What is the treatment for prepatellar bursitis?

Treatment of Prepatellar Bursitis

Begin with conservative management including rest, NSAIDs, and padding to protect the knee during activities, reserving corticosteroid injections for persistent cases and surgical intervention for failures of conservative treatment. 1

Initial Conservative Management

The first-line approach for prepatellar bursitis depends on the underlying etiology:

For Chronic Microtraumatic Bursitis (Most Common)

• Rest and activity modification to eliminate repetitive kneeling or pressure on the prepatellar bursa 2, 1
• NSAIDs for pain relief (e.g., naproxen 500 mg twice daily, not to exceed 1000 mg/day after the first day) 1, 3
• Ice application for 10-minute periods through a wet towel for pain relief 2
• Padding to protect the knee during necessary activities 1
• Avoid aspiration in microtraumatic bursitis due to risk of introducing infection (iatrogenic septic bursitis) 4

For Acute Traumatic/Hemorrhagic Bursitis

• Conservative treatment with ice, elevation, rest, and analgesics 4
• Aspiration may be considered to shorten symptom duration in acute traumatic cases 4

Critical Distinction: Septic vs. Non-Septic Bursitis

Before proceeding with any treatment, you must rule out infection:

• Perform bursal aspiration if infection is suspected based on warmth, erythema, fever, or systemic symptoms 4
• Send fluid for Gram stain, culture, cell count, glucose, and crystal analysis 4
• If septic: Start antibiotics effective against Staphylococcus aureus (most common pathogen); hospitalize if acutely ill, otherwise outpatient antibiotics may suffice 4
• If purulent aspirate: Proceed to bursotomy with incision and drainage, or bursectomy 5

Second-Line Treatment for Persistent Cases

Corticosteroid Injections

• May be considered for prepatellar bursitis that fails conservative management, though high-quality evidence for benefit is lacking 1
• Must be performed with strict aseptic technique to avoid introducing infection 1
• Generally reserved for cases where infection has been definitively ruled out 4

Common Pitfall: Do not inject corticosteroids if there is any suspicion of infection, as this can worsen septic bursitis and lead to serious complications.

Surgical Management

Indications for Surgery

• Intractable bursitis after failed conservative treatment 6
• Recurrent septic bursitis not responsive to antibiotics 4
• Chronic cases interfering with function or quality of life 7, 6

Surgical Approach

• Endoscopic bursectomy is the preferred technique, offering superior cosmetic and functional outcomes compared to open surgery 7, 6
• Can be performed as outpatient surgery under local anesthesia 6
• Uses 2-3 mini-arthroscopic portals with minimal or no sutures needed 6
• Average operation duration is 18 minutes 6
• Return to competitive sports averages 24 days; return to work averages 18 days 7
• Open bursectomy is reserved for failed endoscopic procedures or when endoscopic approach is not feasible 7

Surgical Outcomes

• Excellent symptom resolution and functional recovery in properly selected patients 6
• Low recurrence rates with endoscopic technique 6
• Minimal wound complications compared to open surgery 6

Treatment Algorithm Summary

1. Rule out infection first - aspirate if any concern for septic bursitis 4
2. If non-septic: Start conservative management (rest, NSAIDs, padding, ice) for 4-6 weeks 2, 1
3. If persistent after conservative treatment: Consider corticosteroid injection with strict aseptic technique 1
4. If still refractory: Proceed to endoscopic bursectomy 7, 6
5. If septic: Antibiotics ± surgical drainage depending on severity 4, 5

Key Caveat: Address underlying causative factors (occupational kneeling, sports-specific activities) to prevent recurrence, as failure to modify activities will lead to treatment failure regardless of intervention chosen 4, 7