What is the best treatment approach for a patient with prepattella bursitis, likely caused by repetitive kneeling or trauma to the knee?

Treatment of Prepatellar Bursitis

For prepatellar bursitis caused by repetitive kneeling or trauma, initial management should consist of conservative therapy including ice, rest, compression, activity modification (avoiding kneeling), and NSAIDs, with bursal aspiration reserved for tense, symptomatic effusions to shorten symptom duration. 1, 2

Initial Assessment Priorities

The critical first step is determining whether the bursitis is septic versus non-septic, as this fundamentally changes management 1, 2:

• Signs suggesting septic bursitis: fever, erythema extending beyond bursal borders, warmth, severe tenderness, systemic symptoms 1
• If infection is suspected: perform bursal aspiration with fluid analysis including Gram stain, culture, cell count, glucose measurement, and crystal analysis 1
• Ultrasonography can help distinguish bursitis from cellulitis when the diagnosis is unclear 1

Non-Septic Traumatic/Microtraumatic Bursitis

First-Line Conservative Management

For acute traumatic or chronic microtraumatic prepatellar bursitis 1, 2:

• Ice application and elevation 1, 2
• Rest and activity modification (eliminate repetitive kneeling) 1, 2, 3
• Compression with padding or knee sleeves 2, 3
• NSAIDs for pain control 1, 3

Role of Aspiration

• Acute traumatic/hemorrhagic bursitis: Aspiration may shorten symptom duration and is reasonable for tense, symptomatic effusions 1, 2
• Chronic microtraumatic bursitis: Aspiration is generally not recommended due to risk of iatrogenic septic bursitis 1

Corticosteroid Injection Considerations

Intrabursal corticosteroid injections are sometimes used for microtraumatic prepatellar bursitis, but high-quality evidence demonstrating benefit is unavailable 1. The ACR gout guidelines note that management of acute bursal inflammation due to gout would have comparable recommendations to gouty arthritis, supporting corticosteroid injection as an option 4. However, given the lack of strong evidence and infection risk, this should be reserved for cases not responding to conservative measures 1, 3.

Septic Bursitis Management

If bursal fluid analysis confirms infection 1, 2:

• Outpatient oral antibiotics effective against Staphylococcus aureus for patients who are not acutely ill 1
• Inpatient IV antibiotics for acutely ill patients 1
• Repeated aspiration may be needed for decompression 2
• Incision and drainage is rarely needed but indicated for non-responsive cases 2

Refractory Cases

For bursitis failing 6-8 weeks of conservative management 1, 2, 5:

• Novel sclerotherapy: Ultrasound-guided aspiration followed by intrabursal injection of sclerosing agents (e.g., polidocanol) has shown promise in case reports, with resolution at 10 months follow-up 6
• Endoscopic bursectomy: Outpatient arthroscopic excision under local anesthesia through 2-3 mini-portals is effective for post-traumatic prepatellar bursitis, with average 18-minute procedure time and no recurrence at 36-month follow-up 5
• Open surgical excision: Reserved only for truly recalcitrant cases, though carries higher risk of wound complications 2, 3

Key Pitfalls to Avoid

• Do not inject corticosteroids into potentially infected bursae—always rule out septic bursitis first 1
• Avoid routine aspiration of chronic microtraumatic bursitis due to iatrogenic infection risk 1
• Do not delay antibiotics if septic bursitis is suspected, as this can progress to septicemia 2
• Address underlying cause: Provide knee pads for occupational kneeling or modify activities to prevent recurrence 1, 2