Treatment of Prepatellar Bursitis
Begin with conservative management including rest, NSAIDs, and knee padding, reserving corticosteroid injections for persistent cases and surgery only for recalcitrant disease. 1
Initial Conservative Treatment (First-Line)
The American Academy of Family Physicians recommends starting with a stepwise conservative approach before considering invasive interventions 2:
- Rest and activity modification to reduce pressure on the affected bursa 2
- Ice application for 10-minute periods through a wet towel for pain relief 2
- NSAIDs (such as naproxen 500 mg twice daily) for pain and inflammation control 2, 3
- Protective padding during activities to prevent further trauma 1
This conservative regimen is effective for most patients with chronic microtraumatic prepatellar bursitis 1. Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 2.
Critical Diagnostic Step: Septic vs. Non-Septic
Before proceeding with treatment, you must differentiate between septic and non-septic bursitis through bursal aspiration 4:
Clinical findings suggesting septic bursitis:
Bursal aspirate findings indicating septic bursitis:
- Purulent appearance 5, 4
- White cell count >3,000 cells/μL 4
- Polymorphonuclear cells >50% 4
- Fluid-to-serum glucose ratio <50% 4
- Positive Gram staining or culture 4
Treatment Algorithm Based on Aspirate
For serous (non-septic) aspirate:
- Continue conservative measures with compression and immobilization 5
- Corticosteroid injection may be considered for persistent cases, particularly in patients with high athletic or occupational demands, though high-quality evidence is lacking 1, 4
- Injections should be performed with strict aseptic technique 1
For purulent (septic) aspirate:
- Initiate antibiotic therapy immediately 4
- Bursal aspiration as part of general treatment 4
- Reserve surgical intervention (incision, drainage, or bursectomy) for severe, refractory, or chronic/recurrent cases only 4
Surgical Intervention (Last Resort)
Surgery should be restricted to cases that fail conservative management 4, 6:
- Endoscopic bursectomy under local anesthesia is effective for post-traumatic prepatellar bursitis after failed conservative treatment 7
- Outpatient procedure with 2-3 mini-arthroscopic portals, average duration 18 minutes 7
- Provides excellent cosmetic and functional results with no recurrence 7
- Immediate bursectomy is not supported by evidence and should not be the initial approach even for septic cases 4
Common Pitfall to Avoid
Do not rush to surgical bursectomy for septic bursitis—the available evidence does not support the central European concept of immediate bursectomy 4. A conservative treatment regimen with antibiotics should be pursued first, with surgery reserved only for refractory cases 4.