iatrogenic septic bursitis 9

Critical Distinction: Rule Out Septic Bursitis

• If infection is suspected (acute onset, warmth, erythema, fever), bursal aspiration with fluid analysis is mandatory before initiating treatment 9
  • Fluid should undergo Gram stain, culture, cell count, glucose measurement, and crystal analysis 9
  • Septic bursitis requires antibiotics effective against Staphylococcus aureus, not corticosteroid injection 9

Common Pitfalls to Avoid

• Do not rely solely on pharmacological management without implementing exercise therapy, as this significantly reduces treatment effectiveness 5

• Do not perform corticosteroid injections for chronic microtraumatic bursitis without first attempting conservative measures, as evidence for benefit is lacking and risk of complications exists 9

• Do not inject corticosteroids into the retrocalcaneal bursa, as this may adversely affect Achilles tendon biomechanics 2

• Do not continue NSAID monotherapy beyond 1 month if symptoms persist without reassessment and treatment modification 10

• Do not exceed acetaminophen 4,000 mg/day due to hepatotoxicity risk 5

Treatment Algorithm Summary

1. Week 0-2: NSAIDs (topical if ≥75 years, oral otherwise) + ice + activity modification + quadriceps exercises 1, 2

2. Week 2-4: If inadequate response, add weight reduction strategies (if applicable), assistive devices, and intensify exercise program 1, 5

3. Beyond 4 weeks or acute exacerbation with effusion: Consider intra-articular corticosteroid injection 1, 3

4. Refractory cases: Surgical excision may be required for chronic bursitis unresponsive to conservative management 2, 7